Primary ovarian insufficiency
|Primary ovarian insufficiency|
|Other names||Premature ovarian insufficiency, premature menopause, and premature ovarian failure.|
|Specialty||Obstetrics and gynecology|
Primary ovarian insufficiency (POI) (also called premature ovarian insufficiency, premature menopause, and premature ovarian failure) is the partial or total loss of reproductive and hormonal function of the ovaries before age 40 because of folliclular (egg producing area) dysfunction or early loss of eggs. POI can be seen as part of a continuum of changes leading to menopause that differ from age-appropriate menopause in the age of onset, degree of symptoms, and sporadic return to normal ovarian function. POI affects approximately 1 in 10,000 women under age 20, 1 in 1,000 women under age 30, and 1 in 100 of those under age 40. A medical triad for the diagnosis is amenorrhea, hypergonadotropism, and hypoestrogenism.
Physical and emotional symptoms include hot flashes, night sweats, dry skin, vaginal dryness, irregular or absent menstruation, anxiety, depression, mental fog, irritability, nervousness, decreased libido, and increased autoimmune disruption. The sense of shock and distress on being informed of the diagnosis can be overwhelming. The general treatment is for symptoms, bone protection, and mental health. Although 5 to 10% of women with POI may ovulate sporadically and become pregnant without treatment, others may use assisted reproductive technology including in vitro fertilization and egg donation or decide to adopt or remain childless.
The causes of POI are heterogeneous and are unknown in 90% of cases. It can be associated with genetic causes, autoimmune disease, enzyme deficiency, infection, environmental factors, radiation, or surgery in 10%. Two to 5% of women with POI and a premutation in FMR1, a genetic abnormality, are at risk of having a child with fragile X syndrome, the most common cause of inherited intellectual disability.
The diagnosis is based on ages less than 40, amenorrhea, and elevated serum follicle-stimulating hormone (FSH) levels. Typical serum FSH levels in POI patients is in the post-menopausal range. Treatment will vary depending on the symptoms. It can include hormone replacement therapy, fertility management, and psychosocial support, as well as annual screenings of thyroid and adrenal function.
Signs and symptoms
The signs and symptoms of POI can be seen as part of a continuum of changes leading to menopause. POI contrasts with age-appropriate menopause in the age of onset, degree of symptoms and sporadic return to normal ovarian function. As some women retain partial ovarian function, symptoms may not be as severe as regular menopause. In others, particularly with coexistent depression, symptoms such as decreased quality of life can be severe.
Hormonally, POI is defined by abnormally low levels of estrogen and high levels of FSH, which demonstrate that the ovaries are no longer responding to circulating FSH by producing estrogen and developing fertile eggs. The ovaries will likely appear smaller than normal.[medical citation needed] The age of onset can be as early as 11 years. POI can be seen as part of a continuum of changes leading to menopause that differ from age-appropriate menopause in the age of onset, degree of symptoms, and sporadic return to normal ovarian function. A contrasting problem can be when a girl never begins menstruation due to a genetic condition causing primary amenorrhea.
The cause of POI is idiopathic in 90% of cases. Some cases of POI are attributed to autoimmune disorders, genetic disorders such as Turner syndrome and Fragile X syndrome, metabolic defects, and enzyme defects. One study showed a strong correlation between incidence of POI and certain variants in the inhibin alpha gene.[medical citation needed] Chemotherapy and radiation treatments for cancer can sometimes cause POI. The effect of chemotherapy or radiation is variable and in a mouse model, with results consistent with observations in humans, cyclophosphamide can result in an 87% reduction in primordial follicles 72 hours after administration. Women who have had a hysterectomy tend to go through menopause early and have a nearly twofold increased risk of POI. Almost any pelvic surgery has the potential to damage the ovary by affecting its blood supply or causing inflammation in the area resulting in POI.
The pathogenic mechanisms of POI are highly heterogeneous and can be divided into four major categories: follicular migration defect early in embryogenesis; an early decrease in the primordial follicles; increased follicular death; and altered maturation or recruitment of primordial follicles. These result in a decrease of the ovaries general supply of eggs that normally lasts until an average age of 51 for age of age-appropriate menopause.
Genetic causes such as Turner syndrome have initial ovarian development but then ovaries degenerate rapidly during prenatal life, often leading to gonadal dysgenesis with streak ovaries. In those cases where POI is associated with adrenal autoimmunity, histological examination almost always confirms the presence of an autoimmune oophoritis in which follicles are infiltrated by lymphocytes, plasma cells, and macrophages that attack mainly steroid-producing cells and eventually result in follicular depletion.
In some women FSH may bind to the FSH receptor site, but be inactive. By lowering the endogenous FSH levels with ethinylestradiol (EE) or with a GnRH-a the receptor sites are free and treatment with exogenous recombinant FSH activates the receptors and normal follicle growth and ovulation can occur. (Since the serum Anti-Müllerian hormone (AMH) level is correlated with the number of remaining primordial follicles some researchers believe the above two phenotypes can be distinguished by measuring serum AMH levels.
Mutations in FOXL2 cause Blepharophimosis Ptosis Epicanthus inversus Syndrome (BPES). Premature ovarian failure is part of the BPES Type I variant of the syndrome but not of the BPES Type II variant.
DNA repair deficiency
BRCA1 protein plays an essential role in the repair of DNA double-strand breaks by homologous recombination. Women with a germline BRCA1 mutation tend to have premature menopause as evidenced by the final menorrhea appearing at a younger age. BRCA1 mutations are associated with occult POI. Impairment of the repair of DNA double-strand breaks due to a BRCA1 defect leads to premature ovarian aging in both mice and humans.
In addition to BRCA1, the MCM8-MCM9 protein complex also plays a crucial role in the recombinational repair of DNA double-strand breaks. In humans, an MCM8 mutation can give rise to premature ovarian failure, as well as chromosomal instability. MCM9, as well as MCM8, mutations are also associated with ovarian failure and chromosomal instability. The MCM8-MCM9 complex is likely required for the homologous recombinational repair of DNA double-strand breaks that are present during the pachytene stage of meiosis I. In women homozygous for MCM8 or MCM9 mutations, failure to repair breaks apparently leads to oocyte death and small or absent ovaries.
The diagnosis is based on age less than forty, amenorrhea for four months or more, and two elevated serum follicle-stimulating hormone (FSH) measurements at one-month intervals. The anterior pituitary secretes FSH and LH at high levels to try to increase the low estrogen levels that are due to the dysfunction of the ovaries. Typical FSH in POI patients is over 40 mlU/ml (post-menopausal range).
Between 5 and 10 percent of women with POI may become pregnant with no treatment. As of 2016 no fertility treatment has been found to effectively increase fertility in women with POI, and the use of donor eggs with in-vitro fertilization (IVF) and adoption are a means of achieving parenthood for women with POI. Some women with POI choose to live child-free.
Researchers have investigated the use of a hormone called dehydroepiandrosterone (DHEA) in women with POI to increase spontaneous pregnancy rates. Results from studies on DHEA in 2010 indicated that DHEA may increase spontaneously conceived pregnancies, decrease spontaneous miscarriage rates and improve IVF success rates in women with POI. This includes women referred for donor eggs or surrogacy in 2009. In 2018, there was no significant improvement in ovarian function by 12-month on DHEA supplementation in women with POI. Given the inconclusiveness of potential benefits and risks of testosterone and DHEA supplementation, longer-term, randomized studies are warranted for women and girls with POI.
Ovarian tissue cryopreservation can be performed on prepubertal girls at risk for premature ovarian failure, and this procedure is as feasible and safe as comparable operative procedures in children.
In 2013, Kawamura in Japan and his collaborators at Stanford University published treatment of infertility of POI patients by fragmenting ovaries followed by in vitro treatment of ovarian fragments with phosphatidylinositol-3 kinase activators to enhance the AKT pathway followed by autografting. They successfully promoted follicle growth, retrieved mature oocytes, and performed in vitro fertilization. Following embryo transfer, a healthy baby was delivered. A 2020 review covered variations including phosphatidylinositol-3 kinase activators to enhance the AKT pathway, fragmentation of ovarian cortex, combining those two into in-vitro activation (IVA), and drug-free IVA. Two laparoscopies are needed in conventional IVA and one with drug-free IVA.
Women with POI can develop symptoms of estrogen deficiency, including vasomotor flushes and vaginal dryness that respond to physiologic replacement of hormones. Most authorities recommend that this hormone replacement continue until age 50 years, the normal age of menopause. The leading hormone replacement regimen recommended involves the administration of estradiol daily by either skin patch or vaginal ring. This approach reduces the risk of pulmonary embolism and deep venous thrombosis by avoiding the first pass effect on the liver that is induced by oral estrogen therapy. The transdermal estradiol patch also provides the replacement by steady infusion rather than by bolus when taking daily pills.
Concerns of estrogen supplement are addressed in The US Medical Eligibility Criteria for Contraceptive Use, 2010 provides guidance for safety of contraceptive methods and include guidance for conditions associated with increased risk of thrombosis such as postpartum, history of thrombosis, thrombogenic mutations, systemic lupus erythematosus, diabetes, and hypertension. There is also an increased risk with valvular heart disease and cardiomyopathy.
To avoid the development of endometrial cancer young women taking estradiol replacement need also to take a progestin in a regular cyclic fashion. The most evidence supports the use of medroxyprogesterone acetate per day for days one through 12 of each calendar month. This will induce regular and predictable menstrual cycles. It is important that women taking this regimen keep a menstrual calendar. If the next expected menses is late it is important to get a pregnancy test. It this is positive, the woman should stop taking the hormone replacement. Approximately 5 to 10% of women with confirmed POI conceive a pregnancy after the diagnosis without medical intervention.
Infertility can be a result of this condition and is the most discussed problem resulting from it, but there are additional health implications of the problem, and studies are ongoing. For example, osteoporosis (decreased bone density) affects almost all women with POI due to an insufficiency of estrogen. There is also an increased risk of heart disease, hypothyroidism such as Hashimoto's thyroiditis, Addison's disease, and other autoimmune disorders.
The most common words women use to describe how they felt in the two hours after being given the diagnosis of POI are "devastated", "shocked," and "confused." The diagnosis is more than infertility and affects a woman’s physical and emotional well-being. Patients face the acute shock of the diagnosis, associated stigma of infertility, grief from the death of dreams, anxiety and depression from the disruption of life plans, confusion around the cause, shame, insecurity and lowered self-esteem, anger in reflection of being letdown by the medical system, symptoms of estrogen deficiency, worry over the associated potential medical sequelae such as reduced bone density and cardiovascular risk, and the uncertain future that all of these factors create. Women diagnosed with POI in their 20s have disproportionately reported experiencing dismissiveness, bias, and “not being taken seriously” by healthcare professionals.
There is a need for an evidence-based integrative medicine program to assist women with POI. Presently such a program does not exist in the community, but a community of practice has formed to address this deficiency. Women with POI perceive lower social support than control women, so building a trusted community of practice for them would be expected to improve their well being. Also, when having that social support, it often helps with reducing stress and having better coping skills. It is important to connect women with POI to an appropriate collaborative care team because the condition has been clearly associated with suicide related to the stigma of infertility. Suicide rates are known to be increased in women who experience infertility.
Fuller Albright et al. in 1942 reported a syndrome with amenorrhea, estrogen deficiency, menopausal FSH levels, and short stature. They used the term “primary ovarian insufficiency” to distinguished POI from ovarian insufficiency secondary to a primary failure of pituitary FSH and other hormonal secretion. POI has been described as a more accurate and less stigmatizing term than premature ovarian failure or premature menopause.
Chapter 28 of the early Qing dynasty work Fù Qīngzhǔ Nǚkē (《傅青主女科》Fù Qīngzhǔ's Gynecology) describes the cause and appropriate treatment for premature menopause. 年未老经水断 (niánwèilǎo jīngshuǐduàn) glosses as 'not yet old, menstrual water cut-off.'
- Santoro NF, Cooper AR (2016). Santoro NF, Cooper AR (eds.). Primary Ovarian Insufficiency A Clinical Guide to Early Menopause. Springer. pp. i–207. doi:10.1007/978-3-319-22491-6. ISBN 978-3-319-22490-9.
Each scientific chapter begins with a clinical vignette: 1. "I almost fell out of my chair!" 2. "I could not stop crying..." 3. "I felt like an old woman." 4. "Great! More bad news!" 5. "...just see what happened, and hope." 6. "You push yourself through the fog that is in your head." 7. "I was shocked. Considering I was only 28 years old..." 8. "She is overwhelmed and distraught." 9. "Despite this devastation..." 10. "...some women have more pronounced mood responses to hormonal changes than others." 11. "...could a scientist create more <eggs> from a skin biopsy?... Surely, this kind of technology should exist somewhere." and 12. "...night sweats, severe sleep disturbance, dry eyes, and memory loss."
- Pastore LM, Christianson MS, Stelling J, Kearnsa WG, Segars JH (January 2018). "Reproductive ovarian testing and the alphabet soup of diagnoses: DOR, POI, POF, POR, and FOR". Journal of Assisted Reproduction and Genetics. 35 (1): 17–23. doi:10.1007/s10815-017-1058-4. PMC 5758472. PMID 28971280.
- Kirshenbaum M, Orvieto R (November 2019). "Premature ovarian insufficiency (POI) and autoimmunity-an update appraisal". Journal of Assisted Reproduction and Genetics. 36 (11): 2207–2215. doi:10.1007/s10815-019-01572-0. PMC 6885484. PMID 31440958.
- Nelson LM (February 2009). "Clinical practice. Primary ovarian insufficiency". The New England Journal of Medicine. 360 (6): 606–14. doi:10.1056/NEJMcp0808697. PMC 2762081. PMID 19196677.
- Zhang C (March 2019). "The roles of different stem cells on premature ovarian failure". Current Stem Cell Research & Therapy. 15 (6): 473–481. doi:10.2174/1574888X14666190314123006. PMID 30868961. S2CID 76665931.
- Martin LA, Porter AG, Pelligrini VA, Schnatz PF, Jiang X, Kleinstreuer N, et al. (March 2017). "A design thinking approach to primary ovarian insufficiency". Panminerva Medica. 59 (1): 15–32. doi:10.23736/S0031-0808.16.03259-6. PMID 27827529.
- Cooper AR, Baker VL, Sterling EW, Ryan ME, Woodruff TK, Nelson LM (May 2011). "The time is now for a new approach to primary ovarian insufficiency". Fertility and Sterility. 95 (6): 1890–7. doi:10.1016/j.fertnstert.2010.01.016. PMC 2991394. PMID 20188353.
- Eckhardt S, Wellons, M (2016). "Chapter 1 Defining Menopause: What Is Early, What Is Late?". In Santoro NF, Cooper AR (eds.). Primary Ovarian Insufficiency A Clinical Guide to Early Menopause. Springer. pp. 1–17. doi:10.1007/978-3-319-22491-6. ISBN 978-3-319-22490-9.
- Allshouse AA, Semple AL (2016). "Chapter 3 Signs and Symptoms of Primary Ovarian Insufficiency". In Santoro NF, Cooper AR (eds.). Primary Ovarian Insufficiency A Clinical Guide to Early Menopause. Springer. pp. 40–49. doi:10.1007/978-3-319-22491-6. ISBN 978-3-319-22490-9.
- Welt CK (April 2008). "Primary ovarian insufficiency: a more accurate term for premature ovarian failure". Clinical Endocrinology. 68 (4): 499–509. doi:10.1111/j.1365-2265.2007.03073.x. PMID 17970776. S2CID 21359408.
- van Kasteren YM, Schoemaker J (1999). "Premature ovarian failure: a systematic review on therapeutic interventions to restore ovarian function and achieve pregnancy". Human Reproduction Update. 5 (5): 483–92. doi:10.1093/humupd/5.5.483. PMID 10582785.
- Ikhena DE, Robins JC (2016). "Chapter 8 IVF and Egg Donation: Special Considerations". In Santoro NF, Cooper AR (eds.). Primary Ovarian Insufficiency A Clinical Guide to Early Menopause. Springer. pp. 125–136. doi:10.1007/978-3-319-22491-6. ISBN 978-3-319-22490-9.
- Bevilacqua B (2016). "Chapter 10 Primary Ovarian Insufficiency (POI) and Mood Disorders". In Santoro NF, Cooper AR (eds.). Primary Ovarian Insufficiency A Clinical Guide to Early Menopause. Springer. pp. 145–138. doi:10.1007/978-3-319-22491-6. ISBN 978-3-319-22490-9.
- Foyouzi N, Green LJ, Camper SA (2016). "Chapter 2. Etiologies of Primary Ovarian Insufficiency". In Santoro NF, Cooper AR (eds.). Primary Ovarian Insufficiency A Clinical Guide to Early Menopause. Springer. pp. 19–35. doi:10.1007/978-3-319-22491-6. ISBN 978-3-319-22490-9.
- Tiosano D, Mears JA, Buchner DA (October 2019). "Mitochondrial Dysfunction in Primary Ovarian Insufficiency". Endocrinology. 160 (10): 2353–2366. doi:10.1210/en.2019-00441. PMC 6760336. PMID 31393557.
- Going through the menopause aged 11 BBC News 13 April 2018
- "OMIM - Online Mendelian Inheritance in Man". omim.org. Johns Hopkins University. 3 November 2020. Retrieved 4 November 2020.
An Online Catalog of Human Genes and Genetic Disorders
- Thakur, Mili; Feldman, Gerald; Puscheck, Elizabeth E. (January 2018). "Primary ovarian insufficiency in classic galactosemia: current understanding and future research opportunities". Journal of Assisted Reproduction and Genetics. 35 (1): 3–16. doi:10.1007/s10815-017-1039-7. ISSN 1573-7330. PMC 5758462. PMID 28932969.
- de Bruin JP, Bovenhuis H, van Noord PA, Pearson PL, van Arendonk JA, te Velde ER, et al. (September 2001). "The role of genetic factors in age at natural menopause". Human Reproduction. 16 (9): 2014–8. doi:10.1093/humrep/16.9.2014. PMID 11527915.
- Blumenfeld Z, Halachmi S, Peretz BA, Shmuel Z, Golan D, Makler A, Brandes JM (April 1993). "Premature ovarian failure—the prognostic application of autoimmunity on conception after ovulation induction". Fertility and Sterility. 59 (4): 750–5. doi:10.1016/S0015-0282(16)55854-3. PMID 8458491.
- Blumenfeld Z (September 2007). "Pregnancies in patients with POF gonadotropin stimulation and pretreatment with ethinyl estradiol". Fertility and Sterility. 88 (3): 763, author reply 763. doi:10.1016/j.fertnstert.2007.07.001. PMID 17681336.
- Méduri G, Massin N, Guibourdenche J, Bachelot A, Fiori O, Kuttenn F, et al. (January 2007). "Serum anti-Müllerian hormone expression in women with premature ovarian failure". Human Reproduction. 22 (1): 117–23. doi:10.1093/humrep/del346. PMID 16954410.
- "Blepharophimosis, ptosis, and epicanthus inversus syndrome". Medline Plus. Retrieved 10 November 2020.
- Rzepka-Górska I, Tarnowski B, Chudecka-Głaz A, Górski B, Zielińska D, Tołoczko-Grabarek A (November 2006). "Premature menopause in patients with BRCA1 gene mutation". Breast Cancer Research and Treatment. 100 (1): 59–63. doi:10.1007/s10549-006-9220-1. PMID 16773440. S2CID 19572648.
- Oktay K, Kim JY, Barad D, Babayev SN (January 2010). "Association of BRCA1 mutations with occult primary ovarian insufficiency: a possible explanation for the link between infertility and breast/ovarian cancer risks". Journal of Clinical Oncology. 28 (2): 240–4. doi:10.1200/JCO.2009.24.2057. PMC 3040011. PMID 19996028.
- Titus S, Li F, Stobezki R, Akula K, Unsal E, Jeong K, et al. (February 2013). "Impairment of BRCA1-related DNA double-strand break repair leads to ovarian aging in mice and humans". Science Translational Medicine. 5 (172): 172ra21. doi:10.1126/scitranslmed.3004925. PMC 5130338. PMID 23408054.
- Lee KY, Im JS, Shibata E, Park J, Handa N, Kowalczykowski SC, Dutta A (July 2015). "MCM8-9 complex promotes resection of double-strand break ends by MRE11-RAD50-NBS1 complex". Nature Communications. 6: 7744. Bibcode:2015NatCo...6.7744L. doi:10.1038/ncomms8744. PMC 4525285. PMID 26215093.
- AlAsiri S, Basit S, Wood-Trageser MA, Yatsenko SA, Jeffries EP, Surti U, et al. (January 2015). "Exome sequencing reveals MCM8 mutation underlies ovarian failure and chromosomal instability". The Journal of Clinical Investigation. 125 (1): 258–62. doi:10.1172/JCI78473. PMC 4382257. PMID 25437880.
- Wood-Trageser MA, Gurbuz F, Yatsenko SA, Jeffries EP, Kotan LD, Surti U, et al. (December 2014). "MCM9 mutations are associated with ovarian failure, short stature, and chromosomal instability". American Journal of Human Genetics. 95 (6): 754–62. doi:10.1016/j.ajhg.2014.11.002. PMC 4259971. PMID 25480036.
- Fauchereau F, Shalev S, Chervinsky E, Beck-Fruchter R, Legois B, Fellous M, et al. (May 2016). "A non-sense MCM9 mutation in a familial case of primary ovarian insufficiency". Clinical Genetics. 89 (5): 603–7. doi:10.1111/cge.12736. PMID 26771056. S2CID 33006407.
- Mamas L, Mamas E (August 2009). "Dehydroepiandrosterone supplementation in assisted reproduction: rationale and results". Current Opinion in Obstetrics & Gynecology. 21 (4): 306–8. doi:10.1097/gco.0b013e32832e0785. PMID 19610174. S2CID 23452697.
- Wong QH, Yeung TW, Yung SS, Ko JK, Li HW, Ng EH (May 2018). "The effect of 12-month dehydroepiandrosterone supplementation on the menstrual pattern, ovarian reserve markers, and safety profile in women with premature ovarian insufficiency". Journal of Assisted Reproduction and Genetics. 35 (5): 857–862. doi:10.1007/s10815-018-1152-2. PMC 5984890. PMID 29520734.
- Gleicher N, Weghofer A, Barad DH (November 2010). "Dehydroepiandrosterone (DHEA) reduces embryo aneuploidy: direct evidence from preimplantation genetic screening (PGS)". Reproductive Biology and Endocrinology. 8: 140. doi:10.1186/1477-7827-8-140. PMC 2992540. PMID 21067609.
- Mamas L, Mamas E (February 2009). "Premature ovarian failure and dehydroepiandrosterone". Fertility and Sterility. 91 (2): 644–6. doi:10.1016/j.fertnstert.2007.11.055. PMID 18321501.
- Joachim CM (2016). "Chapter 12 Hormone Replacement Therapy in Women with POI: A Patient's Perspective". In Santoro NF, Cooper AR (eds.). Primary Ovarian Insufficiency A Clinical Guide to Early Menopause. Springer. pp. 179–199. doi:10.1007/978-3-319-22491-6. ISBN 978-3-319-22490-9.
- Jadoul P, Dolmans MM, Donnez J (2010). "Fertility preservation in girls during childhood: is it feasible, efficient and safe and to whom should it be proposed?". Human Reproduction Update. 16 (6): 617–30. doi:10.1093/humupd/dmq010. PMID 20462941.
- Ferreri J, Fàbregues F, Calafell JM, Solernou R, Borrás A, Saco A, Manau D, Carmona F (February 2020). "Drug-free in-vitro activation of follicles and fresh tissue autotransplantation as a therapeutic option in patients with primary ovarian insufficiency". Reprod Biomed Online. 40 (2): 254–260. doi:10.1016/j.rbmo.2019.11.009. PMID 31956062. S2CID 210830148.
- Kawamura K, Cheng Y, Suzuki N, Deguchi M, Sato Y, Takae S, et al. (October 2013). "Hippo signaling disruption and Akt stimulation of ovarian follicles for infertility treatment". Proceedings of the National Academy of Sciences of the United States of America. 110 (43): 17474–9. Bibcode:2013PNAS..11017474K. doi:10.1073/pnas.1312830110. PMC 3808580. PMID 24082083.
- Kalantaridou SN, Nelson LM (2000). "Premature ovarian failure is not premature menopause". Annals of the New York Academy of Sciences. 900 (1): 393–402. Bibcode:2000NYASA.900..393K. doi:10.1111/j.1749-6632.2000.tb06251.x. PMID 10818427. S2CID 37586048.
- Tepper NK, Whiteman MK, Marchbanks PA, James AH, Curtis KM (December 2016). "Progestin-only contraception and thromboembolism: A systematic review". Contraception. 94 (6): 678–700. doi:10.1016/j.contraception.2016.04.014. PMID 27153743.
- American College of Obstetricians Gynecologists' Committee on Adolescent Health Care (November 2020). "Gynecologic considerations for adolescents and young women with cardiac conditions: ACOG Committee Opinion, Number 813". Obstet Gynecol. 136 (5): e90–e99. doi:10.1097/AOG.0000000000004133. PMID 33093425.
- Santoro NF, Wierman ME, Canty-Woessner C (2016). "Chapter 6 Nonreproductive Conditions Associated with Primary Ovarian Insufficiency (POI)". In Santoro NF, Cooper AR (eds.). Primary Ovarian Insufficiency A Clinical Guide to Early Menopause. Springer. pp. 101–114. doi:10.1007/978-3-319-22491-6. ISBN 978-3-319-22490-9.
- Groff AA, Covington SN, Halverson LR, Fitzgerald OR, Vanderhoof V, Calis K, Nelson LM (June 2005). "Assessing the emotional needs of women with spontaneous premature ovarian failure". Fertility and Sterility. 83 (6): 1734–41. doi:10.1016/j.fertnstert.2004.11.067. PMID 15950644.
- Orshan SA, Ventura JL, Covington SN, Vanderhoof VH, Troendle JF, Nelson LM (August 2009). "Women with spontaneous 46,XX primary ovarian insufficiency (hypergonadotropic hypogonadism) have lower perceived social support than control women". Fertility and Sterility. 92 (2): 688–93. doi:10.1016/j.fertnstert.2008.07.1718. PMC 2734403. PMID 18829005.
- Nelson LM (May 2011). "Synchronizing the world of women's health: young Turks and transformational leaders report for duty". Fertility and Sterility. 95 (6): 1902. doi:10.1016/j.fertnstert.2011.03.009. PMC 3153063. PMID 21841843.
- Nelson LM (May 2011). "One world, one woman: a transformational leader's approach to primary ovarian insufficiency". Menopause. 18 (5): 480–487. doi:10.1097/GME.0b013e318213f250. PMC 3115754. PMID 21686065.
- Sterling EW, Nelson LM (July 2011). "From victim to survivor to thriver: helping women with primary ovarian insufficiency integrate recovery, self-management, and wellness". Seminars in Reproductive Medicine. 29 (4): 353–61. doi:10.1055/s-0031-1280920. PMC 4350677. PMID 21969269.
- Kjaer TK, Jensen A, Dalton SO, Johansen C, Schmiedel S, Kjaer SK (September 2011). "Suicide in Danish women evaluated for fertility problems". Human Reproduction. 26 (9): 2401–7. doi:10.1093/humrep/der188. PMID 21672927.
- Beck-Peccoz P, Persani L (April 2006). "Premature ovarian failure". Orphanet Journal of Rare Diseases. 1: 9. doi:10.1186/1750-1172-1-9. PMC 1502130. PMID 16722528.
- Hubayter ZR, Popat V, Vanderhoof VH, Ndubizu O, Johnson D, Mao E, et al. (October 2010). "A prospective evaluation of antral follicle function in women with 46,XX spontaneous primary ovarian insufficiency". Fertility and Sterility. 94 (5): 1769–74. doi:10.1016/j.fertnstert.2009.10.023. PMC 2888894. PMID 19939372.
- Albright F, Smith PH, Fraser R (1941). "A syndrome characterized by primary ovarian insufficiency and decreased stature: report of 11 cases with a digression on hormonal control of axillary and pubic hair". Am J Med Sci. 204: 625–48. doi:10.1097/00000441-194211000-00001. S2CID 59095440.
- Qing-Zhu F (1992). Fu Qing-zhu's Gynecology. Translated by Yang S, Liu D. Boulder CO: Blue Poppy Press. ISBN 978-0-936185-35-4.
- Primary Ovarian Insufficiency (POI): Overview National Institutes of Health