Incidence and factors associated with premature ovarian insufficiency: a population-based cohort study

What is the incidence of premature ovarian insufficiency (POI) and its associated factors in Ontario, Canada, between 1995 and 2019?

The incidence of POI increased after 2011, driven primarily by non-iatrogenic POI, and was highest among women with a history of endometriosis.

Recent estimates suggest a global POI prevalence of ∼3.7%, with increasing rates over time. POI has heterogeneous etiologies, including genetic, autoimmune, infectious, and iatrogenic causes; however, the cause remains unknown in ∼70% of non-iatrogenic cases. Existing incidence estimates are limited by recall bias, cross-sectional designs, small sample sizes, and limited assessment of associated factors.

This population-based cohort study included all women aged ≤ 39 years residing in Ontario between 1995 and 2019. Follow-up continued until POI diagnosis, age 40 years, death, loss of provincial health insurance, or end of the study period.

POI was defined using administrative health data as a diagnosis occurring before age 40 years identified by either (i) surgical menopause or (ii) ≥1 physician consultation coded as menopause (ICD-9 627). Annual incidence rates (IRs) were calculated using census data, with the Ontario female population aged ≤ 39 years as the denominator. POI was classified as non-iatrogenic, surgical, post-chemotherapy and/or radiotherapy, or combined surgical with chemotherapy and/or radiotherapy. Associations between clinical factors and POI were estimated using age-adjusted modified Poisson regression to derive incidence rate ratios (IRRs).

Among 3 635 702 eligible women, 168 173 developed POI from any etiology (IR 389.4 per 100 000 person-years). Median follow-up was 11 years (IQR 6-18), and median age at POI diagnosis was 31 years (IQR 25-36). IRs were 351.4 per 100 000 person-years for non-iatrogenic POI, 30.2 for surgical POI, 5.5 for post-chemotherapy and/or radiotherapy POI, and 2.3 for combined surgical with chemotherapy and/or radiotherapy POI. Overall POI incidence declined between 2002 and 2008, followed by a sustained increase through 2019, largely attributable to non-iatrogenic POI. The incidence of surgically induced POI decreased from 60 per 100 000 person-years in 1995 to 20 in 2019, while combined surgical with chemotherapy and/or radiotherapy POI increased steadily over the study period. Factors associated with higher POI incidence included endometriosis (IRR 3.45, 95% CI 3.39, 3.52), cancer treated with chemotherapy or radiotherapy (IRR 2.01, 95% CI 1.89, 2.14), drug or tobacco use (IRR 1.59, 95% CI 1.51, 1.67), chromosomal disorders (IRR 1.50, 95% CI 1.42, 1.59), and autoimmune diseases (IRR 1.19, 95% CI 1.17, 1.22).

Use of administrative health data may result in outcome misclassification and limited availability of detailed clinical and demographic information.

These findings provide contemporary population-based estimates of POI incidence and identify endometriosis as a major associated factor. The marked decline in surgically induced POI over time suggests increased adoption of ovarian-preserving surgical approaches, while rising non-iatrogenic POI incidence underscores the need for improved risk stratification, counselling, and further studies to elucidate underlying mechanisms and modifiable risk factors.

Canadian Menopause Society.

Nothing to disclose.

N/A.