QuestionQUESTION: Dear Mr Ramirez I am writng from Birmingham in the uk.
I am 38 years of age and I have been trying to concieve for two years.
After experiencing irregual periods and sometimes having 3 4 month absences my hormone levels were tested and my fsh was shown to be 62 this was October 08, I am unsure of what my estrogen level was.
I was told that either I was experiencing pof or an early menopause.
The course of action I was given at that time to determine which I had was to take a months supply of hrt obviously the bleed at the end would not have accounted for anythng but the idea was to see if my periods came back after that.
They did come back for about 3 months and a day 21 progesterone test showed my level as 20 suggesting some kind of ovarian activity.
My gyno was very encouraged and said it showed that I was not in menopause and had pof instead he also said this shows that I still had a chance of concieving naturally.
I have been through a very confusing time since that appointment I have not been able to see that same gyno since.
I was told to take a month of hrt whenever my periods stop to try and spur them into action again and was told that if ever the hrt did not bring back my periods then that would show I was in menopause.
On the last go the hrt did not bring back my periods making me think I am in menopause I was told that if the hrt did not bring back my periods then I would have to go onto hrt permanently.
They have basically washed their hands of me at the clinic saying that they can,t diagnose me as being in menopause until two years have passed without periods.
They also said that I am jumping back onto the hrt too soon but I have waited up to 50 days for a period before commencing another month of hrt.
I suppose my question to you is is there any tests that can show whether I am in menopause or have pof and if that gynos words that I still have a chance naturally still stand.
Can they check me for follicles to see if there is any viable eggs or if there is indeed a good ovarian reserve there to work on.
Sorry if this has been a bit long but very confused at the moment just want to make sure that I have done verything in my power to make sure I can,t produce just one more child.
Also is it worth me seeing a reproductive endo.
I also have hypothyrodism.
Regards
Miss S Turner
ANSWER: Hello,
I'm sorry for the delay. I can't figure out exactly what your docs have been advising you. It doesn't make any sense to me, one way or the other.
The elevated FSH level is definitely concerning. It needs to be confirmed and should have been done on cycle day #2 or 3 of the first available menstrual cycle. If you are not having periods any more, then a random FSH can be done (done at any time in the cycle). If that level is greater than 20, then your ovaries have shut down and you are menopausal. The only difference between that an premature ovarian failure, is pof occurs in women under the age of 40 (as in your case). Otherwise, the net effect is the same. The ovaries have shut down. In that case, you cannot conceive naturally and have to use an egg donor. Having a period is not a sign of the lack of menopause. You can have breakthrough bleeding or dysfunctional bleeding, which are caused by a lack of hormones, not the result of ovulation.
My recommendation is to see a reproductive specialists immediately if you are contemplating having children. If there is still ovarian function, then you need to do IVF to give yourself the highest chances of pregnancy in the quickest period of time. Other tests that might be done to check your ovaries include a antral follicle count and anti-mullarian factor hormone level.
Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.
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QUESTION: Dear Mr Ramirez thank you very much for your reply.
I don,t think that I maybe explained properly exactly what I have been advised by my gyno.
What he told me was that sometimes the ovaries can shut down for whatever reason and because of this the pituitary gland is desperately sending out more and more fsh to try and spur the ovaries into action and they are not responding hence the high fsh.
I was told that by taking a month of hrt it will switch off the pituitary gland and give the ovaries a rest from this constant hammering and that sometimes after this rest the ovaries start working again on their own.
I was told if I was in menopause the ovaries would not respond to this but because I did get my periods back after the hrt for about 3 months it showed that I had pof not menopause I was also told that if I didn,t get my periods back then they would be able to confirm menopause with a laproscopy.
My gyno said that because the hrt brought back my periods it showed that I have eggs so I am not in menopause.
Of course I also had the day 21 progesterone test which showed a level of 20 and my gynos words were well something happened.
I was also told by one gyno that I can continue to take a month of hrt whenever my periods stop as long as I want but if ever the hrt doesn not bring back my periods then that would show I am in menopause and that I need to go on hrt permanently but on the last go the hrt didn,t bring my periods back obviously I get the bleed at the end of the hrt but of course that counts for nothing its any further bleeds that count.
Does this make any more sense to you at all.
I have now been advised to stay off hrt for 2 months and then just go and get my hormone levels tested again and if my levels show menopausel then go on hrt permanently.
I sort of feel as though I was given false hope.
does it make any sense to you now the regime with the hrt.
Thank you and look foward to hearing off you.
Miss S Turner
AnswerHello Again
1. The first paragraph is correct. The pituitary sends FSH to the ovary to stimulate ovulation. If the ovary does not pick up the hormone from the blood stream, the level is increased. I tell my patients to think of the ovary as a ball with lots of holes in it. If the holes are plugged up, the FSH can't get into the ovary and hence the FSH levels in the blood stream are elevated.
2. The exact cause of POF is unknown. Most think that it is an autoimmune problem, whereby somehow the body is shutting down the ovary. However, pregnancies have occurred in POF patients from random spontaneous ovulation. If your doc thinks this will work, then it is worth a try, but his explanation for it "the pituitary increases the amount of FSH to stimulate the ovary and bombards the ovary" is not correct. The problem is that the ovary is not picking up the FSH so the levels are increased. Fertility medications work by "bombarding" the ovary with increased FSH. The pituitary does not do that. It sends a steady stream. Laparoscopy CANNOT diagnose menopause. It is a purely clinical and hormonal diagnosis.
3. In order to have a period on HRT, you need to be cycled i.e. take estrogen and then progesterone. In a young woman, the best method for HRT and cycling is the birth control pill. DO NOT USE menopausal hormone replacement drugs. It is too low for a young woman and you won't get adequate estrogen replacement.
4. POF is NOT due to the lack of eggs. It is due to the lack of ovarian stimulation/function.
5. If you are indeed in POF, then you need to take estrogen and progesterone because your ovaries are not making them. The lack of these hormones will have long term detrimental effects. If you want to get pregnant, then you need to see a reproductive specialist as soon as possible. Sometimes, in the early evoluation of POF, the ovary can still be stimulated with HIGH dose FSH, which can lead to pregnancy. Sometimes, as it did with you previously, it can rebound and ovulate. You want to be doing the optimal treatment method for pregnancy to ensue if either of these occur. That optimal treatment method is IVF because it performed 7 of the 9 steps required to get pregnant and has the highest chances of pregnancy. That is what I would advise.
Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.
