In a significant development for women’s health, new guidelines on the diagnosis and management of premature ovarian insufficiency (POI) are set to be published (pending confirmation) simultaneously in three leading journals. These guidelines are the result of a collaborative effort between the Centre for Research Excellence in Women’s Health in Reproductive Life (CRE-WHiRL) at Monash University, key international women’s health organizations, and an international team of experts that even includes women with lived experience.
POI is defined as the loss of ovarian function before the age of 40, which is considerably earlier than the average age of menopause, typically around 48 – 51 years globally. Globally, approximately 4 percent of women are affected by POI. This condition brings with it a host of associated issues such as infertility, psychological distress, and an increased risk of osteoporosis, cardiovascular disease, mortality, dementia, and cognitive dysfunction. Although hormone therapy has demonstrated some ability to alleviate certain effects, the overall management of POI on a global scale has been less than satisfactory, marred by delayed diagnoses, inconsistent care, and patient dissatisfaction.
The POI guidelines were last updated in 2015. The 2024 update of the POI Guidelines of the European Society of Human Reproduction and Embryology (ESHRE) marks a new milestone as it involves an international partnership among ESHRE, the International Menopause Society, the American Society for Reproductive Medicine, and the NHMRC-funded CRE-WHiRL (led by the Monash Centre for Health Research and Implementation at Monash University).
The 2024 guidelines offer a total of 145 recommendations covering various aspects related to POI, including symptoms, diagnosis, causation, sequelae, and treatment. These recommendations are carefully crafted based on the best available evidence and are graded according to the strength of that evidence. The topics incorporated into the guideline were determined through an international survey of both women and healthcare professionals. Moreover, the updated guidelines provide novel information regarding the genetic causes of POI, its impact on muscle health, the use of anti-mullerian hormone, non-hormonal therapies, lifestyle interventions, and complementary therapies.
Associate Professor Amanda Vincent from CRE-WHiRL, who is the Co-Chair of the guideline development group, points out a crucial change in the updated 2024 guidelines regarding the diagnosis of POI. Now, just one elevated follicle stimulating hormone (FSH) level, when combined with irregular or absent menstrual periods for at least four months, suffices for diagnosis. The FSH level only needs to be retested if the diagnosis remains uncertain. Women with lived experience have played an important role by offering suggestions on how to communicate the diagnosis and care to those dealing with POI. As Associate Professor Vincent explains, “The new Guideline means faster diagnosis of POI, conveyed in a sensitive manner and involving shared decision making between the healthcare professional and the woman experiencing POI.”
She also emphasizes that a comprehensive clinical evaluation must extend beyond simply assessing symptoms. “It must also include asking a patient about her sexual wellbeing, fertility needs, psychological health, cardiovascular and osteoporosis risks, and co-morbidities,” she states.
The updated guideline places great emphasis on personalized hormone therapy, provided there are no contraindications, for both symptom relief and chronic disease prevention. There’s an emphasis on its prompt initiation and continuation until the usual age of menopause. “This provides healthcare professionals with clear advice on best practice in POI care, based on the best evidence currently available,” Associate Professor Vincent remarks.
To further assist women and healthcare professionals, the POI guideline comes with co-designed resources. For consumers, there’s an updated Ask Early Menopause App (www.askearlymenopause.org), which has over 9,000 users worldwide. This app offers evidence-based resources, a personal dashboard, and a discussion forum to help women manage early menopause. Additionally, there’s a toolkit designed for healthcare professionals.
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