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Year 2 RE > Disorders of Ovulation > Flashcards

Disorders of Ovulation Flashcards

1
Q

What is the normal pathway from the hypothalamus to the hormones releases in the ovaries?

A
  • gonadotrophin releasing hormone (GnRH) release by hypothalamus
  • GnRH stimulates anterior pituitary gland to release FSH and LH
  • FSH and LH stimulate follicular development and maturation and release of oestrogen and progesterone
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2
Q

What happens during day 1 of the menstrual cycle?

A
  • identified as when bleeding occurs
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3
Q

What important event occurs half way through the menstrual cycle, and what hormone peaks at the same time?

A
  • ovulation

- leutenising hormone (LH) peaks

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4
Q

Which hormone in the ovaries is in highest concentration during days 0-15?

1 - testosterone
2 - estrogen
3 - cortisol
4 - progesterone

A

2 - estrogen

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5
Q

Following ovulation, the follicle becomes the corpus luteum following the release of the oocyte. What happens to oestrogen and progesterone levels and why is this important?

A
  • estrogen and progesterone levels increase
  • prepares the uterus for receiving the oocyte
  • also provide negative feedback loop for LH and FSH
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6
Q

During the growth and maturation of the follicles the levels of oestrogen are increased. Why is this?

A
  • follicles produce estrogen as they mature

- more mature follicles means more estrogen

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7
Q

Estrogen produced by the developing follicles does what to the uterus and what is the name of this phase from around days 4-15?

A
  • called proliferative phase

- endometrium grows, blood vessels grow, cervical mucus thins

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8
Q

Estrogen is able to have positive and negative feedback loops. As estrogen levels increase during follicular development and due to maturation estrogen levels begin to rise causing a negative feedback to the hypothalamus, resulting in what to happen?

A
  • gonadotropin releasing hormone (GnRH) will be decreased from hypothalamus
  • FSH release from anterior pituitary will be reduced
  • follicles will begin to atrophy
  • follicle with most FSH will survive becoming dominant follicle
  • dominant follicle is very sensitive to very low levels of FSH and it continues to develop and mature
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9
Q

During follicular development and maturation, the follicles will die off due to the negative feedback loop caused by high estrogen and reduced levels of FSH. However, the 1 dominant follicle will continue to respond to low FSH and secrete estrogen.

When estrogen peaks around day 12-14, this causes a positive feedback loop causing a surge in another hormone released by the anterior pituitary gland that is marked by an important point in the menstrual cycle. What hormone is released and what is the important point that is marked by the surge in this hormone?

A
  • high estrogen causes an LH surge

- triggers ovulation

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10
Q

The corpus luteum is created following the release of the oocyte into the fallopian tubes. The corpus luteum then remains for 2 weeks. If there is no pregnancy what then happens to the corpus luteum and the 2 hormones it was producing?

A
  • no pregnancy = corpus luteum will shrink away and be reabsorbed
  • estrogen and progesterone levels will drop
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11
Q

What happens to the corpus luteum if pregnancy occurs?

A
  • early embryo secretes human chorionic gonadotropin (HCG)
  • HCG promotes corpus luteum acting like LH
  • corpus luteum continues to secrete estrogen and progesterone until placenta takes over
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12
Q

Women are born with the eggs that they will use for pregnancy throughout their lives. What happens to the number of eggs a female has as they age?

A
  • decreases
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13
Q

If a female is having regular pain, mucus and blood once a month, this confirms a normal menstrual cycle. it is also diagnostic of what occurring in the ovaries?

A
  • ovulation
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14
Q

What are 2 biochemical markers that can be used to diagnose ovulation?

A

1 - serum progesterone (increased during ovulation) (peak around day 21)
2 - urinary LH kits (LH surge causes ovulation)

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15
Q

There are 2 biochemical markers that can be used to diagnose ovulation:

1 - serum progesterone (increased during ovulation)
2 - urinary LH kits (LH surge causes ovulation)

When would be the most appropriate time to measure serum progesterone during the menstrual cycle?

A
  • in second half of the cycle

- aprox 21 days

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16
Q

There are 2 biochemical markers that can be used to diagnose ovulation:

1 - serum progesterone (increased during ovulation)
2 - urinary LH kits (LH surge causes ovulation)

When would be the most appropriate time to measure LH during the menstrual cycle?

A
  • aprox 12-14 days

- peaks at this time to signify ovulation

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17
Q

What imaging modality is used to diagnose ovulation?

1 - transvaginal ultrasound
2 - X-ray
3 - CT scan
4 - MRI

A

1 - transvaginal ultrasound
- can scan from days 10 onwards to show development of dominant follicle and then ovulation (black circles in image are follicles)

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18
Q

What does the singleton pregnancy mean?

A
  • one dominant follicle develops and ovulation occurs

- leads to the birth of only one child during a single delivery with a gestation of 20 weeks or more

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19
Q

What is a functional ovarian cyst?

A
  • normal follicles do not release the oocyte and continue to grow
  • ovaries generally deal with these
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20
Q

What is hormonal replacement therapy (HRT)?

A
  • HRT is replacement hormones given to women
  • provided when no more eggs are produced, meaning no more estrogen
  • estrogen deficiency occurs
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21
Q

What are the 2 key hormones that make up hormonal replacement therapy (HRT)?

A

1 - estrogen

2 - progesterone

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22
Q

What does anovulation mean?

A
  • when an egg is not released from the ovary during your menstrual cycle
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23
Q

Anovulation is when an egg is not released from the ovary during your menstrual cycle. What are 3 causes that can affect the hypothalamus, which would ultimately cause a reduction in gonadotropin releasing hormone?

A

1 - stress related
2 - exercise related
3 - anxiety related

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24
Q

Anovulation is when an egg is not released from the ovary during your menstrual cycle. In addition to problems with the hypothalamus, what other parts of the body can be affected, thus causing anovulation?

A
  • pituitary problems
  • ovarian problems
  • hyperandrogenism (excessive levels of testosterone)
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25
Q

Hyperandrogenism refers to the excessive presence of the male sex hormones testosterone, androsterone and androstenedione in women, and the effects that they have on the female body, which can cause anovulation where the oocyte is not released from the ovary. There are 2 key types of hyperandrogenism:

1 - polystic ovary syndrome (PCOS)
2 - congenital adrenal hyperplasia CAH)

What is PCOS?

A
  • LH levels are high causing theca cells to over produce androstenedione
  • excessive androstenedione is converted to estrone in adipose tissue (contributes to obesity)
  • estrone inhibits FSH
  • no FSH means no follicular development
  • high LH means no surge in LH causing ovulation
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26
Q

Hyperandrogenism refers to the excessive presence of the male sex hormones testosterone, androsterone and androstenedione in women, and the effects that they have on the female body, which can cause anovulation where the oocyte is not released from the ovary. There are 2 key types of hyperandrogenism:

1 - polystic ovary syndrome (PCOS)
2 - congenital adrenal hyperplasia (CAH)

What is CAH?

A
  • autosomal recessive disorders affecting the adrenal glands
  • deficiency in enzymes for cortisol and aldosterone synthesis
  • everything is shifted to androgen synthesis instead
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27
Q

If a patient has a problem in the hypothalamus causing reduced levels of gonadotrophin releasing hormone (GnRH), this will result in low or no levels of FSH and LH. What will then happen to the follicular development?

A
  • anovulation will occur as follicles do no develop leading to ovulation
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28
Q

If a patient has a problem in the hypothalamus causing reduced levels of gonadotrophin releasing hormone (GnRH), this will result in low or no levels of FSH and LH. This will lead to anovulation as follicles do not develop and ovulation will not occur. Will estrogen levels be:

1 - high
2 - normal
3 - low or none

A

3 - low or none as no FSH or LH to stimulate follicular growth
- can treat these patients with estrogen

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29
Q

If a patient has a problem in the ovaries but the hypothalamus and pituitary gland are fine, what will we see in the levels of estrogen and how can this be treated?

A
  • granulosa cells do not respond to LH and FSH
  • low levels of estrogen
  • no follicular development
  • patient would need an egg donor and then estrogen and progesterone therapy
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30
Q

If the ovaries are damaged and unable to go through the normal menstrual cycle, what would we expect to see in the levels of gonadotrophin releasing hormone (GnRH), FSH, LH and oestrogen levels?

A
  • GnRH, FSH and LH levels will all be high as no negative feedback
  • ovaries are essentially deaf and no eggs to respond to LH and FSH
    = estrogen will be low as no eggs to produce it
31
Q

If there is hypothalamic-pituitary failure, what would we expect to see in the levels of gonadotrophin releasing hormone (GnRH), FSH, LH and estrogen levels?

A
  • GnRH, FSH and LH levels will all be low
  • estrogen levels will be low as there is no stimulus to cause follicular development and maturation which leads to estrogen production
32
Q

If there is hypothalamic-pituitary dysfunction, what would we expect to see in the levels of gonadotrophin releasing hormone (GnRH), FSH, LH and estrogen levels?

A
  • all would generally be normal

- but increased male sex androgens impairs follicular development and maturation

33
Q

If there is dysfunction of hypothalamus-pituitary-ovarian axis and interfere with the follicular cycle and ovulation. What is the most common syndrome that this causes by dysfunction of the hypothalamus-pituitary-ovarian axis?

1 - polycystic ovary syndrome
2 - endometrial cancer
3 - congenital adrenal hyperplasia
4 - endometriosis

A

1 - polycystic ovary syndrome

- caused by excessive LH

34
Q

What is amenorrhoea?

A
  • absence of periods
  • primary = never started
  • secondary = none for 3-6 months
35
Q

Amenorrhoea is the absence of periods. What is primary amenorrhoea?

A
  • failure to establish menstruation by 15 years of age
36
Q

Amenorrhoea is the absence of periods. What is secondary amenorrhoea?

A
  • menstruation cycles have been present but they have been absent for 3 consecutive menstruation cycles
37
Q

What is oligomenorrhoea?

A
  • few or infrequent periods

- <7-8 periods/year

38
Q

What is polymenorrhoes?

A
  • a menstrual cycle lasting less than 21 days
  • the average is 28 days
  • this means she will have more periods in a year
39
Q

What is hirsutism?

A
  • a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern
  • common on the face, chest and back
  • common in PCOS and congenital adrenal hyperplasia
40
Q

Hirsutism is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern, commonly on the face, chest and back. An excess of which group of hormones is responsible for this?

A
  • androgens
41
Q

Hirsutism is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern, commonly on the face, chest and back. This is commonly caused by excessive levels of androgens. What is the most common condition that causes hirsutism?

A
  • polycystic ovary syndrome (PCOS)
  • dysfunction of hypothalamus-pituitary-ovarian axis
  • too much androstenedione interfering with follicular cycle and ovulation
  • ovulation does not occur and the cyst is formed
42
Q

Hirsutism is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern, commonly on the face, chest and back. This is commonly caused by excessive levels of androgens, with the most common being polycystic ovary syndrome (PCOS). What are the most common warning features that a patient may have hirsutism?

A
  • sudden onset of severe hair growth
  • virilisation (development of male like features)
  • cushing’s syndrome (excessive cortisol)
43
Q

Polycystic ovary syndrome (PCOS) is when there is a dysfunction of hypothalamus-pituitary-ovarian axis. This causes too much androstenedione, which interferes with follicular cycle and ovulation, meaning ovulation does not occur and the cyst is formed. What is the name of the criteria used to diagnose a patient with PCOS?

A
  • Rotterdam criteria
44
Q

Polycystic ovary syndrome (PCOS) is when there is a dysfunction of hypothalamus-pituitary-ovarian axis. This causes too much androstenedione, which interferes with follicular cycle and ovulation, meaning ovulation does not occur and the cyst is formed. The Rotterdam criteria is used to diagnose a patient with PCOS. What is the criteria for diagnosis based on the Rotterdam criteria?

A

1 - anovulation (oocyte not release and menstrual cycle fails)
2 - hyperandrogegism (elevated levels of androgens such as testosterone)
3 - transvaginal ultrasound of follicles (≥ 12 follicles and/or ↑ ovarian volume)

PATIENT NEEDS 2 OR MORE OF THESE TO BE DIAGNOSED WITH PCOS

45
Q

Polycystic ovary syndrome (PCOS) is when there is a dysfunction of hypothalamus-pituitary-ovarian axis. This causes too much androstenedione, which interferes with follicular cycle and ovulation, meaning ovulation does not occur and the cyst is formed. The Rotterdam criteria is used to diagnose a patient with PCOS. One of the criteria for a diagnosis of PCOS is hyperandrogegism (elevated levels of androgens such as testosterone). How can this be determined clinically and biochemically?

A
  • clinically = hirsutism (excessive male pattern hair growth or acne)
  • biochemically = excessive androgens in serum
46
Q

What condition does the ultrasound image below show:

1 - normal follicles in the ovaries
2 - polycystic ovary syndrome
3 - ovarian cancer
4 -hyperandrogegism

A

2 - polycystic ovary syndrome

- >12 follicles can be seen

47
Q

In a patient with polycystic ovary syndrome (PCOS) would we expect to see normal, low or high levels of the following hormones:

  • LH
  • FSH
  • Testosterone
  • sex hormone binding globulin (SHBG) protein that carries testosterone
  • Estrogen
  • Progesterone
A
  • LH = high
  • FSH = normal
  • Testosterone = high (causes PCOS)
  • SHBG = low because testosterone is not bound so testosterone is biologically active causing PCOS
  • Estrogen = normal
  • Progesterone = low (no ovulation so low levels of this)
48
Q

In a patient with polycystic ovary syndrome (PCOS) we see normal, low and high levels of the following hormones:

↑ LH
Normal FSH
↑ T
↓ SHBG
Normal E
↓ Progesterone (P)

What are the 4 main effects PCOS can have on female reproduction?

A

1 - infertility (no ovulation so no eggs released during ovulation)
2 - miscarriage (low progesterone so uterus is not prepared)
3 - gestational diabetes mellitus
4 - no effect

49
Q

In a patient with polycystic ovary syndrome (PCOS) we see normal, low and high levels of the following hormones:

↑ LH
Normal FSH
↑ T
↓ SHBG
Normal E
↓ Progesterone (P)

What are the 4 main effects PCOS can have on female non-reproduction factors?

A

1 - diabetes mellitus
2 - dyslipidaemia
3 - cardiovascular disease
4 - endometrial cancer (no ovulation, but lots of estrogen which causes proliferation of endometrium and without progesterone can cause cancer)

50
Q

Polycystic ovary syndrome (PCOS) is when there is a dysfunction of hypothalamus-pituitary-ovarian axis. This causes too much androstenedione, which interferes with follicular cycle and ovulation, meaning ovulation does not occur and the cyst is formed. How can PCOS be treated?

A
  • lifestyle modification = lose weight
  • irregular periods = combined oral contraception
  • hirsutism = anti-androgens or hair removal
  • insulin resistance = metformin
  • infertility = ovulation induction, ovarian drilling or IVF
51
Q

What is primary ovarian failure?

A
  • a woman’s ovaries stop working normally before she is 40

- described as early menopauses

52
Q

Primary ovarian failure is when a woman’s ovaries stop working normally before she is 40, commonly described as early menopauses. What is the incidence of this?

A
  • 1%
53
Q

Primary ovarian failure is when a woman’s ovaries stop working normally before she is 40, commonly described as early menopauses. What are the 3 most common ways this can present clinically?

A
  • amenorrhoea (absence of menstruation as no eggs for ovulation to occur)
  • menopausal symptoms (low estrogen causing hot flushes etc..)
  • infertility
54
Q

Primary ovarian failure is when a woman’s ovaries stop working normally before she is 40, commonly described as early menopauses. What are the most common causes of primary ovarian failure?

A
  • genetics
  • autoimmune
  • iatrogenic (caused by surgical procedure)
55
Q

Primary ovarian failure is when a woman’s ovaries stop working normally before she is 40, commonly described as early menopauses. This can be caused by Turners syndrome, what is turners syndrome?

A
  • one of the X chromosomes (sex chromosomes) is missing or partially missing
  • can result in abnormal development of female reproductive organs
56
Q

Primary ovarian failure (POF) is when a woman’s ovaries stop working normally before she is 40, commonly described as early menopauses. What happens to LH and FSH levels in a patient with POF?

A
  • both will be high

- body produces excessive LH and FSH to stimulate menstruation

57
Q

Primary ovarian failure (POF) is when a woman’s ovaries stop working normally before she is 40, commonly described as early menopauses. What are 3 useful tests, other than measuring LH and FSH that can be performed to diagnose patients?

A
  • karyotyping (examine chromosomes for missing X chromosome)
  • ultrasound
  • autoimmune screening
58
Q

Primary ovarian failure (POF) is when a woman’s ovaries stop working normally before she is 40, commonly described as early menopauses. What are 3 treatment options that should be considered?

A

1 - psychological support
2 - hormone replacement therapy
3 - egg donor IVF

59
Q

What does congenital Adrenal Hyperplasia mean?

A
  • congenital = present from birth
  • adrenal = adrenal glands
  • hyperplasia = increased cell proliferation
  • adrenal glands have deficiency in enzymes so cortisol and aldosterone cannot be synthesised and is shifted to androgens. Lots of androgens are released
60
Q

Congenital Adrenal Hyperplasia (CAH) is when there is excessive proliferation of the adrenal tissue, causing abnormal adrenal gland growth. This is caused by a deficiency in an enzyme involved in steroid production. What is the most common enzyme deficiency and what is the pathway for this enzyme?

A
  • 21 hydroxylase is deficient
  • 21 hydroxylase converts progesterone into 17 hydroxyprogesterone
  • 17 hydroxyprogesterone then becomes androgen steroid hormones
61
Q

Congenital Adrenal Hyperplasia (CAH) is when there is excessive proliferation of the adrenal tissue, causing abnormal adrenal gland growth. This is caused by a deficiency in an enzyme involved in steroid production. 21 hydroxylase is the most common deficiency. What will happen to aldosterone and cortisol levels if the patient has 21 hydroxylase deficiency?

A
  • both will be low
62
Q

Congenital Adrenal Hyperplasia (CAH) is when there is excessive proliferation of the adrenal tissue, causing abnormal adrenal gland growth. This is caused by a deficiency in an enzyme involved in steroid production. 21 hydroxylase is the most common deficiency. What will happen to androgen levels if the patient has 21 hydroxylase deficiency?

A
  • aldosterone and cortisol will be low as their precursors are not converted by 21 hydroxylase
  • all precursors are then converted into androgens such as testosterone
  • females may undergo virilisation (develop male like characteristics)
63
Q

Congenital Adrenal Hyperplasia (CAH) is when there is excessive proliferation of the adrenal tissue, causing abnormal adrenal gland growth. This is caused by a deficiency in an enzyme involved in steroid production. 21 hydroxylase is the most common deficiency. What is the method in which this is transmitted genetically?

A
  • autosomal recessive

- 2 copies of abnormal gene present on autosomal chromosome must be present in order for the disease to develop

64
Q

Congenital Adrenal Hyperplasia (CAH) is when there is excessive proliferation of the adrenal tissue, causing abnormal adrenal gland growth. This is caused by a deficiency in an enzyme involved in steroid production. 21 hydroxylase is the most common deficiency and is transferred by autosomal recessive (2 abnormal genes transferred). There are 2 types of CAH, what are they?

A

1 - classic in childhood = severe (salt losing and/or virilisation)
2 - non classic in adulthood = mild

65
Q

Congenital Adrenal Hyperplasia (CAH) is when there is excessive proliferation of the adrenal tissue, causing abnormal adrenal gland growth. This is caused by a deficiency in an enzyme involved in steroid production. 21 hydroxylase is the most common deficiency and is transferred by autosomal recessive (2 abnormal genes transferred). There are 2 types of CAH:

1 - classic in childhood = severe (salt losing and/or virilisation)
2 - non classic in adulthood = mild

How would the more severe classing form present in children?

A
  • salt wasting
  • hypovolaemic shock
  • virilisation
  • precocious puberty (puberty begins to early)
  • abnormal growth
66
Q

Congenital Adrenal Hyperplasia (CAH) is when there is excessive proliferation of the adrenal tissue, causing abnormal adrenal gland growth. This is caused by a deficiency in an enzyme involved in steroid production. 21 hydroxylase is the most common deficiency and is transferred by autosomal recessive (2 abnormal genes transferred). There are 2 types of CAH:

1 - classic in childhood = severe (salt losing and/or virilisation)
2 - non classic in adulthood = mild

How would the mild non classic form present in adults?

A
  • hirsutism (male hair growth) & acne
  • oligo / amenorrhoea (infrequent or no periods)
  • infertility
67
Q

Congenital Adrenal Hyperplasia (CAH) is when there is excessive proliferation of the adrenal tissue, causing abnormal adrenal gland growth. This is caused by a deficiency in an enzyme involved in steroid production. 21 hydroxylase is the most common deficiency and is transferred by autosomal recessive (2 abnormal genes transferred). There are 2 types of CAH:

1 - classic in childhood = severe (salt losing and/or virilisation)
2 - non classic in adulthood = mild

What is the main aim of treatment for CAH?

A
  • normalise androgen levels
  • replace low aldosterone and cortisol
  • can have surgery where required
68
Q

What term would you use for a woman who has only 2 periods/year?

A
  • oligomenorrhea
69
Q

What term would you use for a woman who has periods lasting less than 21 days, meaning she will have more than 12 periods/year?

A
  • polymenorrhea
70
Q

What term would you use for a 19 year old woman who has no periods?

A
  • amenorrhea
71
Q

What are the name of the diagnostic criteria and the 3 criteria for polycystic ovary syndrome

A
  • Rotterdam criteria
    1 - anovulation (egg not released during menstrual cycle)
    2 - hyperandrogenism (excessive male hormones)
    3 - increased follicles identified using ultrasound
72
Q

In a 30 year old women with no periods and she is presenting with morning sickness, what is the most likely diagnosis?

A
  • pregnancy
73
Q

In a 20 year old athletic women has no periods, what part of the hypothalamic pituitary ovarian axis is likely to be affected?

A
  • hypothalamus

Year 2 RE (53 decks)

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