021315 ovulatory dysfxn Flashcards
what phase determines the length of the menstrual cycle
follicular phase
what should be done on every pt with irregular menstrual cycles
history and physical (weight? hirsutism?) TSH prolactin baseline FSH and estradiol hCG (FIRST LINE)
what is the purpose of the progestin challenge?
to see if there’s adequate estrogen exposure in the uterine lining
if after the H and P, TSH, prolactin, FSH, estradiol, and hCG tests, you find that FSH is low or normal, what should you do
progestin challenge
if pts test positive for a progestin withdrawal bleed, what does this suggest?
they have an ovulatory dysfxn
virilization
exaggerated male characteristics
if you decide pt has ovulatory dysfxn, what could it be?
if there’s clinical or biochemical hyperandrogenism:
- tumor
- PCOS
if there’s no clinical or biochem hyperandrogenism:
-unexplained ovulatory dysfxn
most common endocrine cause of infertility and irregular menstrual cycles
PCOS
PCOS requires what criteria
2 of 3:
polycystic-like ovaries on US
oligomenorrhea (more than 35 days in length or irregular length)
hyperandrogenism
other causes of hyperandrogenism and oligomenorrhea must be excluded
tx for PCOS
if not desiring fertility:
tx for endometrial protection (progesterone)
counsel regarding health risks
if desiring fertility:
weight loss (first line in obese)
clomiphene citrate (first line)-selective ER antagonist
aromatase inhibitors
what allows for a withdrawal bleed when exposed to progestin?
estrogen, b/c it results in manifestation of progesterone receptors
algorithm for amenorrhea
see slide 24
reasons for lack of withdrawal bleed in response to pregesteron therapy
lack of circulating estradiol
severe endometrial adhesions
pregnancy
hypogonadotropic hypogonadism
low/normal FSH and low estradiol
may be stress/exercise or weight related (most common)
ensure absence of sellar mass
hypergonadotropic hypogonadism/premature ovarian insufficiency/premature menopause
elevated FSH/LH–hypergonadotropic hypogonadism BEFORE the age of 40
causes of premature menopause/premature ovarian insufficiency?
genetic (chromosomal number, fragile X)
autoimmune
iatrogenic (chemo, radiation)
idiopathic
likelihood of spontaneous conception in pts with premature ovarian insufficiency
extremely low, so consider oocyte donation or adoption
definition of infertility
unable to conceive after trying for 1 year
in infertile couples, what is the female tested for?
ovarian reserve testing:
day 3 FSH/estradiol levels
antral follicle counts by US
anti-mullerian hormone levels (they correlate with egg reserve)
uterine and tubal anatomy
risk factors for tubal dis
hx of pelvic infec
tubal or pelvic surgery
endometriosis
tx for infertility
intrauterine insemination
in vitro fertilization
amenorrhea
cessation of periods for long time
