Infertility, Anvoluation, Amenorrhea Flashcards
1
Q
When is Unexplained Infertility diagnosed?
A
Once a woman has unsuccessfully been trying to get pregnant for at least one year and has had all the routine infertility evaluations done including assessment of ovulation, a semen analysis, a Hysterosalpingogram (HSG) to evaluate any uterine blockages, blood tests to asess ovarian reserve and potentially a laparoscopic investigation.
When those all come back normal, a woman is diagnosed with unexplained fertility.
2
Q
Is unexplained infertility an acceptable diagnosis?
A
No! The problem is that the convo often stops with unexplained infertility. A woman is suggested to go through IVG if she wants to get pregnant or to consider surrogacy or adoptin, but there isn’t any additional conversation about her nutritional status, hormone balance, egg quality, or other areas of her systemic function.
3
Q
True infertility makes up what percentage of the entire population?
A
Very small and is often observable, such as structural damage, scar tissue build-up, or other reproductive abnormalities that inhibit ovulation or proper implantation.
4
Q
Is it true that olvuation always occurs on cycle day 14 or halfway through a woman’s menstrual cycle?
A
No, but women and even physicians and ferility specialists are taught this incredibly misleading info. This can lead women to inaccurately time their sexual encounters and it also leads to inaccurate test results and poor outcomes on therapies such as artificial insemination.
5
Q
Can LH tests guarantee when exactly a woman is going to ovulate?
A
No!
6
Q
What is one of the biggest factors that can play a role in ovulation variability?
A
Stress, whether internal, emotional, psychological, or environmental.
7
Q
From a biopsyhiological perspective, how does stress effect ovulatoin?
A
In the presence of norepinphrine, which is released by the locus Coeruleus and Amygdala in the brain, as well as the adrenals i response to stress, the hypothalamus and pituitary instruct the ovaries to shut down their follicle development and hormone production, stunting ovulation and contributing to the development of cysts.
8
Q
What is the longest phase of the menstrual cycle?
A
The luteal phase, typically between 10-16 days.
9
Q
Anything longer than BLANK days in the luteal phase is typically a sign of pregnancy?
A
16 days.
10
Q
On occasion, some women may experience extremely long luteal phases without being pregnant as a result of BLANK?
A
Corpus Luteum Cyst.
11
Q
For some people, early ovulation may result in what?
A
Prematurely developed ovarian follicle, which may impact the quality of their corpus lteum, having an impact on the quantity of progesterone they are able to produce.
12
Q
Early ovulation can often be a sign of what?
A
Estrogen excess (not estrogen dominance0.
13
Q
In the follicular phase, if estrogen levels are higher than normal due to poor estrogen clearance and/or xenoestrogen exposure, they may dampen BLANK and BLANK, negatively affecting BLANK?
A
FSH and LH; ovarian follicle development (which requires ample FSH).
14
Q
In early ovulation, estrogen levels may be at or higher than 200 pg/ml which can trigger the BLANK, initating BLANK and an early ovulation.
A
the LH surge, initiating luteinization.
In this case, although ovulation may occur and there is potential for fertilization, the corpus luteum may not form properly due to poor ovarian follicle development, resulting in lowered progesterone and an increased risk for miscarriage.
15
Q
To determine if early ovulation could be negatively impacting your client’s hormonal health you’ll want to take note of what?
A
When they ovulate in their cycle and observe whether or not they experiene any luteal phase symptoms.
You can also observe their cycle charts and/or BBTs to assess the quality of their temperature rise.
Do they ovulate routinely before cycle day 12 or 13? If so, do they experience any other signs of estrogen excess? How about symptoms of low progesterone such as short luteal phases, PMS, or premenstrual spotting? Do they have a history of miscarriage?
16
Q
What can indicate poor corpue luteum quality due to premature ovulation?
A
Slow or sluggish temperature rises or a temperature shift that does not significantly rise above the coverline.
17
Q
What percentages of infertility cases are due solely to the male factor?
A
30-50%
18
Q
When analyzing male fertility, it is common to receive data on what?
A
- sperm quantity
- motility
- morphology
19
Q
What is a normal quantity of sperm?
A
Over 15 million sperm per milliliter
20
Q
What does motility indicate?
A
- Quantity of movement
- How fast they swim
- If they swim in a linear line
- If they moe at all
21
Q
What does morphology indicate?
A
The sperm’s shape, size, and structure. Abnormally large or small heads, multiple heads, multiple tails, or other abnormalities that can interfere with proper function.
22
Q
What isn’t commonly tested for sperm quality?
A
The sperm’s DNA. Sperm analysis may come back normal, yet DNA breaks or mutations in the sperm could still be a contributing factor behind male-factor infertility, genetic complications, and even miscarriage.
23
Q
What is the most accurate test for assessing sperm DNA quality?
A
Sperm Chromatin Structure Assay (SCSA)
24
Q
Wht factors should be looked at if all routine fertility tests come back “normal”?
A
- Structural abnormalities
- Anovulation
- HP Axis Dysfunction
- Sperm & Egg/Follicle Quality
- Chromosomal and embryonic abnormalities
- Genetic mutations and predispositions
- Chronic stress, heightened inflammation, chronic immune system activation
- Micronutrient Deficiencies
25
What can lead to structural abnormalities?
* Scar tissue build up in the uterine tubes or uterus (Asherman's syndrome) or as a consquence of STIs like chlamydia
* MRKH syndrome which a woman is born with an underdeveloped or missing uterus
* Cervical Stenosis which leads to a narrowed or closed cervix
26
There needs to be a balanced level of BLANK to grow the endometerial lining to the preferred thickness.
Estrogen.
27
Estrogen excess is associated with the growth of BLANK which may all hinder fertility and pregnancy chances
* Cysts
* Fibroids
* Endometriosis
28
Where does progesterone get its name?
Pro-gestation! It's one of the most important hormones when it comes to sustaining a pregnancy.
29
What does progesterone do?
Slows the pulsation of GnRH from the hypothalamus, telling the ovaries to stop growing follicles and producing estrogen, which inhibits the endometrial lining from becoming too thick.
Also helps to hold the endometrial lining intact so that it doesn't shed prematurely if an egg does implant.
30
Why is it important to have a healthy corpus luteum for pregnancy?
Up until the 8-9th week, the corpus luteum is the primary source of progesterone production until the placenta forms and can take over.
31
Luteal phase deficiency (<10 luteal phase days) due to low BLANK levels can further hinder fertility as it takes roughly 5-6 days for the egg to travel down the uterine tubes into the uterus and 7-10 days for the uterine lining to become receptive to implantation. If the endometrial lining were to shed before that point, it may result in a failed pregnancy.
Low progestrone
32
Progesterone promotes BLANK, which stimulates the production of thyroid hormone.
Thermogenesis
33
Adequate BLANK plays a role in maintaining proper body temperature within the luteal phase.
Thyroid hormone
34
What does adequate thyroid hormone do in maintaining a proper body temp during the luteal phase?
Helps to sustain and "incubate" an embyro once implanted.
Womenw ith hypothyroidism tend to have lower BBTs than average, which may affect proper embyronic development. Due to the lower than optimal body temperatures, many early miscarriages may be linked to undiagnoses hypothyroid conditions.
35
Thyroid hormone is necessary for proper BLANK hormone production and metabolism.
Steroid. So hypothyroidism may play a role in various sex hormone imbalances that could also impact fertility and conception changes.
36
Poor egg quality and BLANK health often go hand in hand, as in order to ovulate properly, a woman has to develop a fully funcitonal follicle.
Follicle
Often these issues happen within the preantral stages of follicle development
37
Can those with SNPS (single nucleotide polymorphisms in MTHFR or other genes support their genetic health and expression through nutrition and lifestyle, often going on to have healthy pregnancies?
Yes
38
Chronic stress, heightened inflammation, and chronic immune system activation such as with autoimmune disease, impaired intestinal integrity, and insuling resistance may factor into BLANK and BLANK as well as BLANK and BLANK?
Poor egg quality and follicle development as well as unfavorable environment for implantation and embryonic growth.
39
What is the reason why women with chronic immune system activation, such as autoimmune conditions and gut infections may have a more difficult time conceiving or carrying to term?
During pregnancy, the immune system shifts into being TH2 dominant, which is not associated with inflammation.
This shift plays a role in preventing the immune system from attacking the tissues of the growing fetus.
Progesterone also plays a role in mildly suppressing the immune system, helping to ensure that the body doesn't reject the newly implanted embryo.
40
How can micronutrients play an important role in ovulatory health?
* They can either directly support the act of follicle development and ovulation OR
* They can serve as antioxidants, supporting a healthy oxidative environment for ovulation to occur.
Micronutrient deficinecies and/or imbalances may hinder both of these important processes.
41
How does zinc deficiency impact ovulation and fertility outcomes?
* Zinc helps support FSH production and is necessary for antral follicle development
* Deficiency can result in poor follicle and corpus luteaum health. This can impact the quality and quantity of progesterone, which can impact one's fertility.
* Zinc helps facilitate embryogenesis and development
* Zinc is necessary for sperm count, density, motility, morphology, and viability, as well as seminal pH.
*
42
What is hypochlorhydria?
A deficiency of stomach acid
43
Zinc absorption can be greatly hindered in the presence of BLANK so if your client experiences digestive disturbances in addition to ovulatory or fertility complications, it is possible they may be deficient in zinc.
Hypochlorhydria
| a deficiency of stomach acid
44
Zinc may not be recommended in high dosages for those who experience low BLANK levels?
Estrogen, as zinc can act as an aromatase inhibitor, potentially lowering estrogen levels further.
45
What is aromatase?
The enzyme responsible for the convesrion of androgens to estrogen in many tissues, including the goands.
46
Iron deficiency and anemia issues can lead to poor BLANK?
Poor ovulatory function, as iron is a necessary component of heme and hemoglobin.
47
What does hemoglobin do?
Delivers oxygen to the body's tissues, including the ovaries.
Without enough oxygen, follicles and eggs may not be able to develop properly.
48
CYP enzymes are heme-dependent, so anemia may lead to poor BLANK, potentially contributing to estrogen dominance-related conditions.
Hormone elimination
49
Low dietary intake of Selenium, Manganese, and Sodium were associated with increased risk of BLANK?
sporadic anovulation
50
Vitamin D deficiency is associated with diminished rates of what?
Anovulation
51
Vitamin A is necessary for facilitating both folliculogenesis and spermatogensis and deficiency can impact bLANK
Both male and female fertility
52
What is folliculogenesis?
Development of ovarian follicles
53
What is spermatogensis?
Development of sperm
54
Is it possible to still experience frequent bleeds that mimic periods without ovulation?
Yes.
55
What is a breakthrough bleed?
As estrogen builds up the endometrial lining, without ovulation, it may reach a certain threshold and without progesterone to hold the lining intact, it may result in premature shedding, AKA a breakthrough bleed.
This is common in women who tend to have very short or very long cycles.
56
What is polymenorrhea?
Short cycles, such as bleeding every 2 weeks
57
What is an LH surge?
A rapid increase in luteinizing hormone levels around 24-48 hours before ovulation.
58
Polymenorrhea may be a sign of what?
Ovulatory failure due to low estrogen and/or the inability to reach an LH surge to facilitate ovulation.
If estrogen is not sufficient enough, what is available will proliferate the endometerial lining to an extent, yet won't be able to trigger the LH surge which means ovulation will likely not occur.
59
Estrogen must reach at least BLANK pg/mL for BLANK hours to trigger the LH surge.
200 pg/ml; 50 hours
If estrogen cannot reach this peak to let up on its FSH and LH suppression, this can eventually result in the degradation of the ovarian follicles, and in some cases the formation of ovarian cysts (as commonly seen in cases of PCOS).
When the follicles die and progesterone isn't present, this results in the premature shedding of the endometrial lining, similar to what would happen at the end of the ovulatory cycle.
60
Is anovulatory bleeding different than ovulation spotting?
Yes, it's different. Ovulation spotting can be normal for some and potentially even a sign of fertility.
61
What is oligomenorrhea?
Bleeding every 2 months
62
What can oligomenorrhea be a sign of?
Anovulation due to prolonged stress or other factors that may inhibit ovulation from occurring.
In this case, estrogen continbnues to build as there is no progesterone to oppose it. Eventually, this will result in a breakthrough bleed that may be very heavy and long.
63
If there is a presence of oligomenorrhea does that always mean a woman is experiencing excess estrogen even if her bleeds are long and heavy?
No it doesn't, it may have more to do with the prolonged endometrial buildup due to insufficient progesterone as a result of anovulation.
In some cases, bleeding still may be scanty, usually as the result of low estrogen and less endometrial proliferation due to the HPG-dysregulation.
Instead of releasing every 2 weeks, it takes longer for the body to break through.
64
Anovulation of any form left unchecked can be dangerous because?
It can increase the risk for endometerial hyperplasia (excessive proliferation of the endometrium due to unopposed estrogen which increases the risk for endometrial cancer)
65
High prolactin levels (hyperprlactinemia) may also contribute to BLANK?
anovulation as prolactin has an inhibitory effect on GnRH.
66
What is GnRH?
Gonadotropin-releasing hormone, responsible for the release of follicle stimulating hormone and lutenizing hormone from the anterior pituitary.
67
High prolactin can interfere with granulosa cell aromatiziation leading to BLANK
an increase in ovarian testosterone production and lower estrogen conversion, further contributing to anovulation.
68
For supoprt with hyperprolactinemia, supplementation of what may be helpful?
Vitex, may be able to lower prolactin levels
69
What is abnormal uterine bleeding (AUB)?
May result in bleeding patterns similar to anovulation. However, AUB could be the result of another concern such as an ovarian cyst, uterine polp or fibroid, pelvic inflammatory disease (PID), a bleeding or blood clotting disorder, miscarriage, and uterine or cervical cancer.
When in doubt, refer out.
70
For women with excessive bleeding due to anovulation, conventional treatments may include what?
An endometrial ablation (a medical procedure that involves destroying the uterine lining through the use of electricity, radio-frequency, heat or freezing).
An ablation should never be done on people who might want children, as it causes so much destruction that implantation would be near impossible.
Doesn't address the root cause.
Doesn't inhibit ovulation or hormone production, as it doesn't interfere with the ovaries.
71
What is dilation and curettage?
a conventional treatment option for anovulatory bleeding. Removes the endometrial lining to temporarily mitigate the symptoms of anovulation.
In most cases, the endometrial lining just grows back because the procedure doesn't address the anovulation and unopposed estrogen.
72
What is progesterone therapy?
Semi-conventional and less invasive treatment for anovulation. Recommended through the use of a progestin-only HBC such as the Mirena IUD, or through bioidentical progesterone therapy.
73
Roughly 90% of anovulatory cases are caused by what?
PCOS
74
What natural options are there for reducing bleeding in the moment?
Herbs such as yarrow, shepard's purse, ladies mantle, cramp bark, and cinnamon which may help with coagulation properties.
75
What can have blood thining effects, potentially worsening menorrhagia?
Anti-inflammatory compounds such as
* curcumin
* high dose fish oil
* ginger
* ibuprofen
* naproxen
Many herbs that reduce inflammation and period pain also have blood thinning properties.
76
What is Lutenizied Unruptured Follicle (LUF)?
Characterized by a failure to ovulate due to the absence of ovarian follicle rupture and can be a factor behind unexplained fertility for some individuals.
77
Why is Lutenizied Unruptured Follicle (LUF) difficult to observe?
A woman may still bleed and have regular cycles, and her cycle charts may appear "normal".
Despite the follicle not releasing an egg, it is still luteinized, meaning it transforms into a corpus luteum and produces progesterone. With that, we may see a biphasic bBT pattern and "normal" progestrone levels within the luteal phase.
78
What is Lutenizied Unruptured Follicle (LUF) been linked to?
Many other conditios such as PCOS, pelvis inflammatory disease, and endometriosis (specifically in regard to adherions).
79
What is the biggest factor in LUF?
Cellular health.
In order for an egg to ovulate, it has to penetrate the phospholipid bilayer (cell membrane) of the ovarian follicle.
There are a handful of things that might negatively affect the phospholipid bilayer and the ability to ovulate such as fatty acid imbalance, cellular inflammation, and poor enzymatic activity, or deficiencies in cofactors needed for proteolytic enzyme production (amino acids and micronutrients, esp. zinc)
80
The use of NSAIDs and other anti-inflammatory compounds around ovulation can contribution to what?
Unruptured follicles, as they directly inhibit the natural inflammatory event of ovulation.
Sometimes these unruptured follicles can swell and lead to the formation of ovarian cysts.
81
What is Amenorrhea?
Absence of a period entirely. This is esp. true if a woman has stopped ovulating altogether, rather inconsistently.
82
When is Amenorrhea diagnosed?
When there is a lack of a menstrual bleed for 3 months or more if a woman's cycles were previously regular and 6 months or more if she has a history of cycle irregularities.
83
What is Primary amenorrhea?
Occurs when one is over the age of 16 and has never had a period
84
What is secondary amenorrhea?
Occurs when there is an absence of a period after previously having one.
85
What is the most common type of secondary amenorrhea?
Hypothalamic Amenorrhea (HA), which occurs when there are hormonal disruptions in GnRH, FSH and LH, typically triggered by excessive unmanaged stress, overexercise and/or malnutrition.
Can be common in women who are underweight, have eating disorders, who are highly athletic or a combination of all three.
86
What are the factors contributing to the inhibition of ovulation and amenorrhea?
* Malnutrition
* Stress
* Overexercise
* Low pituitary hormone output
* High levels of prolactin (which can stunt GnRH)
* Thyroid disease such as hypothyroidism (which can lead to poor follicle development)
* Hormonal contraceptives
* Non-steroidal anti-inflammatory drugs (which can inhibit the act of ovulation itself)
* Genertic polymorphisms in KAL1, FGFR1, PROKR2, and GNRHR
87
How is Hypothalamic Amenorrhea (HA) characterized?
* Lowered anterior pituitary hormones (FSH & LH)
* low estrogen and low/normal androgens
* decreased leptin (due to low body fat)
* and/or increased cortisol (due to exercise and stress)
88
In some cases HA can be confused with what?
PCOS, but the differentiating factors would be the lack of hyperandrogenism and insulin resistance, as well as the specific ratios of LH to FSH.
89
What is a conventional diagnosis of HA?
May consist of a progestin challenge (10 days of moderated progestin intake)
The goal is to attempt to induce a withdrawal bleed.
If a withdrawal bleed occurs, it indicates the woman does have estrogen in her system but is experiencing anovulation.
If a withdrawal bleed doesn't occur after 2-7 days of ceasing the challenge, an attempt with progestin plus ethyinyl estradiol may be adminstered. This is said to induce endometrial buildup and induce a withdrawal bleed.
If a person demonstrates a negative progestin challenge, but positive progestin plus estradoil challenge, an order for FSH and Estradiol are administered.
90
A normal/elevated FSH with low estradiol ( <50ng/ml) would demonstrate what?
Ovarian failure
91
A low FSH (<10 IU/L) in tandem with low estradiol would conclude what?
Either a functional hypothalamic amenorrhea, Sheehan's syndrome or primary ovarian insufficiency diagnosis, depending upon the woman's age, symptomalogy, and AMH levels.
92
If both the progestin and the progestin plus estradiol challenge come back negative, what would be considered?
A more serious condition such as Asherman's syndrome (adhesions) or certical stenosis (scarring) may be considered.
93
An ultrasound of the endometerial lining, in which a lining < 1.5 mm thick is indicative of a hypo-estrogenic state, helps diagnose what?
HA
94
PMS is often a result of what?
Estrogen dominance in ratio to lowered progesterone due to poor ovulation or ovulatory failure.
In this case, estrogen is not being opposed as it should leading to symptoms of heavy periods, tender breasts, bloating, water rentention, headaches/migraines, etc.
95
Progesterone can increase amygdala activity with the brain, increasing chances of what?
Luteal-phase anxiety, which may be mistaken for PMS
96
What has been shown to be very supportive for women with PMS?
A combination of magnesium and b6.
97
What can progesterone naturally lead to?
* Increased apetite
* Slowed gut motility and constipation
* Increased sebum production
* Decreased insulin sensitivity
98
The luteal phase may lead to more cravings naturally because?
Estrogen is lowered and estrogen contributes to the production of serotonin and dopamine. Their brain may crave simple sugars and carbs to produce the missing serotonin/dopamine from the lowered estrogen during this time.
99
What is PMDD?
Considered a very severe form of PMS. The severity of symptoms may lead to self-harm or suicide.
The progesterone metabolite, Allopregnanolone, can irritate the GABA receptors in those with PMDD which can lead to heightened mood discrepancies within the luteal phase when progesterone is at its highest.
100
How can you distinguish between PMS and PMDD?
Look at the severity of their symptoms and also take a DUTCH test to observe their progesterone levels and which pathway their progesterone metabolism is favoring.
If they experience extreme symptoms yet when you observe their DUTCH test they produce ample progerstone and favor more of the 5a-Reductase pathway, they may be experiencing an issue with PMDD over PMS.
101
If someone with PMDD produces ample progesterone and favor more fo the 5a-Reductase pathway, what may be supportive of their symptoms?
* Palmetto
* Nettle
* Reishi mushroom
* Zinc
102
What questions should you ask a client to get to the root imbalances that may be causing ovulatory dysfunction?
* Are they eating enough, particularly enough protein and fat?
* What about their lifestyle influences, toxin exposure, digestive function, sleep quality, energy levels and level of daily activity?
103
How long can it take to restore hormone balance and ovulation when addressing the root causes?
3-4 months
104
What are additional support mechanisms that you can add to help restore ovulation by promotoing healthy HPG communciation as well as stress and inflammation balance?
* Vitex
* Phophatidylserine
* Cytozyme PT/HPT
105
What is Vitex and what does it do?
An herb that helps to normalize the function of the pituitary and reduce levels of prolactin, which if high can inhibit ovulation.
May take up to 6 months to have a positive effect on ovulation.
106
What are the contraindications for Vitex?
Not recommended for those with PCOS as it may increase LH in some individuals which can contribute to hyperandrogenism.
In some cases, vitex may also increase feelings of anxiety and depression as well as nausea, increased menstrual flow, and cramping, therefore it is important to monitor clients who are taking vitex, and potentially recommend they seek support alongside a qualified herbalist.
Do not take during menstruation
107
What is Phosphatidylserine?
A phospholipid derived from soy or sunflower lecithin helps support the central nervous system from damage due to excess stress and cortisol.
This may be a good option for those you suspect are experiencing ovulatory issues due to high amounts of psychological and/or physical stress.
108
What is Cytozyme PT/HPT?
A lamb pituitary/hypothalamus glandular that supports the normalization of pituitary function, helping to support HPG communication.
109
When working with women who experience ovulatory dysfunction, BLANK can be a common occurence?
Low estrogen, so you have to be really careful about types of supplements you are recommending as some have the potential to lower one's estrogen levels further.
110
High quantities of fish oil and other anti-inflammatory compounds and medications should be used with caution when?
Around ovulation becuase although anti-inflammatory and anti-oxidant compounds can support egg quality, taken in high quantities around ovulation may inhibit proper luteinization of the ovarian follicle, which is a naturally inflammatory process.
111
What is a way that you can support the HPG axis communication?
Improving the cortisol awakening response and circadian rhythm.
112
What BMI is said to be ideal for ovulatory health?
Greater than 19 kg/m2 or roughly 26-28% body fat
113
Supportig a client who has HA, what should you recommend first?
* Ensure they are getting in plenty of quality proteins and fats with every meal
* Consuming a high calorie diet to nourish their body and adrenals and drecrease the stress response
* Manage their stress appropriately, nourish their adrenals and not over-exercise
* For some Vitex can be helpful for promoting ovulatory function by normalizing FSH and LH.
114
High doses of zinc supplementation must be monitored because?
It can inhibit aromatase activity, which can lead to lower levels of estrogen and higher testosterone, increasing the risk for ovulatory dysfunction.
Need to monitor this when working with women who experience ovulatory dysfunction
115
Dinnodolymethane (DIM and its inactive form Indole 3 Carbinol (i3c) found within cruciferous veggies, are not recommended for women with?
Low estrogen as they may contribute to phase 1 estrogen metabolism and catechol estrogen metabolite production
116
For women with lower estrogen, Calcium D Glucarate (CDC) may?
further deplete their estrogen and serotonin levels
117
Phytoestrogens such as flax seed and soy in excess amounts may
Block estrogen receptors. They may lower estrogen levels further for those who still experience low estrogen.
This is very bioindividualistic and may be more problematic for women for overcome phytoestrogens such as those who adhere to a vegan/veg diet.
