Ovaries

Ovaries: Anatomy, Physiology, Assessment, and Associated Health Conditions

Overview and Definition

The ovary is the female gonad — a paired intraperitoneal endocrine organ typically found in the lower left and right quadrants of the abdomen, respectively. The ovaries play a fundamental role in reproduction as well as the production of hormones. Together, the two ovaries constitute the central organs of the female reproductive endocrine system, integrating signals from the brain to coordinate the menstrual cycle, fertility, and lifelong hormonal health.

The female, or ovarian, reproductive system functions to produce gametes and reproductive hormones; however, it also has the additional task of supporting the developing fetus and delivering it to the outside world.

Anatomy and Structure

Gross Anatomy

The ovaries are small, oval-shaped, and grayish in color, with an uneven surface. The actual size of an ovary depends on the woman's age and hormonal status; covered by a modified peritoneum, they are approximately 3–5 cm in length during childbearing years and become much smaller, then undergo atrophy, once menopause occurs.

The ovaries are located in the lateral wall of each side of the pelvis in a region called the ovarian fossa. The fossa usually lies beneath the external iliac artery and in front of the ureter and internal iliac artery. The ovaries are attached to the uterus via the ovarian ligament, which runs in the broad ligament.

Microscopic Structure and Follicular Architecture

A cross-section of the ovary reveals many cystic structures that vary in size. These structures represent ovarian follicles at different stages of development and degeneration.

At birth, ovaries contain about 1–2 million primordial follicles. By puberty, this number decreases to around 300,000–400,000. Only a tiny fraction of the tens of thousands of ovarian primordial follicles initially present at birth will survive to mature, produce vital hormones, and ovulate. The remaining pool of ovarian follicles, termed the ovarian reserve (OR), provides important insights for the assessment of ovarian function and indicates a woman's maximum reproductive potential and the time remaining until menopause.

Granulosa cells and theca cells found in the ovary secrete multiple hormones, including estrogen and progesterone. Cooperation of theca and granulosa cells at the ovarian level and the formation of the corpus luteum are defining features of ovarian function, and the significance of growth factors and cytokines is central to this process.

Physiological Functions

Hormone Production

The first function of the ovary is hormone production, which changes at puberty. The ovaries begin to secrete increasing levels of hormones, including estrogen, testosterone, inhibin, and progesterone, in response to rising levels of gonadotropin-releasing hormone (GnRH). This activity creates the hypothalamus-pituitary-ovarian (HPO) axis.

Many events in the adult ovary are controlled by two hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), secreted from the anterior pituitary gland under the control of pulses of GnRH from the hypothalamus. Low-frequency GnRH pulses stimulate a slight increase in FSH levels early in a woman's menstrual cycle, enhancing follicle growth, while high-frequency GnRH pulses lead to a sharp rise in LH levels just before mid-cycle — an event known as the "LH surge."

The ovary responds to gonadotropin stimulation in dual fashion: secretion of sex steroids and the liberation of a fertilizable oocyte. In addition, the ovary is also able to secrete peptide hormones such as inhibin and activin. Sex steroids and inhibin modulate the pulsatile secretion of GnRH and gonadotropins, forming a tightly regulated feedback loop.

The Menstrual Cycle: Follicular and Luteal Phases

Throughout both phases, hormonal feedback loops involving FSH, LH, estradiol, and progesterone tightly regulate ovarian function. FSH promotes follicular development during the early follicular phase, while LH is crucial for ovulation and corpus luteum formation in the luteal phase. Estradiol dominates during the follicular phase, promoting endometrial growth and preparing for ovulation. Progesterone takes over in the luteal phase to support endometrial maturation for potential pregnancy.

The ovary is actively involved in maintaining cyclicity, as reflected by the processes of follicular growth, follicle rupture, and formation of the corpus luteum, with the dramatic morphological changes involved.

The corpus luteum, a temporary endocrine organ, takes its place in the ovary and secretes large amounts of progesterone along with smaller amounts of inhibin A and estradiol. This hormonal production protects the oocyte and allows time for the sperm and egg to meet and implant before menstruation. If fertilization occurs, the newly formed blastocyst will secrete human chorionic gonadotropin (hCG), which signals the corpus luteum to continue secreting progesterone. This function will be taken over by the placenta once it has matured. If fertilization does not occur, then the corpus luteum will degenerate into the corpus albicans, and the withdrawal of progesterone will start the process of menstruation.

Studies have suggested that some women experience multiple "waves" of follicular development within a single cycle. While most cycles involve one dominant follicle that ovulates mid-cycle, some women may have two or even three waves of antral follicles developing throughout their cycle.

Oocyte Production and Gametogenesis

The ovaries are the female gonads. The gamete they produce is called an oocyte. Usually, the ovaries take turns releasing eggs every month; however, if one ovary is absent or dysfunctional, the other ovary releases eggs every month.

Systemic Effects of Ovarian Hormones

Functional ovaries are necessary to maintain fertility as well as hormonal balance during the reproductive years. Problems with the ovaries can lead to systemic issues including anemia, increased risk for cardiac disease, and pain. Ovarian function has relevance to wider aspects of women's health, most clearly established for bone health, but likely also having implications for cardiovascular and cognitive function, and overall lifespan.

Premature ovarian failure, or premature menopause, brings a multitude of problems other than infertility. It brings symptoms of menopause and reduces the benefits of estrogen.

Assessment of Ovarian Function and Health

Clinical and Laboratory Markers

Assessment of ovarian function relies on the use of surrogate markers such as follicle-stimulating hormone (FSH), inhibin-B, and anti-Müllerian hormone (AMH), as well as ultrasound assessment of ovarian volume and antral follicle count.

The dynamic nature of ovarian function means that there are large variations in conventional markers of ovarian activity, notably estradiol and FSH. These largely reflect the latest stages of follicle growth in relation to ovulation, and it has been the advent of the measurement of anti-Müllerian hormone (AMH) that has given the opportunity to explore ovarian activity in terms of its smaller follicles.

The usefulness of AMH for the quantitative evaluation of ovarian reserve has been established, and serum AMH has been recently applied to the assessment of ovarian reserve outside infertility treatment. Follicle-stimulating hormone (FSH), a widely used marker, was found to be insufficient for predicting ovarian reserve after IVF. Among newly developed ovarian reserve tests, the serum level of AMH has been recognized as an improved and informative marker.

Primary outcome measures used in research settings include AMH levels, FSH levels, and antral follicle count (AFC). Secondary outcomes include the change in mean ovarian volume, menstruation recovery, and pregnancy rate.

Imaging

Ultrasound is one of the most common modes of evaluating ovaries. Laparoscopic procedures also provide valuable information if other modalities fail to provide answers. On physical examination, healthy ovaries are palpable; however, depending on anatomical variation and body habitus, it may not be easy to palpate them. Ovaries that contain cysts may be easier to feel.

Lifestyle Factors Supporting Normal Ovarian Function

Personalized dietary therapy and weight loss, if required, are first-line treatments for young women with PCOS and obesity. In women with obesity, weight loss of at least 5% can improve hyperandrogenism, insulin resistance, fertility, and menstrual function. Dietary therapy prevents infertility, restores normal body mass, improves physiology, and preserves ovarian health.

Data from systematic reviews suggest that a simple nutritional approach for reproductive health would be to adopt a Mediterranean diet.

Nutrients, Herbs, and Natural Ingredients

The following section reviews both the traditional use and scientific evidence for nutrients and botanicals studied in the context of ovarian health. Traditional use and scientific evidence are explicitly separated under each entry. Evidence strength is characterized as accurately as the available literature permits.

Myo-Inositol and D-Chiro-Inositol

Traditional Use

Inositols are naturally occurring polyols found in fruits, beans, grains, and nuts. They were not historically used in the same manner as classical herbal medicines but have a background as naturally occurring dietary constituents. Myo-inositol is a natural molecule present in fruits and vegetables that participates in FSH signaling, which orchestrates ovulation.

Scientific Evidence

Natural molecules derived from herbal medicines and nutritional supplements, including inositol, have been shown to play a therapeutic role in ameliorating inflammation and insulin sensitivity, restoring ovarian function, maintaining regular hormonal balance, and normalizing the menstrual cycle. Oral supplementation with myo-inositol has been shown to improve hyperandrogenism and menstrual cycles, and restore spontaneous ovulation in women with PCOS.

Inositol lowers insulin resistance, improves reproductive function, improves oocyte quality, and restores ovulation in patients with PCOS, according to published reviews. Inositols had the best results among included nutraceuticals to ameliorate HOMA-IR, fasting blood glucose, fasting insulin, triglycerides, total cholesterol, and LDL-C, and were correlated with improvements in BMI. There was no significant difference between the CoQ10 or vitamin E group and the placebo group in ameliorating lipid metabolism, and vitamin D had no positive effects in ameliorating hyperandrogenism, BMI, or glycolipid metabolism profiles compared with placebo. For women with PCOS, inositol supplementation showed advantages in increasing SHBG and improving glycolipid metabolism compared with nutraceuticals like CoQ10, vitamin E, and vitamin D.

Evidence strength: Multiple randomized controlled trials and meta-analyses support inositol's effects on ovulatory function and metabolic parameters specifically in women with PCOS. Evidence is strongest for this population; data in women without PCOS are limited.

Coenzyme Q10 (CoQ10)

Traditional Use

CoQ10 is an endogenous fat-soluble benzoquinone with no historical use as a botanical remedy. Its application to ovarian and reproductive health is an entirely modern development grounded in biochemistry and clinical research.

Scientific Evidence

CoQ10 is among the most consumed nutritional supplements and has both antioxidant and pro-oxidant activity. Insufficient CoQ10 levels are associated with increased oxidative stress, mitochondrial damage, lower ROS counteraction, less ATP synthesis, and subsequent mitochondrial dysfunction. In infertility treatments, CoQ10 supplementation may significantly ameliorate women's oocyte quality, alter the ovarian environment, and promote oocyte development by enhancing mitochondrial function and decreasing oxidative stress.

Decrease in CoQ10 level is commonly observed in individuals in their late 30s and appears to co-occur with the age-related decline in fertility and increased rate of embryo aneuploidy, suggesting a contribution of the reduced expression of CoQ10 to ovarian ageing. Several animal studies have demonstrated that CoQ10 protects ovarian reserve, counteracts physiological ovarian ageing by restoring mitochondrial function, and increases the rate of embryo cleavage and blastocyst formation.

A prospective, randomized controlled study included 186 consecutive patients with poor ovarian reserve parameters (age <35). The participants were randomized to CoQ10 pre-treatment for 60 days preceding an IVF-ICSI cycle or no pre-treatment. A total of 169 participants were evaluated. The baseline demographic and clinical characteristics were comparable between groups. CoQ10 pretreatment resulted in significantly lower gonadotrophin requirements and higher peak estradiol levels. Women in the CoQ10 group had an increased number of retrieved oocytes, higher fertilization rate (67.49%), and more high-quality embryos (p < 0.05).

The conclusion of this RCT was that pretreatment with CoQ10 improves ovarian response to stimulation and embryological parameters in young women with poor ovarian reserve in IVF-ICSI cycles. Further work is required to determine whether there is an effect on clinical treatment endpoints such as live birth rate.

With regard to supplements to treat poor ovarian response to ovarian stimulation, starting CoQ10 before cycle commencement is better than control therapies. CoQ10 may have some merit, although it is unclear whether its place is specifically for older women, for those with a poor response to ovarian stimulation, or for poor embryonic development.

Evidence strength: Preliminary to moderate. RCT evidence supports improvements in intermediate markers (oocyte number, embryo quality) in women with poor ovarian reserve, but trials are generally small and inconsistent on live birth rates as an endpoint. Effect in women with normal ovarian reserve is not established.

Vitamin D

Traditional Use

Vitamin D has no classical use as a botanical or herbal remedy in the context of reproductive health. Its relevance to ovarian biology was identified through 20th- and 21st-century biochemical and epidemiological research.

Scientific Evidence

Vitamin D is a fat-soluble steroid hormone with essential physiological functions beyond calcium and bone metabolism. In recent years, its role in women's reproductive health has gained attention, influencing ovarian function, follicular development, endometrial receptivity, and steroid hormone regulation. Vitamin D deficiency has been linked to reproductive disorders such as PCOS, endometriosis, and infertility.

The presence of vitamin D receptors and vitamin D metabolising enzymes in female reproductive tissue implies a possible reproductive function. A potential relationship between vitamin D deficiency and anovulatory infertility as a symptom of PCOS was identified in a large prospective observational study, where 70.3% of infertile women with PCOS had vitamin D levels <20 ng/ml and 90.6% had levels <30 ng/ml.

The consistent association between deficiencies in vitamin D and premature ovarian insufficiency (POI), alongside the potential to influence ovarian reserve markers like AMH and FSH, suggests that assessing and optimizing the levels of vitamin D in women at risk for or diagnosed with POI could be a promising supportive approach. Of 2,067 references identified in an initial systematic review search, a total of ten observational studies, one RCT, and one quasi-experimental study were included. A total of 521 women were included across all studies. All studies showed an overall association between serum levels of vitamins D, E, and selenium and POI and ovarian reserve markers. However, not all studies found this association. Supplementation was associated with elevated AMH levels while simultaneously reducing FSH hormone.

In a systematic review of vitamin D and IVF outcomes, eighteen articles were selected. Five showed a positive correlation between serum vitamin D levels and IVF results, twelve lacked any association, and one exhibited a negative correlation. The three studies that assessed vitamin D in follicular fluid found a positive correlation between serum and follicular levels.

Evidence strength: Mixed. Observational studies consistently identify associations between vitamin D deficiency and adverse ovarian reserve markers and reproductive outcomes. However, interventional studies, particularly RCTs of supplementation in IVF populations, have produced inconsistent results, with most systematic reviews failing to confirm a clear benefit on live birth rates. Outcomes may depend on baseline deficiency and individual factors.

Dehydroepiandrosterone (DHEA)

Traditional Use

DHEA is an endogenous adrenal steroid precursor. It has no traditional botanical or herbal use; its application to ovarian function is a modern clinical development.

Scientific Evidence

With regard to supplements to treat poor ovarian response to ovarian stimulation, starting DHEA before cycle commencement is better than control therapies. A systematic review and network meta-analysis published in Reproductive Biology and Endocrinology evaluated DHEA, CoQ10, growth hormone, and acupuncture for poor ovarian response (POR) in IVF cycles. Adjuvant treatment with DHEA has a significant impact on various pregnancy outcomes. Results showed that DHEA produced better clinical outcomes in terms of improving the embryo implantation rate, the high-quality embryo rate, and the number of oocytes retrieved.

Evidence strength: Preliminary to moderate. Network meta-analyses and RCTs suggest benefits in intermediate and some early clinical pregnancy outcomes in POR populations undergoing IVF, but the overall evidence base remains heterogeneous, and clinical practice guidelines differ on recommendations.

N-Acetylcysteine (NAC)

Traditional Use

NAC is a synthetic derivative of the amino acid L-cysteine and has no traditional herbal use. It functions primarily as a precursor to glutathione, the body's principal intracellular antioxidant.

Scientific Evidence

Natural molecules including N-acetylcysteine have been shown to play a therapeutic role in ameliorating inflammation and insulin sensitivity, restoring ovarian function, maintaining regular hormonal balance, and normalizing the menstrual cycle in PCOS. Research in women with PCOS has examined NAC as an insulin sensitizer and antioxidant with potential benefit for ovulatory function, though the evidence base is smaller than that for inositol or metformin.

Evidence strength: Preliminary. Most evidence is from small RCTs in PCOS populations examining intermediate hormonal endpoints. Large-scale trials on live birth rates are lacking.

Curcumin (from Curcuma longa)

Traditional Use

Curcuma longa belongs to the family Zingiberaceae, and its rhizome is routinely used as a spice in the Asian continent. It is commonly called yellow ginger, Indian saffron, and yellow root. In traditional Ayurvedic and Chinese medicine, turmeric has been used for centuries to support digestive function, reduce inflammation, and address gynecological complaints.

Scientific Evidence

Treatment of PCOS patients with different natural molecules coming from nutritional supplements and herbal medicines has attained satisfactory results with the absence of notable side effects. Among these, curcumin, vitamin D, inositol, and CoQ10 are discussed for their therapeutic ability in PCOS. Curcumin's proposed mechanisms in ovarian health center on its anti-inflammatory and antioxidant properties, with preclinical studies showing effects on androgen metabolism and insulin signaling relevant to PCOS. Clinical data in humans are limited to small trials.

Evidence strength: Preliminary; predominantly based on preclinical and mechanistic data. Human RCTs are few and small. Clinical conclusions cannot be drawn at this time.

Vitex agnus-castus (Chasteberry)

Traditional Use

Vitex agnus-castus, also called chasteberry, has been used in herbal medicine for the past 2,000 years. It is a large shrub native to Europe and is also broadly disseminated in southern regions of the United States. Vitex agnus-castus is a large flowering shrub found throughout Southern Europe, the Mediterranean, and Central Asia, and has been used widely since ancient times for female reproductive problems. Chastetree/Vitex has been approved by German health authorities for PMS, breast tenderness, and irregularities in the menstrual cycle, and is often recommended for women in early menopause experiencing irregular menstrual cycles.

Scientific Evidence

Vitex agnus-castus has a long tradition in the treatment of menstrual cycle disorders. The clinical pharmacological effects of VAC extract are not fully understood, but are supposed to be due to dopaminergic activity in the hypothalamic-pituitary-gonadal axis, leading to reduced prolactin secretion and potentially alleviating symptoms of PMS and associated mastalgia/mastodynia.

A 2017 systematic review and meta-analysis identified randomized controlled trial evidence for Vitex in PMS. Data from 1,700 women with a mean age of 30.2 years were analyzed in a retrospective cohort study. The most common menstrual cycle disorders were dysmenorrhea (43.8%) and mastodynia/mastalgia (21.1%). Three-month treatment with VAC extract substantially decreased the percentage of patients with irregular cycle (from 9.1% to 0.1%) and breast tenderness (from 39.9% to 0.8%).

There was evidence for an equivalent effect between two herbal medicines and pharmaceutical agents: Vitex agnus-castus compared with bromocriptine, and Cimicifuga racemosa (black cohosh) compared with clomiphene citrate. There was less robust evidence for the complementary combination of spironolactone and Glycyrrhiza spp. for hyperandrogenism.

Preclinical and clinical studies provide evidence that six herbal medicines may have beneficial effects for women with oligo/amenorrhoea, hyperandrogenism, and PCOS. However, the quantity of preclinical data was limited, and the quality of clinical evidence was variable. Further preclinical studies are needed.

Evidence strength: Moderate for PMS symptom relief, particularly reduction in breast pain and luteal-phase symptoms, supported by multiple RCTs and meta-analyses. Evidence for direct improvement of ovulation or fertility is more limited and comes from smaller and less rigorous trials. Approved in Germany for specific gynecological indications.

Black Cohosh (Actaea/Cimicifuga racemosa)

Traditional Use

Black cohosh is a perennial plant native to North America. Native American peoples used the root for a variety of gynecological complaints, including menstrual irregularities and labor support. It subsequently entered European botanical practice in the 19th and 20th centuries.

Scientific Evidence

Older women suffering menopausal symptoms are increasingly likely to use botanicals, especially since the Women's Health Initiative showed an increased risk for breast cancer associated with traditional hormone therapy. Serotonergic mechanisms similar to antidepressants have been proposed for black cohosh and valerian.

In summary, black cohosh shows great promise for relief of menopausal symptoms, primarily for treatment of vasomotor symptoms and possibly mood, with an overall positive safety profile for at least six months and likely longer. Its mechanism of action in the context of ovarian hormonal axes remains incompletely understood; it does not appear to exert classical estrogenic activity at the receptor level in reproductive tissues.

Evidence strength: Moderate for menopausal vasomotor symptom relief. Evidence for direct benefit to ovarian function (e.g., folliculogenesis or hormone production) is lacking. Evidence base is stronger than for many herbs in this category, but does not support claims of restoring ovarian function per se.

Dong Quai (Angelica sinensis)

Traditional Use

Dong quai or danggui is the dried root of Angelica sinensis, which is commonly used in traditional Chinese medicine to tonify the blood, regulate menstruation, and support women's reproductive health. In traditional Chinese medicine (TCM), dong quai is called "Women's Ginseng" and is considered to be an overall tonic for women's sexual health.

Scientific Evidence

Botanical dietary supplements for premenstrual syndrome are less commonly studied in rigorous clinical trials. Vitex agnus-castus and Angelica sinensis (dong quai) are among the botanicals examined, but rigorous clinical trials have not been completed for several of these. Available evidence for dong quai as a standalone agent is insufficient to draw conclusions regarding its specific effects on ovarian hormone production or ovulation. Most favorable data come from traditional Chinese medicine combination formulas.

Evidence strength: Weak to insufficient as a standalone agent for ovarian health. Most clinical evidence exists for multi-herb TCM formulas. A placebo-controlled trial of dong quai alone in postmenopausal women found no estrogenic effects on the endometrium, and the overall clinical trial evidence base for its use in ovarian-related conditions remains limited.

Omega-3 Fatty Acids

Traditional Use

Omega-3 fatty acids are dietary constituents found in fatty fish, flaxseed, and walnuts. Their systematic use as a supplement for reproductive health is a contemporary practice without a defined traditional-medicine precedent.

Scientific Evidence

Omega-3 fatty acids may support reproductive outcomes through anti-inflammatory mechanisms and have been associated with improved assisted reproduction outcomes in observational studies. Proposed mechanisms include effects on prostaglandin synthesis, oocyte membrane fluidity, and systemic inflammation relevant to conditions such as endometriosis and PCOS.

Evidence strength: Preliminary. Predominantly observational data. Interventional trial evidence for improved ovarian function or ovarian reserve is limited. Larger RCTs are needed.

Selenium and Vitamin E

Traditional Use

Neither selenium nor vitamin E has a classical herbal or botanical tradition in the context of ovarian health. Their relevance is grounded entirely in nutritional biochemistry.

Scientific Evidence

A systematic review of vitamins D, E, and selenium (SE) in women with premature ovarian insufficiency found that the consistent association between deficiencies in these micronutrients and POI, alongside their potential to influence ovarian reserve markers like AMH and FSH, suggests that assessing and potentially optimizing the levels of these vitamins and minerals in women at risk for or diagnosed with POI could be a promising supportive approach. Reducing reactive oxygen species through supplementation with vitamins D, E, and selenium can improve ovarian function according to the data reviewed.

Evidence strength: Preliminary. Most data are observational with limited interventional evidence. Supplementation may be of greatest relevance in the context of documented deficiency.

Conditions and Concerns Associated with the Ovaries

Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS), one of the most common abnormalities in reproductive age women, is defined by ovulation abnormalities, high levels of androgens, and polycystic ovaries on ultrasonography. PCOS is a common endocrine disorder affecting 4–12% of females of reproductive age.

Diagnosis requires the presence of two of the following criteria: hyperandrogenism, ovulation dysfunction, and polycystic ovarian morphology, as per the Rotterdam PCOS diagnostic criteria. PCOS is a complex condition with multiple potential contributors, including genetic and epigenetic mechanisms, insulin resistance, hormonal imbalances, inflammation, oxidative stress, and obesity, which may gradually lead to cancer over time.

PCOS is associated with several conditions, including glucose intolerance, diabetes, hypertension, central obesity, metabolic syndrome, and cardiovascular diseases. Women with PCOS have a 2.7-fold increased risk for developing endometrial cancer. A major factor for this increased malignancy risk is prolonged exposure of the endometrium to unopposed estrogen that results from chronic anovulation. Lifestyle modification with caloric restriction and exercise is appropriate to treat obesity as a concomitant risk factor for developing endometrial disease.

Endometriosis

Endometriosis is a chronic gynecological condition in which tissue similar to the uterine lining grows outside the uterus. As a multi-systemic disease, the chronic inflammatory response and immune dysregulation caused by endometriosis may increase the risk of other gynecological diseases, including adenomyosis, uterine fibroids, and ovarian cancer. Ovarian endometriomas (so-called "chocolate cysts") are a specific manifestation of endometriosis within ovarian tissue.

Laparoscopic excision of bilateral endometriomas leads in 2.4% of cases to premature ovarian insufficiency, and ovarian endometrioma surgery is associated with a decline in serum AMH and diminished ovarian reserve.

Premature Ovarian Insufficiency (POI)

Premature ovarian insufficiency (POI) is defined as a cessation of ovarian function before the age of 40 years. It is associated with hypoestrogenism and loss of residual follicles, both of which lead to menstrual abnormalities, pregnancy failures, and decreased health-related quality of life. The prevalence of POI is estimated at 1% in the general population.

Current European Society of Human Reproduction and Embryology (ESHRE) diagnostic criteria include: amenorrhoea or oligomenorrhoea for at least four months and increased follicle-stimulating hormone (FSH) levels greater than 25 IU/l measured twice with a four-week interval.

The aetiopathogenesis of POI in most cases remains unexplained. Nevertheless, in some patients with POI, genetic abnormalities, metabolic disorders, autoimmunity, iatrogenic procedures, infections, or environmental factors have been established as underlying causes of the syndrome.

To date, there is no effective therapy or intervention that can reliably improve residual ovarian function. Hormone replacement therapy (HRT) is recommended for women with POI, both for symptom management and for minimizing the burden from chronic disorders directly impacted by premature loss of estrogen. For women who want to plan a family, assisted conception by IVF using donor eggs could improve conception rates in women with POI.

Ovarian Cancer

Ovarian cancer is a complex disease, mostly observed in postmenopausal women, and is associated with poor survival rates. It is the sixth most common cancer and the fifth most common cause of death due to cancer among women in developed countries. Despite representing less than one third of all gynaecologic cancers, deaths due to ovarian cancer account for more than two thirds of deaths due to gynaecologic cancers.

Unlike other female cancers that have early warning symptoms, ovarian cancer's symptoms are non-specific. As a result, ovarian cancers are normally undetected until advanced stages (III or IV).

The major risk factors for ovarian cancer include older age, genetics, family history, hormone replacement therapy, nulliparity, and dietary fat. Controversial factors include obesity, infertility, talc powder, radiation exposure, fertility medications, and in vitro fertilization.

Advances in molecular genetics have found mutations in the BRCA1 and BRCA2 tumor suppressor genes responsible for the majority of hereditary ovarian cancer. Additional risk factors include nulliparity and refractory infertility. Protective factors include multiparity, oral contraceptives, and tubal ligation or hysterectomy. With five years of oral contraceptive use, women can cut their risk of ovarian cancer approximately in half; this also holds true for individuals with a family history.

Diminished Ovarian Reserve (DOR)

Diminished ovarian reserve refers to a reduction in the quantity or quality of oocytes remaining in the ovaries, resulting in reduced fertility potential. It may occur in the context of aging, iatrogenic ovarian damage, or idiopathically. Research criteria for poor ovarian response (POR) include: advanced maternal age (≥40 years) or other risk factors; a previous POR (≤3 oocytes with a conventional stimulation protocol); and an abnormal ovarian reserve test such as antral follicle count less than 5–7 follicles or AMH less than 0.5–1.1 ng/ml. POR can be diagnosed if at least two of the three characteristics are met.

Ovarian Cysts

Multiple pathologic processes can occur in the ovaries, including ovarian cancer, ovarian torsions, ectopic pregnancies, ovarian abscesses, hormonal imbalances, and cysts. These conditions can have detrimental effects on the health of those affected. Functional cysts arising from the ovulatory process are common and usually self-resolving; pathological cysts such as dermoid cysts, cystadenomas, and endometriomas require clinical evaluation and often intervention.

Iatrogenic Ovarian Damage

During radiotherapy, a dosage over 9 Gy carries a high risk of ovarian insufficiency. Surgery may also contribute to POI directly because of excision of ovaries or during operations within the pelvis resulting in diminished blood supply to gonads. Premature ovarian failure is recognized as a complication of radiotherapy to a field that includes the pelvis and alkylating-agent-based chemotherapy. Young pre-pubertal girls are not protected from the effects of gonadally toxic therapy.

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