Axis Clinical Session

Question 1

What can irregular periods signify?

Answer 1

Oligo- or anovulation

Question 2

Breast milk is indicative of what?

Answer 2

High prolactin

Question 3

Prolactin secretion, and HPO axis and cause of high prolactin

Answer 3

Secreted by AP and has negative feedback on the HT causing less GnRH.
Dopamine has a negative feedback on the AP, stopping Prl.

Cause of increased is less dopamine (drugs, e.g for schiz) or pituitary adenoma.

Question 4

Diagnoses for high prolactin

Answer 4

Pituitary adenoma (prolactinoma)
Drugs such as haloperidol
Lactation
Stress

Question 5

Prolactinoma treatment

Answer 5

Bromocriptine or cabergoline: Dopamine agonists

Surgery

Question 6

CASE: 16 y/o girl, primary amenorrhea. Potential diagnoses? All levels
Note important to exclude pregnancy

Answer 6

HT: Stress; anorexia nervosa; low body fat
AP: prolactinoma, thyroid, dopamine
Ovary: PCOS; premature ovarian failure
Uterus: absent, atrophic endo
Vagina: imperforate hymen, vaginal septum

This case was hypothalamic ameorrhea due to low FSH, LH and oestrogen. Would manage with counselling, then maybe hormone therapy (COCP)

Question 7

Secondary infertility and premature ovarian insuffiiency

NB remember thirds, male, female and unexplained

Answer 7

In case discussed was premature ovarian insufficiency.
Very high FSH but low oestrogen. Ovaries not responding. Defined prior to 40, less frequent menses and no vasomotor symptoms.
Counsel, and refer to fertility clinic. If does not want a kid can offer menopausal hormone therapy

Question 8

Standard tests

Answer 8

bHCG first!
Hormone profile (FSH,LH, oestrogen, free testosterone etc). Sometimes need to know dates
US

Question 9

What is structurally different about ovaries in PCOS?

Answer 9

Stromal hyperplasia, larger than usual and lots of peripheral larger follicles

Question 10

PCOS definition

Answer 10

2 out 3

• hyperandrogenism
• polycystic ovaries on US
• oligo/an ovulation

Question 11

Fundamentally what is going on with PCOS?

Answer 11

Imbalance of LH and FSH, higher LH, more androgens

Question 12

How does PCOS present clinically?

Answer 12

Acanthosis nigricans, hirsutism, acne, excess hair, diabetes, high BMI, ,menstrual disturbance

Question 13

Other diagnoses to consider with a possible PCOS

Answer 13

Hyperprolactinaemia
Androgen tumour
Late onset congenital adrenal hyperplasia
hypogonadotrophic hypopituitarism

Question 14

PCOS management

Answer 14

1) Lifestyle: Losing some body weight. Calorie restriction will increase SHBG. (lowers free test.)
ALWAYS FIRST LINE
2) Medication to induce ovulation, or reduce insulin resistance
3) surgery to induce ovulation

Question 15

Medications used for PCOS

Answer 15

Clomiphene citrate: One tablet first 5 days of cycle. Anti-estrogen, results in increased FSH. (low E levels drives pituitary) Need to monitor cycle

Metformin: insulin modifier to reduce insulin resistance (supposedly increased insulin makes more GnRH, favouring LH)

Question 16

PCOS in the long run, untreated

Answer 16

Stuck in proliferative phase as no ovulation and LH surge. 
Can cause endometrial hyperplasia, precursor for cancer etc.
Can biopsy (pipelle)

Question 17

How can you manage anovulation

Answer 17

Give progesterone to mimic luteal phase

prevent proliferation: using hormones like COCP or a Mirena IUS