B8.008 Prework 1: Female Infertility: Secondary Amenorrhea Flashcards
what is infertility
unprotected intercourse for 12 mo if a female is < 35 or 6 mo if a female is > 35
broad categories of female infertility
tubal
uterine
ovarian
unexplained (20%)
tubal causes of infertility
blockage: prior ligation, scarring, prior infection
hydrosalpinx
endometriosis
uterine causes of infertility
submucosal fibroids
intrauterine scarring: prior procedures, scarring
ovarian causes of infertility
anovulation
low ovarian reserve
prevalence of infertility
12%
what is amenorrhea
absence of menses
primary amenorrhea
no menarche by age 15
secondary amenorrhea
absence of menses for > 3 mo in females with prior regular cycles
absence of menses for > 6 mo in females with prior irregular cycles
anatomic locations of amenorrhea etiologies
hypothalamus (35%)
pituitary (17%)
ovary (40%, most common)
uterus (7%)
hypothalamic causes of amenorrhea
suppression due to systemic illness, radiation, low energy states
pituitary causes of amenorrhea
any hormone secreting tumor hyperprolactinemia (13%) empty sella syndrome (1.5%) sheehan syndrome (1.5%) cushing's syndrome (1%)
empty sella syndrome
rare
enlargement of sella tunica in pituitary
sheehan syndrome
pituitary infarct, usually due to post partum hemorrhage
ovarian causes of amenorrhea
PCOS (30%)
primary ovarian insufficiency (10%)
general “cause” of secondary amenorrhea
inappropriate hormone signaling in HPA
prohibits cyclic oocyte release
follicular phase HPA
hypothalamus secretes GnRH
anterior pituitary stimulated to secrete FSH and LH
ovary is stimulated to release estradiol due to production by rapidly maturing oocytes
estradiol has an inhibitory effect at the level of the hypothalamus and the anterior pituitary
midcycle HPA
hypothalamus secretes GnRH
anterior pituitary stimulated to secrete FSH and LH
LH surge
ovary is stimulated to release estradiol
estradiol has stimulatory effect at level of hypothalamus and the anterior pituitary
luteal phase HPA
hypothalamus secretes GnRH
anterior pituitary stimulated to secrete FSH and LH
ovary contains corpus luteum (remnant of follicle) which secretes progesterone from glandular endometrium
progesterone has inhibitory effect at the level of the hypothalamus and anterior pituitary
GnRH pulsatility for LH release
increasing amplitude, high frequency
GnRH pulsatility for FSH release
decreased amplitude, low frequency
effect of estrogen on GnRH
increases pulse frequency
effect of progesterone on GnRH
decreases pulse frequency
WHO 1 amenorrhea
hypothalamic
decreased FSH, LH, E2
WHO 2 amenorrhea
PCOS
normal levels
can have increased LH and T (but not necessary for diagnosis)
WHO 3 amenorrhea
ovarian failure
increased FSH, LH
decreased E2
what needs to be excluded in hypothalamic amenorrhea
craniopharyngioma radiation of sellar tumor infiltrative disease systemic illness do an MRI to rule out tumor
risk factors for hypothalamic amenorrhea
excess exercise
stress
nutritional deficiency (hypoleptinemia)
low energy states
rotterdam criteria for PCOS
need 2/3:
- PCO
- >12 antral follicles on US - hyperandrogenism
- irregular menstrual cycles
signs of hyperandrogenism
hirsutism
acne
elevated T
irregular menstrual cycles
< 21 days
> 35 days
why does PCOS lead to infertility
increased ratio of LH:FSH induces thecal proliferation
follicles continue to grow but done mature and rupture, thus ovulation does not occur
characteristics of primary ovarian insufficiency (POI)
< 40 years of age
FSH > 30 on 2 occasions
etiology of POI
iatrogenic (radiation, chemo) immunologic chromosomal -turners -galactosemia -fragile x -perrault
treatment for WHO 1 amenorrhea
decrease stress
increase energy intake
gonadotropins
treatment for WHO 2 amenorrhea
decrease energy intake
letrozole (aromatase inhibitor)
clomid, gonadotropins, ovarian drilling (last resorts)
mechanism of action of letrozole
inhibits aromatase in ovaries and peripheral tissues, reducing estrogen levels
estrogen reduction stimulates HPA to produce more FSH
FSH mediated follicle stimulation, which causes estrogen to rise
once estrogen begins to rise again, FSH is suppressed leaving a single dominant follicle
treatment for WHO 3 amenorrhea
donor oocytes
