Premature Ovarian Insufficiency
NICE guideline [NG23] Menopause: identification and management. Last updated: Apr 2026.
NICE CKS Menopause. Last revised: Jul 2025.
Premature Ovarian Insufficiency
Premature ovarian insufficiency is the loss of ovarian function before the age of 40. It may be transient or permanent and can present with menstrual disturbance, menopausal symptoms, and infertility.
This updated UKMLA guide to premature ovarian insufficiency is based on NICE NG23 and NICE CKS, which covers causes, symptoms, complications, diagnosis, and management.
Definition
Premature ovarian insufficiency refers to the transient or permanent loss of ovarian function before 40 y/o.
Some other closely related terms:
| Term | Definition |
|---|---|
| Menopause | Biological stage where menstruation stops permanently due to loss of ovarian follicular activity. |
| Early menopause | Menopause that happens between 40-45 y/o |
| Peri-menopause | The period before menopause, where there are irregular cycles of ovulation and menstruation |
| Post-menopause | The period after menstruation has not occurred for 12 consecutive months |
Causes and Risk Factors
Premature ovarian insufficiency can occur spontaneously with no underlying cause.
Identifiable cause / risk factors include:
- Genetic factors
- Strong family history
- Galactosaemia
- Chromosomal abnormalities (e.g. Turner syndrome)
- Autoimmune diseases (e.g. T1DM, Addison’s disease, thyroid disorders)
- Infections (e.g. TB, mumps)
- Iatrogenic causes
- Bilateral oophorectomy
- Gonadotoxic medications (e.g. GnRH agonist)
- Pelvic radiotherapy
- Chemotherapy
Clinical Features
Clinical features of premature ovarian insufficiency overlap significantly with those of menopause (see the Menopause article)
Some key differences:
- Premature ovarian insufficiency occurs in <40 y/o women
- Infertility is often a prominent presenting complaint
- There aren’t always permanent immediate amenorrhoea
Complications
Complications are largely similar to those of menopause:
- Osteoporosis and associated fragility fractures
- Cardiovascular diseases
- Cerebrovascular disease (stroke and TIA)
Investigation and Diagnosis
If a <45 y/o woman presents with menopause symptoms → measure serum FSH level (take 2 samples, 4-6 weeks apart)
- Persistently elevated FSH indicates reduced ovarian function
- The exact diagnosis depends on the age of the patient:
- <40 y/o → premature ovarian insufficiency
- 40-44 y/o → early menopause
In other words, premature ovarian insufficiency can be diagnosed if:
- <40 y/o with menopause-associated symptoms, and
- ↑ FSH levels on 2 blood samples taken 4-6 weeks apart
Do not routinely use anti-Müllerian hormone testing to diagnose premature ovarian insufficiency
Management
Offer sex steroid replacement to all patients:
- Form: HRT or COCP
- Duration: continue until at least the age of natural menopause (usually 51 y/o)
Importance of sex steroid replacement:
- Offer bone protection
- Offer cardiovascular protection
- Improve menopause-associated symptoms and quality of life
References