Premature ovarian insufficiency (POI) remains poorly understood and under-researched [1]. It describes a syndrome consisting of early cessation of periods, sex steroid deficiency and elevated menopausal levels of the pituitary hormones FSH and LH in women below the age of 40. POI can be primary (spontaneous POI) or secondary (induced by radiation, chemotherapy or surgery). Controversy persists over nomenclature with terms such as “Premature ovarian failure/dysfunction” and ‘primary ovarian insufficiency’, which are still in usage.

POI has been estimated to affect about 1 % of women younger than 40, 0.1 % of women under 30 and 0.01 % of women under the age of 20. However, as cure rates for cancers in childhood and young women continue to improve, it is likely that the incidence of prematurely menopausal women is rising rapidly [2]. Recent data from Imperial College London suggest that the incidence of POI may be significantly higher than originally estimated. Cartwright and Islam [3] studied 4968 participants from a 1958 birth cohort. They found that 370 (7.4 %) had either spontaneous or medically induced POI. Smoking and low socioeconomic status were predictive of POI, and poor quality of life (SF 36) was twice as common in POI. The incidence of POI also appears to vary according to the population studied. It appears to be significantly higher, greater than 20 %, in some Asian populations (IMSCON 2012 (17-19.02.2012) Faridabad from Indian Menopause Society).

In the past, the focus of medical care has been on improvement of survival rates. Very little attention has been given to the maintenance of quality of life in the short term and to the avoidance of the long-term sequelae of a premature menopause. One of the main reasons for this has been the bias of economic expenditure and medical endeavour to the prolongation of life (e.g. cancer treatments) rather than towards optimising quality of life in cancer survivors. Should this trend continue, we are in danger of creating a population of young women who have been given back the gift of life but left without the zest to live it to its full potential. Maintenance of postmenopausal health is also of paramount importance if we are to minimise the economic impact on society in this and the future generations.

Causes of spontaneous POI include idiopathic (no known cause), genetic, autoimmune and infective causes. The typical presentation of spontaneous POI is erratic or complete cessation of periods in a woman younger than 40 years, which may or may not necessarily be accompanied by symptoms. These symptoms may not be typical vasomotor in nature and include mood disturbances, loss of energy and generalised aches and pains. Our data and data from others [4–6] indicate that the next most disturbing aspect of POI after the loss of fertility is the adverse impact on sexual responsiveness and other psychological problems.

Women with POI require integrated care to address physical, psychosocial and reproductive health as well as preventative strategies to maintain long-term health. However, there is an absence of evidence-based guidelines for diagnosis and management. POI is a difficult diagnosis for women to accept, and a carefully planned and sensitive approach is required when informing the patient of the diagnosis. A dedicated multidisciplinary clinic separate from the routine menopause clinic will provide ample time and the appropriate professionals to meet the needs of these emotionally traumatised patients. At the West London Menopause Centres, we have restructured our services and created a dedicated clinic for the POI patients. Counselling at this stage should include explanation that remission and spontaneous pregnancy can still occur in women with spontaneous or medical POI. Specific areas of management include the provision of counselling and emotional support, diet and nutrition supplement advice, hormone replacement therapy, and reproductive health care, including contraception and fertility issues. There is an urgent need for large-scale long-term randomised prospective studies to determine the optimum routes and regimens of hormone replacement therapy. Outcome measures should include short-term symptoms, vasomotor, urogenital and psychosexual and the long-term effect on cardiovascular, cognitive and skeletal health.