Management of POI

Hormone Replacement Therapy (HRT): The Foundation of Management

Indication: All women with POI should receive Hormone Replacement Therapy (HRT) until at least the average age of natural menopause (~50 years) unless contraindicated.

Oestrogen:

Women with POI need to replace the Oestrogen that is lost to prevent the short and long term health complications of POI. This comes in many forms including oral, transdermal (patch or ring) and oestradiol creams. Transdermal is sometimes preferred over oral due to a lower risk of thrombosis and steady hormone delivery, however there are pro's and con's to each method and it is a patient specific decision that should be made alongside a qualifies health care professional.

Progestogen:

For women with an intact uterus, a progestin (e.g., medroxyprogesterone acetate) should be added cyclically (e.g., days 1–12 monthly) to reduce the risk of endometrial cancer.

Testosterone:

There is some evidence to suggest that Testosterone replacement can have beneficial effects in women suffering with POI. Testosterone therapy in POI may improve sexual desire, mood, energy, cognitive function, and bone health. This should be discussed with a qualified health care professional and carefully monitored.

Overall benefits of HRT:

HRT alleviates hormone-deficiency symptoms (e.g., hot flashes, vaginal dryness), and may protect against bone loss, cardiovascular disease, and early mortality.

Fertility, Contraception & Reproductive Planning

• Fertility Outlook: A spontaneous conception is possible (~5–10%), but no therapies reliably restore ovarian function.

• Contraception: Women wishing to avoid pregnancy should use effective contraception despite POI, as rare ovulations occur.

Options for Assisted Conception:

o Oocyte (egg) donation remains the most effective fertility option for women with established POI.

o Fertility preservation (e.g., oocyte cryopreservation) should be proactively offered to those known to be at high risk of developing POI.

Lifestyle & Preventive Measures

• Healthy Lifestyle: Women with POI should be encouraged to:

o Stop smoking,

o Maintain a healthy weight,

o Engage in regular exercise—especially weight-bearing exercise to support bone health.

• Supportive Measures: The guideline recognizes the impact of emotional and psychological distress, advocating for resources, support groups (e.g., Daisy Network in the UK), and shared decision-making approaches.

Monitoring & Long-Term Health Surveillance

Women receiving management for POI should undergo ongoing monitoring in these areas:

• Bone Health: Regular assessment (e.g., bone mineral density testing) to evaluate for osteoporosis risk.

• Cardiovascular Risk: Monitor traditional risk factors and optimize management through lifestyle and treatments where needed.

• Psychological & Sexual Well Being: Regular evaluation and referral for mental health and sexual function support as needed.

• Endocrine Autoimmune Surveillance:

o If autoimmune etiology suspected, screen once for thyroid (TPO Ab) and adrenal (21 OH or adrenocortical antibodies) autoantibodies—and follow up accordingly.

• Regular Follow-up: Encourage consistent engagement with healthcare providers to reinforce management, assess treatment effectiveness, and adapt care plans over time.

In summary:

The 2024 ESHRE Guideline offers a comprehensive, patient-centered framework for managing POI—highlighting the importance of hormone replacement, addressing fertility and lifestyle components, and emphasizing long-term health and emotional well-being.