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Primary Ovarian Insufficiency (POI) Due to Cancer Treatment

This information will help you understand primary ovarian insufficiency (POI) and stay healthy while living with POI. 
 

Natural Menopause

Ovaries produce hormones (including estrogen) and store and release eggs. Girls are born with about 1 million eggs, but this number decreases as a woman ages. With the loss of eggs, it becomes harder for a woman to become pregnant. At some point between the ages of 40 and 50, there are so few eggs that women are no longer able to get pregnant naturally, even though they may still have monthly menstrual periods. 
 
Once a woman has less than 1,000 eggs, she begins menopause. The average age that women begin menopause in the United States is 51. At this time, estrogen production decreases, the ovaries stop releasing eggs, and monthly menstrual periods stop. In response to this decrease in estrogen, the body produces increasing amounts of follicle stimulating hormone (FSH). 
 

Primary Ovarian Insufficiency (POI)

POI develops when a woman’s ovaries stop working at an age younger than 40, before natural menopause. Other terms that are used to describe this include “premature ovarian failure” and “early menopause.”
 
When a woman develops POI:
 
  • Her ovaries will no longer produce estrogen.
  • She will begin producing more FSH.
  • She will no longer have monthly menstrual periods.
  • She will become infertile.
The loss of estrogen can cause a number of other changes in the body, including:
 
  • An increased risk of osteopenia or osteoporosis (loss of bone density), which can increase the risk of fractures.
  • An increased risk of heart disease.
  • Symptoms such as hot flashes, night sweats, sleep disturbance, and mood changes.
  • Vaginal dryness or pain during vaginal sex.
  • Emotional changes, such as anxiety or depression, related to the loss of fertility and to other changes in the body. 

The Risk of POI in Women Treated for Cancer

If a woman has surgery in which both ovaries are removed, this will always cause POI. Menopause begins right after surgery.
 
Some women receive cancer treatments that destroy their eggs. These women have an increased risk of developing POI. These treatments include certain chemotherapy medications and radiation therapy to the abdomen or pelvis. The chance that cancer treatment will cause POI depends on a number of factors, including:
 
  • Age at the time of treatment. Older women have fewer eggs at the start of treatment and will be more likely to begin menopause after treatment.
  • How well the ovaries are functioning before treatment. Some women have impaired ovarian function for other reasons, but may not know this if they had not tried to get pregnant before their treatment.
  • The type and dose of chemotherapy that was received.
  • The area of the body that was treated with radiation and the dose of radiation that was received.
Some women will develop POI during or immediately after their cancer treatment. Others will develop it years later. However, many women treated for cancer will not develop POI at all. It is hard to predict for sure if or when a woman will develop POI from cancer treatment. 
 
Ask your doctor or nurse if you are at risk for POI based on the cancer treatment you received. If you are, there are steps you can take to manage your health. These are discussed below.
 
Call your doctor or nurse if you develop any signs of POI, including:
 
  • Irregular periods for 3 months or longer
  • No periods for 3 months or longer
  • Hot flashes
  • Night sweats
  • Pain during vaginal sex

Managing POI

Hormone therapy

Your doctor may recommend hormone therapy to replace the hormones your body is no longer producing in their usual amounts. This will prevent many of the health effects of POI. 
 
If you have a uterus, your doctor will prescribe estrogen and progestin. If you have had a hysterectomy and no longer have a uterus, your doctor will prescribe only estrogen. Hormone therapy can be given in several different ways. Your doctor will recommend what is best for you.
 
Some women are concerned about taking estrogen because of various health risks. However, many of these risks are reported in women who take estrogen at an older age, after they reach menopause naturally. There is no evidence that these same risks occur in younger women who take hormones to replace those they would have naturally produced at their age. 
 
However, not all women can safely take hormone therapy. Hormone therapy is generally not recommended for women with:
 
  • Hormone-sensitive tumors (such as breast cancer)
  • A history of blood clots
  • Heart or cerebrovascular disease (e.g., history of heart attack, high blood pressure, stroke)
  • Liver disease
  • Unexplained vaginal bleeding
Talk with your doctor to see if hormone therapy is safe for you.
 

Other strategies 

There are a number of other ways you can stay healthy while living with POI. These are particularly important if you are not able to take hormone therapy. Review the suggestions below and discuss them with your doctor before you begin anything new.
 

Reduce your risk of osteopenia or osteoporosis

  • Take enough calcium to keep your bones strong. You need 1,200 mg of calcium a day.
    • Get at least half of this amount by eating foods high in calcium. Examples include dairy products and foods with added calcium, such as cereals.
    • If you are not able to get all of the calcium you need from your diet, take a supplement for the remaining amount. Read the label carefully to see how much “elemental” calcium is in each tablet. Check the serving size. If you take a multivitamin, be sure to count the amount of calcium in it. There are no health benefits to taking more calcium than needed; in fact, taking too much calcium may not be good for you.
  • Take enough vitamin D to absorb calcium. Most people need 800 to 1,000 IU a day.
    • Eat foods high in vitamin D. Examples include fatty fish (tuna, salmon, mackerel) and foods with added vitamin D, such as cereals.
    • If you are not able to get all of the vitamin D you need from your diet, take a supplement for the remaining amount. 
    • Expose your bare skin to sunlight for short periods of time, if this is a safe option for you.
  • Exercise regularly to strengthen your bones.
    • Do weight-bearing exercises, such as walking, jogging, aerobics, dancing, and stair climbing. Aim for 30 minutes a day.
    • Do muscle-strengthening exercises, such as using weights, bands, and machines. Aim for 2 to 3 times a week.
  • Ask your doctor or nurse if you should have a bone density test. This is used to see how strong your bones are.
  • For more information about osteoporosis, go to the National Osteoporosis Foundation website at: http://nof.org

Reduce your risk of heart disease

Minimize discomfort if you have hot flashes

  • Use fans and air conditioning to keep your surroundings cool.
  • Wear lightweight cotton clothing and dress in layers, so that you can remove them as needed.
  • Some women find acupuncture, meditation, and other forms of complementary therapy to be helpful. If you are interested in trying any of these therapies, call the MSK Integrative Medicine Service at (646) 888-0800.
  • There is no evidence that vitamins or herbs are helpful in treating hot flashes. However, there are nonhormonal medications that may help. Examples are venlafaxine (Effexor®), paroxetine (Paxil®), gabapentin, and clonidine. Talk with your doctor if you are interested in this option.

Improve your sleep routine

  • Create a regular sleep schedule that includes going to bed and getting up at the same time each day, even on weekends.
  • Keep your bedroom dark, cool, and quiet when going to sleep.
  • Avoid doing vigorous exercise for 3 hours before bedtime. However, stretching just before bedtime may be helpful.
  • Avoid caffeine after 2:00 pm (including chocolate and soft drinks with caffeine). Avoid heavy meals in the evening. Avoid drinking anything for 2 hours before bed so you do not have to use the bathroom in the middle of the night.
  • Use your bed and bedroom only for sleep or sexual activity.
  • If you are unable to fall asleep after 15 minutes, get out of bed and do something relaxing.
  • If these suggestions do not work, ask your doctor or nurse if sleep medication may be helpful.

Treat symptoms that can affect your sexual health

  • If you have pain during vaginal sex, a number of strategies can help.
    • Use a vaginal moisturizer 2 to 3 times a week to prevent or treat dryness and irritation.
    • Use a vaginal lubricant to prevent discomfort during any kind of sexual activity that involves vaginal penetration, including with fingers, vibrators, or sex toys. The MSK resource Vaginal Health lists a number of moisturizers and lubricants you may find helpful. Ask your nurse for a copy or go to: www.mskcc.org/cancer-care/patient-education/resources/vaginal-health
    • If you experience vaginal narrowing or tightness, ask your doctor or nurse if using a vaginal dilator may be helpful.
  • Ask your doctor or nurse if it is safe for you to use topical estrogen in your vagina. This comes as a tablet, cream, or ring that you place in your vagina to help the membranes thicken and regain moisture. Only a small amount of estrogen is absorbed into the rest of the body, but it is not recommended for women with certain types of cancer.
  • If these suggestions do not help, ask your doctor or nurse for a referral to the MSK Female Sexual Medicine and Women’s Health Program.
  • The American Cancer Society has an excellent resource called Sexuality for the Woman with Cancer. You can order it by calling 1-800-ACS-2345 or by going to: www.cancer.org/acs/groups/cid/documents/webcontent/002912-pdf.pdf

Explore your options for building a family

Many women want to have children after cancer treatment but do not know if they are fertile. We can refer you to specially trained gynecologists, called reproductive endocrinologists, who can evaluate your fertility.
 
If you hope to have a biological child and still have adequate ovarian function, consider starting your family early if you may lose your fertility at a young age. If you are not yet ready to start a family, and did not freeze eggs or embryos before treatment, you may want to consider egg or embryo freezing now in case you are not able to get pregnant naturally in the future.
 
If you already have POI and did not freeze eggs or embryos before treatment, you will not be able to have a biological child. This is distressing for many women, but keep in mind there are many other ways to build a family. When you are ready, you may want to explore using donor eggs or adoption.
 
For more information, ask your nurse for the resource Building Your Family: Options for Women Who Have Completed Cancer Treatment or go to: www.mskcc.org/cancer-care/patient-education/resources/building-your-family-options-for-women-who-have-completed-cancer-treatment. You can also see a fertility nurse specialist who can discuss your options in more detail. If you would like to talk with her, ask your doctor or nurse for a referral
 

Take steps to improve your emotional well-being

Many women with POI say they have a difficult time emotionally when they are first diagnosed. It may take time to accept the loss of fertility and other health effects. Explore the resources below to learn more about POI. Work with your doctor and nurse to manage your health. Taking control will enhance your feeling of well-being. However, if you find that you are having a hard time adjusting to these changes, or that feelings of anger or sadness related to infertility become overwhelming, last for weeks, or discourage you from taking the next steps, ask your doctor or nurse for help. A referral to the MSK Counseling Center for emotional support or taking medication for depression or anxiety may be helpful for you. 
 

Learn more about healthy living

MSK has a number of resources on healthy living (nutrition, exercise, tobacco treatment) to help you achieve your goals. You can find these resources on the Survivorship Center website at: www.mskcc.org/cancer-care/survivorship/healthy-living. If you want more guidance, ask your doctor or nurse for a referral.
 

Resources

The North American Menopause Society 
 
International Premature Ovarian Failure Association 
 
Women’s Health.gov