Ovarian depletion syndrome is the premature termination of ovarian function in women under 40 years of age who previously had normal menstrual and reproductive function. Ovarian depletion syndrome is manifested by secondary amenorrhea, infertility, and vegetative-vascular disorders. Diagnosis of ovarian depletion syndrome is based on data from functional and drug tests, hormone levels, ultrasound, laparoscopic biopsy of the ovaries. HRT, physiotherapy, vitamin therapy are used in the treatment. To achieve pregnancy, patients with ovarian depletion syndrome require IVF with the help of donor oocytes.
Ovarian depletion syndrome in gynecology is also referred to as “premature menopause”, “premature menopause“, “premature ovarian insufficiency”. The frequency of its occurrence in the population is about 1.6%; among various forms of secondary amenorrhea – up to 10%. With this syndrome, initially normally formed and functioning ovaries stop functioning earlier than the expected menopause.
Among the hypotheses explaining the etiology of ovarian depletion syndrome, there are theories of chromosomal abnormalities, autoimmune disorders and the effects of iatrogenic factors. These disorders cause the formation of ovaries with congenital deficiency of the follicular apparatus, pre- and post-pubertal destruction of germ cells, disorders of hypothalamic regulation.
In almost half of cases, patients with ovarian depletion syndrome have a burdened family history – late menarche, oligomenorrhea, amenorrhea, early menopause in their mother or sisters. Ovarian wasting syndrome is often associated with autoimmune hypothyroidism and other immunological diseases.
Intrauterine damage to the follicular apparatus caused by gestosis, extragenital pathology of the mother, drugs with teratogenic effects, radiation, chemicals may contribute to the development of resistant ovarian syndrome in the future. In the postnatal period, damage to the gonads and their replacement with connective tissue can be caused by rubella viruses, mumps, influenza, streptococcal infection (chronic tonsillitis), starvation, vitamin deficiency, frequent stress.
In some cases, the development of ovarian depletion syndrome is preceded by subtotal resection of the glands for an endometrioid cyst or ovarian cystoadenoma. Often, ovarian resection due to their cystic degeneration is resorted to in the process of conservative myomectomy or operations for ectopic pregnancy. Such not always unjustified actions subsequently lead to a decrease in the follicular reserve of the ovaries and their depletion. With the abrupt cessation of hormone production by the ovaries, the synthesis of gonadoliberin increases by the feedback mechanism, and, consequently, gonadotropic hormones, therefore, a hypergonadotropic form of amenorrhea develops with ovarian depletion syndrome.
The clinic of ovarian exhaustion syndrome develops more often at the age of 36-38 years, although it may manifest earlier. Against the background of the timely onset of menarche, normal menstrual and generative function, oligomenorrhea and secondary amenorrhea suddenly or gradually develop. Persistent cessation of menstruation is accompanied by vegetative symptoms: “hot flashes” to the upper half of the trunk, sweating, weakness, fatigue, irritability, headache, cardialgia.
With the syndrome of ovarian exhaustion, there is a depression of the emotional state, sleep disorders, and a decrease in working capacity. Hypoestrogenism leads to progressive atrophic changes in the mammary glands and genitals (atrophic colpitis), a decrease in bone density (osteoporosis), urogenital disorders. Often, patients develop dry eye syndrome.
The objective status of patients with ovarian depletion syndrome is characterized by a correct physique, typical of the female phenotype. The anamnesis notes the timeliness of menarche, the preservation of menstrual and reproductive function for 15-20 years. Vaginal and bimanual examination determines the dryness of the vaginal mucosa, a decrease in the size of the uterus. Functional tests reveal a negative symptom of the “pupil”, a cervical index of 0-1 points, a monophasic character of the basal temperature.
Transvaginal ultrasound scanning allows the gynecologist to assess the size and structure of the uterus and ovaries. With ovarian depletion syndrome, the uterus is reduced in anteroposterior and transverse dimensions, corresponding to the II st. of genital infantilism; it has a homogeneous structure. Ovaries are also reduced, homogeneous structure, follicles are not visualized. During diagnostic laparoscopy, small wrinkled ovaries are determined, in which the yellow body and follicles are not visible. The cortical layer is completely replaced by connective tissue. Histological examination of the ovarian biopsy confirms the absence of follicular reserve.
Hormonal studies with ovarian depletion syndrome reveal an increase in gonadotropins, especially FSH, with a sharp decrease in estradiol levels. For an in-depth assessment of the preservation of ovarian function, hormonal tests are carried out (a test with progesterone, estrogens and progestogens, dexamethasone, clomiphene, estradiol, LH-RG). In response to a test with progesterone, there is no menstrual-like reaction in ovarian depletion syndrome. The estrogen-progestogenic test is accompanied by the appearance of menstrual-like bleeding 3-5 days after the withdrawal of drugs, thereby confirming the hypofunction of the ovaries while maintaining the reactivity of the endometrium.
To predict the risk of osteoporosis, coronary heart disease and atherosclerosis in ovarian depletion syndrome, diagnostic parameters of bone metabolism, densitometry, determination of cholesterol and lipoproteins are additionally studied. Carrying out a complete diagnostic complex makes it possible to differentiate the syndrome of ovarian exhaustion from pituitary tumors, resistant ovarian syndrome.
Therapy for ovarian depletion syndrome is aimed at correcting vegetative-vascular and estrogen–deficient conditions – general well-being, urogenital disorders, osteoporosis, cardiovascular pathology. The best results are achieved when HRT is prescribed in the contraceptive mode until a woman reaches the age of natural menopause. Young women are prescribed a combination of ethinyl estradiol with desogestrel, gestodene or norgestimate; older women are prescribed estradiol with didrogesterone, ciproterone, levonorgestrel or linestrenol. HRT drugs can be taken orally, administered intramuscularly or percutaneously. For the treatment of genitourinary disorders, local administration of estrogens in the form of candles and ointments is used.
Along with HRT, with ovarian exhaustion syndrome, physiotherapy procedures (electrophoresis, electroanalgesia), hydrotherapy (circular shower and Charcot shower, carbon dioxide, iodine-bromine, pearl, coniferous, radon baths), massage of the cervical-collar zone, acupuncture, physical therapy, psychotherapy are indicated. It is advisable to prescribe vitamin therapy, herbal sedatives, phytoestrogens.
Prognosis and prevention
In exceptional cases (less than 5-10%), patients with ovarian depletion syndrome after prolonged amenorrhea have spontaneous ovulation recovery and even the onset of pregnancy. Basically, with ovarian depletion syndrome, IVF using a donor egg is indicated. Pregnancy management in this category of patients is carried out in specialized centers of reproduction.
The system of measures for the prevention of ovarian depletion syndrome should include the exclusion of teratogenic effects on the fetus during pregnancy, as well as the effects of adverse environmental factors and infectious agents on a growing girl. When performing ovarian resection, one should strive to maximize the preservation of the cortical layer containing the reserve of primordial follicles.