Clinical 2: Axis session Flashcards
What does breastmilk production indicate?
High prolactin
What sort of investigations should you do if someone comes in with Amenorrhoea, breasmilk production and no hot flushes?
1) Blood tests (HCG, LH, FSH, Oestardiol, progesterone, prolactin etc.)
2) Imaging (Transvaginal ultrasound)
Dopamine inhibits…. ______ secretion
Prolactin secretion
Diagnoses for high prolactin level
1) Anterior pituitary tumour (macro or microadenoma, prolactinoma)
2) drugs (psychotropic drugs e.g. haloperidol)
3) Lactation
4) Stress (therefore must repeat prolactin)
What are some symptoms of prolactinoma?
Infrequent very light menstrual cycles
Headache
Visual disturbance
How do you treat prolactinoma?
Bromocriptine or cabergoline (dopamine agonist)
Surgery
Karen is 16, swims 5x per week, stressed about school work and not yet started her menses (has secondary characteristics). BMI is 16, normal breast and hair development and has normal external genitalia.
What can be the cause of these symptoms?
1) Primary amenorrhoea
2) First exclude pregnancy
(start at top and work down)
3) Hypothalamus (stress, exercise, anorexia nervosa, low body fat index)
4) Anterior pituitary (prolactinoma, thyroid, dopamine, etc.)
5) Ovary (PCOS, premature ovarian failure)
6) Uterus (Absent uterus, atrophic endometrium)
7) Vagina (Imperforate hymen, vaginal septum)
Karen is 16, swims 5x per week, stressed about school work and not yet started her menses (has secondary characteristics). BMI is 16, normal breast and hair development and has normal external genitalia.
What can be the cause of these symptoms?
1) Primary amenorrhoea
2) First exclude pregnancy
(start at top and work down)
3) Hypothalamus (stress, exercise, anorexia nervosa, low body fat index)
4) Anterior pituitary (prolactinoma, thyroid, dopamine, etc.)
5) Ovary (PCOS, premature ovarian failure)
6) Uterus (Absent uterus, atrophic endometrium)
7) Vagina (Imperforate hymen, vaginal septum)
What is primary and secondary ammenhoea?
Primary- never had one
Secondary- had one, but stopped
Is PCOS likely to cause primary or secondary ammenhoea?
Secondary.
Very rare that this is secondary.
Link stress with HPO
Decreased central drive, (hypothalamus switches off so you don’t get GnRH pulses, have low FSH and LH, and low oestrogen)
Karen is 16, swims 5x per week, stressed about school work and not yet started her menses (has secondary characteristics). BMI is 16, normal breast and hair development and has normal external genitalia.
What investigations would you do?
1) HCG (exclude pregnancy)
2) LH
3) FSH
4) Estradiol
5) Thyroid stimulating hormone level
6) Prolactin
7) MRI head (exclude empty sella syndrome)- very unlikely.
Karen is 16, swims 5x per week, stressed about school work and not yet started her menses (has secondary characteristics). BMI is 16, normal breast and hair development and has normal external genitalia.
What investigations would you do?
1) HCG (exclude pregnancy)
2) LH
3) FSH
4) Estradiol
5) Thyroid stimulating hormone level
6) Prolactin
7) MRI head (exclude empty sella syndrome)- very unlikely.
Karen is 16, swims 5x per week, stressed about school work and not yet started her menses (has secondary characteristics). BMI is 16, normal breast and hair development and has normal external genitalia.
What is likely to be the cause of her amenorhoea?
Management plan?
Hypothalamus (stress, exercise, anorexia nervosa, low body fat index)
Management: counselling-exclude eating disorder, hormone therapy, regular follow-up.
Nicole is age 30, is a registrar. She works hard, stressed about exams, trying for pregnancy for 12 months.
Less frequent menses, no pelvic pain, no STI. One previous cesarean, BMI is 24.
What is the diagnosis?
Secondary infertility
What are some causes of infertiltiy?
1/3 female factor
1/3 Male factor
1/3 Unexplained
Nicole is age 30, is a registrar. She works hard, stressed about exams, trying for pregnancy for 12 months.
Less frequent menses, no pelvic pain, no STI. One previous cesarean, BMI is 24.
What are some investigations you might do?
1) Blood test
- FSH, LH (ovulate), oestrogen (is she developing follicles?), progesterone, AMH (useful indication of oocyte reserve)
2) Imaging
- Pelvic ultrasound
- Tubal patency
Nicole is age 30, is a registrar. She works hard, stressed about exams, trying for pregnancy for 12 months.
Less frequent menses, no pelvic pain, no STI. One previous cesarean, BMI is 24.
Diagnose
Premature ovarian insufficiency.
Ovaries are not producing as much estrogen which feeds back to AP and HT to secrete more GnRH, FSH and LH
Blood test: high FSH and LH but low estrodiol
What is and what are the symptoms of Premature ovarian insufficiency?
Definition of POI: ovarian insufficiency learning to amenorrhoea in women before age 40; most cases are permanent, some can bet transient.
1) Less frequent menses- will likely stop soon
2) No vasomotor symptoms yet- will develop symptoms of menopause
How do you manage Premature ovarian insufficiency?
1) Counseling and psychological support
2) Refer fertility specialist
Prognosis: sporadic ovulation (ovarian follicles are capable of functioning intermittently) vs donor egg.
If not wishing fertility, offer menopausal hormone therapy.
Kate
BMI = 32, facial hirsutism, no health problems or surgery.
Irregular cycles- oligo- or anovulation, acne and hirsutism
BMI- insulin resistance
PCOS
Describe PCOS
How do you diagnose PCOS
Ovaries are larger than usual, contain multiple small peripheral follicles with stromal hyperplasia.
2/3 features;
1) Oligo-ovulation and/or anovluation
2) clinical or/and biochemical evidence of hyperandrogenism
3) Polycystic ovaries o ultrasound (> 12 small peripheral follicles on each ovary)
Link PCOS with the HPO axis
High insulin interferes with hypothalamus. It interferes with LH (?) Chronically elevated luteinizing hormone (LH) and insulin resistance are 2 of the most common endocrine aberrations seen in PCOS
Raised LH, increases androgen production and free Testosterone
+/- obesity, increased peripheral conversions of androgens to oestrogen, negative feedback on FSH
Insulin Resistance and high oestrogen levels
Describe the pathophysiology of PCOS
Fundamentally, there is an imbalance between LH and FSH leading to follicular arrest.
Chronically elevated luteinizing hormone (LH) and insulin resistance are 2 of the most common endocrine aberrations seen in PCOS
Darkened skin can be caused by ______
Hyperinsulin-anemia
Management of PCOS
1) Lifestyle
- 5-10% of body weight will resume regular ovulation and menses, thus improving fertility
2) Medication
- induce ovulation
- induce insulin resistance
3) Surgery
- induce ovulation
Consequences of anovulation
No ovulation - no LH surge- no rise in progesterone x 14 days - no drop in progesterone triggering next menses
Endometrium continues to proliferate- can lead to endometrial hyperplasia
How do you manage anvoluation?
Need to exclude endometrial hyperplasia if anovulation for a long time
Endometrial biopsy
- pipelle can be done in the office setting
- hysteroscopy and endometrial sampling under general anestehtic
Need to induce a withdrwawal bleed every 4-6 weeks (progesterone pills x 14 days)
Or need to prevent endometrial proliferation (i.e. overgrowth of the lining of the uterus)
Describe 2 drugs that may be prescribed for someone with PCOS
Clomiphene citrate
• Take one tablet for five days of each cycle (start day 2 or day 5), usually start at 25mg
• Clomiphene triggers the brain’s pituitary gland to secrete an increased amount of follicle stimulating hormone (FSH) and LH (luteinizing hormone).
Anti-estrogen results in increased FSH (negative feedback) normal follicular maturation ovulation
• Need to monitor cycle (if unmonitored, can be multiple pregnancy due to maturation of multiple follicles)
• 60-70% ovulate, 20-50% conceive
Metformin
• Take one to three tablets every day, start at 250mg
• Insulin modifier (decreases insulin resistance)
