Clinical 2: Axis session

Question 1

What does breastmilk production indicate?

Answer 1

High prolactin

Question 2

What sort of investigations should you do if someone comes in with Amenorrhoea, breasmilk production and no hot flushes?

Answer 2

1) Blood tests (HCG, LH, FSH, Oestardiol, progesterone, prolactin etc.)
2) Imaging (Transvaginal ultrasound)

Question 3

Dopamine inhibits…. ______ secretion

Answer 3

Prolactin secretion

Question 4

Diagnoses for high prolactin level

Answer 4

1) Anterior pituitary tumour (macro or microadenoma, prolactinoma)
2) drugs (psychotropic drugs e.g. haloperidol)
3) Lactation
4) Stress (therefore must repeat prolactin)

Question 5

What are some symptoms of prolactinoma?

Answer 5

Infrequent very light menstrual cycles
Headache
Visual disturbance

Question 6

How do you treat prolactinoma?

Answer 6

Bromocriptine or cabergoline (dopamine agonist)

Surgery

Question 7

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?

Answer 7

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)

Question 8

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?

Answer 8

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)

Question 9

What is primary and secondary ammenhoea?

Answer 9

Primary- never had one

Secondary- had one, but stopped

Question 10

Is PCOS likely to cause primary or secondary ammenhoea?

Answer 10

Secondary.

Very rare that this is secondary.

Question 11

Link stress with HPO

Answer 11

Decreased central drive, (hypothalamus switches off so you don’t get GnRH pulses, have low FSH and LH, and low oestrogen)

Question 12

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?

Answer 12

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.

Question 13

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?

Answer 13

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.

Question 14

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?

Answer 14

Hypothalamus (stress, exercise, anorexia nervosa, low body fat index)

Management: counselling-exclude eating disorder, hormone therapy, regular follow-up.

Question 15

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?

Answer 15

Secondary infertility

Question 16

What are some causes of infertiltiy?

Answer 16

1/3 female factor
1/3 Male factor
1/3 Unexplained

Question 17

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?

Answer 17

1) Blood test
- FSH, LH (ovulate), oestrogen (is she developing follicles?), progesterone, AMH (useful indication of oocyte reserve)

2) Imaging
- Pelvic ultrasound
- Tubal patency

Question 18

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

Answer 18

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

Question 19

What is and what are the symptoms of Premature ovarian insufficiency?

Answer 19

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

Question 20

How do you manage Premature ovarian insufficiency?

Answer 20

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.

Question 21

Kate

BMI = 32, facial hirsutism, no health problems or surgery.
Irregular cycles- oligo- or anovulation, acne and hirsutism

BMI- insulin resistance

Answer 21

PCOS

Question 22

Describe PCOS

How do you diagnose PCOS

Answer 22

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)

Question 23

Link PCOS with the HPO axis

Answer 23

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

Question 24

Describe the pathophysiology of PCOS

Answer 24

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

Question 25

Darkened skin can be caused by ______

Answer 25

Hyperinsulin-anemia

Question 26

Management of PCOS

Answer 26

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

Question 27

Consequences of anovulation

Answer 27

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

Question 28

How do you manage anvoluation?

Answer 28

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)

Question 29

Describe 2 drugs that may be prescribed for someone with PCOS

Answer 29

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)