Premature Ovarian Failure, Is there any hope? 

Premature Ovarian Failure, Is there any hope? 

Grappling with the diagnosis of premature menopause, women have to come to terms with the huge change being wrought in their future lives. The idea of menopause is a very painful concept to digest for women in their twenties and thirties, the prime childbearing years. They often discover it during their fertility treatment. A reproductive endocrinologist would acknowledge that the chances of conceiving are slim and the only routes to parenthood would be by in vitro fertilization with a donor egg or by following the adoption path. Most women find their loss of fertility one of the most difficult things to come to terms with.

What is Premature Ovarian Failure?

Some women find their FSH at a menopausal level pre-40. Premature ovarian failure (POF) or Premature ovarian insufficiency (POI) is the loss of ovarian function which is characterized by amenorrhea, low oestrogen (hypoestrogenism) and elevated serum gonadotropin levels in women younger than 40. In many cases, patients lose fertility due to the absence of follicles and a failure to respond to the stimulation of hormones.

In addition to subfertility, there are a number of other health issues originating from the decline in oestrogen levels. Patients are advised to use HRT immediately. Women with POF experience menopausal symptoms such as hot flushes, vaginal dryness, dyspareunia, insomnia, vaginitis and mood swings.  They become increasingly vulnerable to heart and bone diseases.

The three diagnostic criteria for POF are as follows:

  • Amenorrhea lasting more than 4 months
  • Age under 40 years 
  • FSH is raised above 40 IU/L on two occasions at least one month apart

In reality, many young women in their 20’s and 30’s miss periods every now and then and assume it is due to stress and never suspect any possibility of POF. They have had vague mental/ physical symptoms that are difficult to pin down. They often wake up in the middle of the night drenched in sweat and/or experience odd episodes of sweating during the day as well. Depression, anxiety and mood swings are commonly felt by young women. But they do not correlate these symptoms with POF and when seeking medical advice often a psychological problem may be suggested rather than POF due to their age and the nebulous nature of their condition. 

Having a baby…rare but still a possibility

Most cases of POF are of unknown origin. The reproductive system has effectively shut down early. Recent studies show that in the majority of cases, POF has autoimmune characteristics. Circulating autoantibodies to ovarian tissue have been demonstrated in women with POF. Involvement of thyroid and adrenal gland is commonly observed. Autoimmunity can attack the ovaries and deplete Ovarian Reserve prematurely.

It is a fact that some women with premature menopause do become pregnant. Between 5 to 8 per cent of women diagnosed with premature ovarian failure suddenly revert back to normal for no apparent reason. Their FSH levels drop to premenopausal levels and they begin to ovulate again. Some studies show that about 8 per cent of women with premature ovarian failure spontaneously ovulate and conceive. That is why when it comes to POF and ovarian inefficiency, we have come to recognise it as a continuum of impaired ovarian function rather than a dichotomous state.

It is known that primary ovarian failure occurs due to the two major mechanisms of follicle dysfunction and follicle depletion. 

  • Follicle dysfunction indicates that follicles remain in the ovary, but a pathological process prevents their normal function. 
  • Follicle depletion indicates that no primordial follicles remain in the ovary. 

Research has shown that as many as 50 per cent of women with POF still have ovarian follicles when their ovaries are examined by ultrasound and this is where we focus our treatment.

 

Chinese herbal medicine treatment for POF

Although the exact mechanism of the action of Chinese herbal medicine(CHM) remains to be proven (no pharmaceutical company is willing to fund the research) and there are a limited number of scientific studies (natural medicine is impossible to patent), we suggest it is an effective alternative therapy for POF in cases of follicle dysfunction. 

According to a recent systemic review/meta-analysis[1], Chinese herbal medicine treatment substantially improves POF. Hormone levels also improved after treatment with CHM when compared to hormone levels prior to treatment. It was confirmed that long term treatment is better than short term treatment when comparing heterogeneity.

Successful therapeutic outcomes for patients with POF may be attributed to the herbal medicine facilitating the removal of barriers which prevent the normal functioning of ovarian follicles as seen in resistant ovary syndrome. 

Another possible mechanism of action may be that ovulation reverts back if the ovarian failure was caused by an autoimmune disease and the autoimmune disease goes into remission. 

Animal experiments have demonstrated the efficacy of Chinese herbal medicine in inhibiting the production of anti-ovarian antibodies (AoAb) and in further protecting the ovaries from autoimmune destruction [2]. 

Studies have been done which reveal CHM’s influence on the serum level of hormones and its involvement with the hypothalamic–pituitary–ovarian (HPO) axis [3,4]. For example, several case reports suggest that CHM may alleviate symptoms, reduce elevations in FSH, promote oestrogen production, and regulate levels of luteinizing hormone (LH) [5, 6]. Studies demonstrate that CHM is effective in the management of the infertility caused by POF [7]

Positive outcomes are most likely to be achieved if the patients are still in the early stages of premature menopause and periodically revert to normal hormone levels, for example, someone in the early stage of premature menopause who has been ovulating periodically even if FSH tested at a high level. 

TCM is the most effective and beneficial treatment for POF, however, treatment should be tailored to individuals in order to achieve the best results.  Following treatment, women suffering from POF and long- term amenorrhea may restart menstruating regularly. We often observe spontaneous reversal of premature menopause. As the women’s ovarian function is restored, FSH levels often dropped to normal and they generally have much better chances of conceiving naturally if they continue with the treatment. Considering the average age of POF onset is twenty-seven, most women prefer a treatment that will restore their ovaries and hormonal system to fully functional health and thus enable them to conceive with their own eggs and have their genetic children. TCM is one of the most effective treatment methods for POF in existence

 


REFERENCES

[1] Chinese Herbal Medicine for premature ovarian failure: A systematic review and meta-analysis

[2] Zhu L, Luo SP, Xu LM, Zhu CL. Influence of Zuogui pill on antiovarian antibodies in immune premature ovarian failure rats [in Chinese]. Modern Journal of Integrated Traditional Chinese and Western Medicine 2006;15:435–8.

[3] Zhu L, Luo SP, Xu LM, Xie YH, Ren MN. Effects of Zuogui pills on expression of Bcl-2 and Bax protein mice ovaries with immune premature ovarian failure [in Chinese]. Traditional Chinese Drug Research & Clinical Pharmacology 2012;23:381–6.

[4] Zhang DW, Li CP, Huang X, Zhang DD, Fan YL, Zhang Y, et al. Effect of invigorating kidney and regulating periphery on rats with premature ovarian failure and its influence on inhibin B and wascular endothelial growth factor [in Chinese]. Chinese Journal of Experimental Traditional Medical Formulae 2011;17:213–6.

[5] Lu XN, Xu XR, Lin LJ. Clinical observation of bushen er’xian decoction in treating premature ovarian failure [in Chinese]. Zhongguo Zhong Xi Yi Jie He Za Zhi 2008;28:594–6.

[6] Hua FF, Xia YH, Yang J. Clinical observation on treatment of premature ovarian failure patients of shen deficiency gan stagnation syndrome by com- bination of bushui roumu recipe and medroxyprogesterone acetate tablet. Zhongguo Zhong Xi Yi Jie He Za Zhi 2012;32:1028–31.

[7] Chao SL, Huang LW, Yen HR. Pregnancy in premature ovarian failure after therapy using Chinese herbal medicine. Chang Gung Medical Journal 2003;26:449–52.