Subjective
Date of visit
Reason for visit (follow-up for POI, evaluation of new symptoms)
Current symptoms:
Menstrual cycle changes:
Amenorrhea (absence of periods for at least 6 months in women under 45)
Oligomenorrhea (infrequent or irregular periods)
Vasomotor symptoms (hot flashes, night sweats) – common in POI
Vaginal dryness and dyspareunia (painful intercourse)
Mood changes (irritability, depression, anxiety) – may occur
Difficulty concentrating or memory problems (less common)
Reduced libido (sex drive)
Fertility concerns (inability to conceive naturally)
Changes in sleep patterns or energy levels
Impact of symptoms on daily life and emotional well-being
Objective
Vital signs (temperature, blood pressure, heart rate)
Physical exam:
General (assessing for signs of hormonal imbalance)
Breast exam (assessing for breast tissue changes)
Laboratory Tests
Follicle-stimulating hormone (FSH): elevated in POI (diagnostic test)
Estradiol level: low in POI
Luteinizing hormone (LH): may also be elevated in POI
Thyroid stimulating hormone (TSH) and free thyroxine (fT4): to rule out thyroid dysfunction (can mimic POI symptoms)
Prolactin level: to rule out hyperprolactinemia (another cause of menstrual irregularities)
Additional Tests (may be ordered depending on clinical presentation):
Pelvic ultrasound: to assess ovarian size and exclude other causes of amenorrhea
Assessment
Primary ovarian insufficiency confirmed (based on elevated FSH, low estradiol, and clinical presentation)
Age at onset of symptoms (early vs. late POI)
Severity of symptoms and impact on quality of life
Evaluation for potential causes (genetic predisposition, autoimmune disease) – may require further investigation
Plan
Treatment plan based on individual needs and preferences:
Hormone replacement therapy (HRT): with estrogen and progesterone to manage menopausal symptoms and prevent long-term complications (osteoporosis, cardiovascular disease)
Vaginal lubricants or moisturizers for vaginal dryness
Referral to a mental health professional (if mood changes are significant)
Genetic counseling (if considering future fertility options)
Education
Explain primary ovarian insufficiency, a condition where the ovaries stop functioning prematurely.
Discuss the reasons for amenorrhea and other symptoms.
Review the benefits and risks of hormone replacement therapy.
Discuss the impact of POI on fertility and explore options (egg donation, surrogacy) for those who desire pregnancy.
Provide information about healthy lifestyle choices (diet, exercise) to manage symptoms and long-term health.
Offer resources for support groups or patient advocacy organizations.
Follow-up
Schedule for follow-up appointments:
Monitor response to HRT and adjust regimen as needed
Address any ongoing challenges or concerns
Bone density scans (to assess for osteoporosis risk)
Cervical cancer screening (important for all women regardless of menopausal status)
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of primary ovarian insufficiency.