lecture 30: disease and disorders 2: ovarian

Question 1

What is ovarian follicle development?

Answer 1

preantral follicle growth (4 months)

• primordial follicles
• initial recruitment
• primary follicles

Antral follicle growth (2 cycles)

• antrum formation
• cyclic recruitment
• some undergo atresia
• selection and dominance
• ovulation

Question 2

What are genes involved in fertility?

Answer 2

• primordial follicles
  
  • KITL, KIT, AMH
• primary follicle
  
  • GDF9, KITL
• secondary follicle
  
  • FSH, FSHR, IGF1, CCND2, TAF4B
• early antral follicle
  
  • INHA, INHBA, CX37
  • ERalpha, ERbeta
• ovulation
  
  • LHR, COX2, PR, CEBPB, NRIP1
• COC integrity
  
  • GDF9, BMP15, PTGER2, PTX3, AMBP
• fertilisation and pre-implantation development
  
  • ZP1, ZP2, ZP3, MATER, DNMT1o, PMS2, HSF1
• implantation
  
  • COX2, HOXA10, HOXA11, LIF, IL11R, HMX3, PR, ERalpha

Question 3

What are examples of people purporting bizarre reasons for ovarian disorders?

Answer 3

• women drivers could suffer damage to ovaries, says Saudi Sheikh

Question 4

What are normal levels of follicles?

Answer 4

• foetus at 20 weeks’ gestation: each ovary contains about 4 million follicles
• term: 1-2 million follicles
• puberty: 300,000 - 400,000
• 37 years: 100,000 then rapid loss
• perimenopausal threshold less than 1000 follicles?
• also decline in quality

Question 5

What is premature ovarian insufficiency (POI)?

Answer 5

• incidence and cause
  
  • POI or premature ovarian failure (POF)
  • affects ~1% of population
  • genetic - Turner and Fragile X syndrome, inhibin alpha gene
  • unknown - autoimmune?
  • side effect of cancer/fertility issues and treatment
• symptoms
  
  • no periods for 4 months before age 40
  • FSH levels greater than 40mlU/ml on 2 occasions at least 1 month apart (never rely on one off level); day 2-6 if cycling
  • abnormally low AMH and oestrogen level
  • exclusion of all other causes of absent periods, chromosome test
• treatment
  
  • no known treatment
  • sometimes responsive to ovarian stimulation, donor eggs to conceive
  • at risk pre-pubertal girls option of ovarian cryopreservation
  • still need contraception: lifetime chance of ever conceiving 5-10%
  • HRT/contraception until around 50 years
  • major problem is decreased oestrogen on related health issues
• related health issues
  
  • osteoporosis
  • heart disease
  • hypothyroidism
  • auto-immune diseases
  • support networks

Question 6

What are problems with ovulation?

Answer 6

• no ovulation = no egg = no pregnancy
• 40% of all infertile women
• symptoms
  
  • oligomenorrhoea (infrequent period)
  • amenorrhoea (absent period), more than 6 months
• causes
  
  • hormone deficiency
  • very low body weight (less than 20%) - eating disorders
  • obesity (10-15%) and weight fluctuations
  • diet and stress
  • over exercise
  • hormone resistance (insulin)
  • damaged or diseases ovaries, pituitary tumour

Question 7

What is anovulation?

Answer 7

• diagnosis
  
  • ultrasound
    
    • abnormalities - ovarian (cysts), uterine growths, endometriosis
  • blood tests
    
    • steroids, gonadotrophins, prolactin, thyroid, AMH
• treatment
  
  • lifestyle changes?
  • hormonal ovulation induction (OI)
    
    • clomiphene citrate (Clomid/Serophene)
      
      • pill for 5 days, side-effects
      • stimulates ovulation (80%), twinning (10%)
    • gonadotrophins (FSH, LH, hCG)
      
      • injections, side-effects
      • promoting follicle growth
      • risk of multiples
  • IVF treatment

Question 8

What is polycystic ovary syndrome (PCOS)?

Answer 8

• affects 5-10% of women - most common endocrine disorder
• indigenous Australian women up to 21%
• issues with diagnosis, could be more?
• syndrome - multifaceted symptoms, several diseases
• symptoms
  
  • weight gain (centralised)
  • increased acne and bad skin
  • hirsutism - face (male patterns)
  • anovulation, irregular menstrual cycles
  • subfertility - lack of pregnancy and higher miscarriage
  • mood swings, decreased libido, ovulation kit useless
• variation in symptoms and how many are evident
• effects on embryo/foetus - programming?

Question 9

How is PCOS diagnosed?

Answer 9

• strict but changing criteria
  
  • increased androgens - hirsutism (70%), increased acne
  • anovulation, irregular menstrual cycles
  • presence of cystic follicles – enlarged ovaries, increased small surface cysts
• must have 2 of 3 - can have PCOS and NOT have cystic ovaries (40%)!
• blood tests
  
  • increased LH, decreased FSH, decreased SHBG, increased androgens, increased oestrogens (oestrone)
• ultrasound
  
  • greater than 12 follicles 2-9mm (small), increased ovary size

Question 10

What is the interaction between theca and granulosa cells?

Answer 10

• interact to make oestrogens
• theca: cholesterol → androgens
• granulosa: androgens → oestrogens

Question 11

What happens to theca and granulosa in PCOS?

Answer 11

• over production of LH and androgens
• theca: cholesterol → androgens
• granulosa: androgens X oestrogens
• testosterone goes into blood → fat cell → production of oestrone → anterior pituitary

Question 12

What are causes and risk factors for PCOS?

Answer 12

• genetic factors??
• weight
  
  • change, over/under, hard to lose (metabolic)
  • loss of just 5% BW can resolve anovulation
  • half of all PCOS women are NOT overweight
• insulin resistant (increased circulating insulin) 80% of women
  
  • insulin → increased androgens
  • insulin → decreased SHBG (liver)

Question 13

What is follicular development in PCOS?

Answer 13

• insulin acts on developing follicle
• responds to LH
• → final step in development
• follicular development stopped
• death of granulosa cells
• death of theca cells prevented by insulin
• cyst
• testosterone secreted

Question 14

What are factors associated with PCOS?

Answer 14

• obesity and metabolic sequelae
• type II diabetes
• cardiovascular disease
• uterine/ovarian carcinomas (increased oestrone)

Question 15

What are treatments for PCOS?

Answer 15

• OCP (+ androgen inhibitors)
• clomiphene - to boost FSH
• blockers of androgen synthesis (e.g. flutamide)
• metformin - insulin sensitiser
• need to treat underlying causes !!
  
  • weight loss
  • exercise
  • dietary interventions
    
    • low GI diet (glucose)
    • vegetables and pulses
    • vitamin D (deficiency - insulin resistance)
• combinations
• patient specific BUT don’t address all symptoms
• sources of advice
  
  • diagnosis, treatments etc
  • Jean Hailes
  • POSAA

Question 16

What is a definition of ovarian tumours?

Answer 16

• ovarian tumours may arise at any age but are most common between 30 and 60 years old
• ovarian tumours are particularly liable to be or to become malignant
• in their early stages they are asymptomatic and painless
• they may grow to a large size and tend to undergo mechanical complications such as torsion and perforation

Question 17

What is diagnosis and incidence of ovarian tumours?

Answer 17

• difficult to diagnose - lack of specific symptoms
• approximately 25% of all tumours are malignant
  
  • 80% primary and 20% secondary growths
• in developed countries, the lifetime risk of developing ovarian cancer is ~2%
• slightly greater than the risk of cervical or endometrial cancers (but well below the 7% risk of breast cancer)
• in 2010 USA< ~22,000 new cases and ~14,000 women died of ovarian cancer (greater than 50% deaths in women 55-74 years old)
• difficult to understand if increase due to better detection methods and/or increased incidence
• poor prognosis as when identified 60% of women have stage III or IV

Question 18

What are suggestive features of tumour malignancy?

Answer 18

• age - over 50 years old, chance greater than 50%, under 50 less than 15%
• rapid growth
• ascites
• solid tumour or multilocular cysts
• referred pain suggests nerve involvement
• identification of blood markers (CA125)

Question 19

What are primary and secondary tumours?

Answer 19

• primary - epithelial carcinomas (90%), stromal, germ cell
• secondary
  
  • krukenberg tumour - from a stomach carcinoma
  • breast
  • other parts of genital tract

Question 20

What are risk factors and reducers of ovarian tumours?

Answer 20

• risk factors
  
  • age is the strongest risk factor, especially postemenopausal and after HRT
  • genetic factors can account for 10% of ovarian tumours, as in the Lynch Syndrome of familial breast, colorectal and ovarian cancer (BRAC1, BRAC2 gene). Epigenetics??
  • obesity increases the risk and the heaviest women have the greatest risk
  • ovulation induction with Clomiphene over more than a year carries a 10-fold increased risk of ovarian cancer
• risk reducers
  
  • long term oral contraceptive - greater than 5 years use reduces by half the risk, reduced ovulation the key?
  • child bearing women are less likely to develop ovarian cancer. risk decreases with every pregnancy, breastfeeding may offer added protection
  • tubal ligation/hysterectomy (Ovaries intact) believed to help
  • removing ovaries for women with genetic mutations and also other high risk factors
  • healthy diet reduced fat and increased vegetables for more than 4 years - still further evidence needed

Question 21

What is screening, treatment and survival rates for ovarian cancer?

Answer 21

• screening methods
  
  • blood test for CA-125 protein (germ cell - hCG, AFP, LDH)
  • ultrasound /CT scans
• surgery
  
  • remove ovary (S1) and other tissues (S2-4)
• chemotherapy
  
  • post-surgery (all stages) - oral, i.v., i.p. administration of drugs
• targeted therapies
  
  • inhibitors of angiogenesis e.g. Avastin
  • new area of research, side effects?
• subsequent treatment
  
  • trigger for increased risk of other medical conditions, fatigue (exercise)
• dependent on stage at diagnosis
  
  • epithelial 18-89% after 5 years, LMP 77-99% after 5 years

Question 22

What are possible ovarian fertility treatments?

Answer 22

• ovarian freezing and grafting
  
  • developed in 1999, first human birth 2004 (belgium)
  • application POI, cancer, or beyond natural reproduction
  • risks, inefficiency, and side-effects?
  • sherman silber (St Louis, MO), greater than 30 babies born
• in vitro follicle culture
  
  • novel 3D follicle culture in alginate hydrogel (teresa woodruff)
  • fresh and cryopreserved tissue
  • primary to mature → healthy offspring
  • mouse, primate, human (pre-ovulation)
• in vitro activation
  
  • POI and PCOS patients
  • brand new, combination of multiple techniques
  • key transcription factors

Question 23

What is in vitro activation?

Answer 23

Hippo signalling disruption and Akt stimulation of ovarian follicles for infertility treatment

grafted ovaries lead to succesful pregnancy

• POI patients
• remove ovaries
• preparation of ovarian strips for vitrification and histology
• cryo-preservation
• (Hippo Siganlling Disruption )
• fragmentation of ovarian strips to cubes
• (Akt stimulators)
• culture of ovarian cubes
• return of activated ovarian cubes beneath serosa of fallopian tubes
• retrieve mature eggs
• IVF with husbands’ sperm
• embryos
• embryo transfer
• baby