New international guidelines announced for premature ovarian insufficiency

New guidelines on the diagnosis and management of premature ovarian insufficiency (POI)—developed by the Center for Research Excellence in Women’s Health in Reproductive Life (CRE-WHiRL) at Monash University, and key international women’s health organizations with an international team of experts including women with lived experience—have been published simultaneously in three journals, including Climacteric.

POI is defined as loss of ovarian function before 40 years. This is much earlier than the usual age of menopause; occurring at an average age of 48-51 years in women globally.

POI affects approximately 4% of women globally and is associated with infertility, psychological distress and an increased risk of osteoporosis, cardiovascular disease, mortality, dementia and cognitive dysfunction. While hormone therapy has been shown to mitigate some of these effects, the management of POI globally remains sub-optimal with delayed diagnosis, variation in care and patient dissatisfaction.

The guidelines were last updated in 2015 and the 2024 update of the POI Guidelines of the European Society of Human Reproduction and Embryology (ESHRE), for the first time, involved an international partnership between ESHRE and the International Menopause Society, American Society for Reproductive Medicine and CRE-WHiRL, which is led by the Monash Center for Health Research and Implementation (MCHRI), at Monash University.

The 2024 guidelines provide 145 recommendations on symptoms, diagnosis, causation, sequelae and treatment of POI. The recommendations were developed using the best available evidence and graded according to the strength of that evidence. Topics to cover in the guideline were informed by an international survey of women and health care professionals.

New information is provided about the genetic causes of POI, the impact of POI on muscle health, use of anti-mullerian hormone, non-hormonal therapies, lifestyle interventions and complementary therapies.

According to Co-Chair of the guideline development group, Associate Professor Amanda Vincent, from CRE-WHiRL, a key change of the updated 2024 guidelines is the recommendation regarding the diagnosis of POI; only one elevated follicle stimulating hormone (FSH) level is needed combined with irregular or absent menstrual periods for at least four months.

The FSH level only requires repeating if the diagnosis remains unclear. Women with lived experience provided recommendations on how to convey the diagnosis and care of women with POI.

“The new guideline means faster diagnosis of POI, conveyed in a sensitive manner and involving shared decision making between the health care professional and the woman experiencing POI,” said Associate Professor Vincent.

A comprehensive clinical evaluation requires more than assessing symptoms, “it must also include asking a patient about her sexual well-being, fertility needs, psychological health, cardiovascular and osteoporosis risks, and co-morbidities,” she said.

The updated guideline stresses the importance of personalized hormone therapy, unless contraindicated, for symptom relief and chronic disease prevention, with the need for prompt institution and continuation until the usual age of menopause.

“This provides health care professionals with the clear advice on best practice in POI care, based on the best evidence currently available,” Associate Professor Vincent said.

The POI guideline is accompanied by co-designed resources for consumers, including an updated Ask Early Menopause App and a toolkit for health care professionals.

The Ask Early Menopause App informs and supports women to manage early menopause with evidence-based resources, a personal dashboard and a discussion forum. The App has over 9,000 users worldwide.