Explanation

Primary ovarian insufficiency describes the development of primary hypogonadism prior to age 40. Common causes of primary ovarian insufficiency include Turner syndrome, fragile X syndrome, autoimmune ovarian failure, and toxins such as chemotherapeutic agents and radiation, but in up to 75–90% of patients, the cause remains unexplained. Manifestations of this condition include changes in the menstrual cycle (oligomenorrhea or amenorrhea), hot flashes, and vaginal dryness. Diagnosis is made by an elevated follicle-stimulating hormone level. While this condition had previously been referred to as premature ovarian failure, this definition has been changed as 50–75% of women can still have intermittent ovarian function. Importantly, 5–10% of women are able to become pregnant after the diagnosis. Unless there is an absolute contraindication to estrogen, all women with primary ovarian insufficiency should receive estrogen therapy. Goals of treatment for primary ovarian insufficiency include prevention of bone loss and osteoporosis, cardiovascular disease, urogenital atrophy, and to maintain sexual health and quality of life. Typical estrogen replacement regimens use transdermal estradiol or an estrogen ring, as these routes have potential advantages including a lower risk of venous thromboembolic disease. In women with an intact uterus, progesterone should be added for the prevention of endometrial hyperplasia and carcinoma. Either oral progesterone or the levonorgestrel intrauterine device can be used. However, standard therapy, which uses a lower dose of estrogen, does not provide effective contraception. An estrogen and progesterone oral contraceptive pill is an acceptable option that also includes contraception, and given this patient’s desire to avoid childbearing, it is the best treatment at this time. Hormone replacement in primary ovarian insufficiency patients should be continued until around age 51, the average of menopause.

While the estradiol patch (A) is standard treatment for estrogen replacement in primary ovarian insufficiency, it does not provide adequate contraception. If used for estrogen replacement in a primary ovarian insufficiency patient who desires contraception, an additional effective form of contraception should be used as well. In contrast, the levonorgestrel intrauterine device (C) is an excellent form of contraception, but would not provide the needed estrogen replacement. Using both the estradiol patch along with the levonorgestrel intrauterine device would be an alternative to the estrogen and progesterone containing oral contraceptive pill for estrogen replacement, endometrial protection, and contraception. No treatment necessary (D) is incorrect as this young patient needs estrogen replacement and contraception.