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O&G > Ovaries + hormonal axis > Flashcards

Ovaries + hormonal axis Flashcards

1
Q

what is the definition of primary amenorrhoea

A

not starting menstruation:

  • or having any other evidence of pubertal development by age 14.
  • by 16 years of age where there are other signs of puberty (e.g. breast bud development).
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2
Q

What is considered normal puberty in females

A
  • 8-14 in girls .
  • takes about 4 years from start to finish.
  • Girls have their pubertal growth spurt earlier in puberty than boys.
  • starts with developing breast buds, then pubic hair and finally starting their periods (usually about 2 years from the start of puberty).
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3
Q

What is considered normal puberty in males

A
  • 9-15 in boys

- boys growth spurt is later in boy

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4
Q

What is Hypogonadotropic Hypogonadism

A
  • deficiency of LH and FSH (gonadotrophins) from the anterior pituitary gland
  • Since there are no gonadotrophins simulating the testes or ovaries (the gonads), they do not respond by producing sex hormones (testosterone and oestrogen)
  • Therefore, a lack of gonadotrophins (“hypogonadotrophic”) leads to underproductive gonads (“hypogonadism”).
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5
Q

What does Hypogonadotrophic hypogonadism tell you

A
  • problem is in the hypothalamus or the pituitary gland.

- If you send a hormonal profile, you will find a low LH and a low FSH result.

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6
Q

what is Hypergonadotrophic Hypogonadism

A
  • the gonads fail to response to stimulation from the gonadotrophins.
  • As there is no negative feedback from the sex hormones (testosterone and oestrogen) the anterior pituitary produces higher levels of gonadotrophins to try harder to stimulate the gonads.
  • Therefore you get high gonadotrophins (“hypergonadotrophic“) and low sex hormones (“hypogonadism“).
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7
Q

What does Hypergonadotrophic hypogonadism tell you

A

The problem is in the ovaries. If you send a hormonal profile, you will find a high LH and high FSH result.

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8
Q

What other endocrine causes can lead to amenorhoea

A 
Hypothyroid
Hyperprolactinaemia
Congenital Adrenal Hyperplasia
Turners Syndrome
Androgen Insensitivity Syndrome
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9
Q

How do you investigate amenorrhoea

A
  • Look for evidence of puberty
  • Look for Hypothalamic causes
  • Signs of androgen excess, thyroid problems or high prolactin (i.e. galactorrhea)
  • Any dysmorphic features
  • Abdominal and pelvic examination/ultrasound
  • Hormone tests (LH, FSH, TSH and prolactin level)
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10
Q

What may you look at to look for signs of puberty

A
  • Height and weight

- Assessing for the development of pubic hair, breast tissue and acne.

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11
Q

How do you investigate hypothalamic causes of amenorrhoea

A
  • History of excessive exercise, stress, eating disorder and chronic disease.
  • Examination revealing low BMI or signs of an eating disorder or chronic disease.
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12
Q

How do you manage primary amenorrhoea

A
  • encourage a reduction in stress and healthy weight gain.
  • Treat/control underlying hormonal conditions
  • Primary ovarian failure or polycystic ovarian syndrome, consider the combined oral contraceptive pill.
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13
Q

What is one of the biggest risk of primary amenorrhoea

A
  • Osteoporosis
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14
Q

How do you treat patients with permenant primary amenorrhoea to reduce the risk of osteoporosis

A
  • Ensure adequate vitamin D and calcium

- Cyclical hormone replacement therapy, for example starting the combined oral contraceptive pill

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15
Q

What is secondary amenorrhoea

A
  • no menstruation for more than 3 months after having previously started periods.
  • Usually investigation would not be indicated until it has lasted more than 6 months.
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16
Q

What are the causes of secondary amenorrhoea

A
  • Pregnancy (most common cause)
  • Menopause
  • Some Hypothalamic causes
  • Pituitary issues
  • Ovarian issues
  • Uterine causes: Ashermans Syndrome
  • hypothyroid
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17
Q

What hypothalamic issues can lead to secondary amenorrhoea

A
  • Excessive exercise
  • Low weight / eating disorders
  • Chronic disease
  • Psychological causes (e.g. stress)
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18
Q

Why do some hypothalamic issues lead to secondary amenorrhoea

A
  • Physiological stress stops the hypothalamus from producing GnRH.
  • This is a way of preventing pregnancy in situations where the body may not be fit for it:
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19
Q

How can pituitary issues lead to secondary amenorrhoea

A 
Pituitary Tumour (e.g. prolactinoma)
Pituitary Failure (e.g. Sheehan Syndrome)
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20
Q

What ovarian issues can lead to secondary amenorrhoea

A

Polycystic Ovarian Syndrome (PCOS)
Premature ovarian failure
Menopause

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21
Q

What is Hyperprolactinaemia

A
  • High prolactin levels act on the hypothalamus to prevent release of GnRH.
  • Without GnRH there is no release of LH and FSH and so there is hypogonadotropic hypogonadism
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22
Q

What is galactorrhoea

A

milky secretion from the breasts as a result of high prolactin levels (30% of high prolactin will have galactorrhoea)

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23
Q

What is the most common cause of galactorrhoea

A

pituitary adenoma

24
Q

What investigations should you undertake if a woman presents with high prolactin

A
  • CT / MRI head to look for a pituitary tumour.
  • Often there is a microadenoma and won’t show up on the initial scan so close follow up is required in case they develop a tumour later.
25
Q

How do we manage hyperprolactinaemia

A
  • Often no treatment is required.
  • Dopamine agonists (bromocryptine / cabergoline) can reduce prolactin levels.
  • These medication are commonly used in conditions such as prolactinomas, Parkinson’s Disease and Acromegaly.
26
Q

What LH/FSH levels suggest primary ovarian failure

A

High FSH

27
Q

What LH/FSH levels suggest PCOS

A

High LH or LH:FSH ratio suggests PCOS

28
Q

What hormonal investigations should you do when investigating amenorrhoea

A
  • FSH/LH
  • Prolactin
  • TSH
  • Progesterone stimulation test
29
Q

What is the progesterone stimulation test

A

Tests whether there is sufficient oestrogen.

Insufficient oestrogen would suggest causes like PCOS, ovarian failure or menopause.

30
Q

What does the progesterone stimulation test show

A
  • No withdrawal bleed = low oestrogen preventing her building up the endometrium
  • Withdrawal bleed = anovulation preventing menstruation
31
Q

How do you do the progesterone stimulation test

A
  • Involves giving progestogen for 5 days (medroxyprogesterone acetate 5mg) then stopped.
  • Menstruation should occur within 7 days of stopping progesterone.
32
Q

What is Androgen insensitivity syndrome

A
  • insensitivity of the body to androgens (e.g. testosterone), so normal male sexual characteristics do not develop.
  • This results in a female phenotype other than the internal pelvic organs.
  • female external genitalia and breast tissue however internally there are testes in the abdomen or inguinal canal and no uterus, upper vagina, fallopian tubes or ovaries.
33
Q

The production of which hormone prevents males from developing female sexual organs

A

mullerian inhibiting factor

34
Q

What Issues lead to androgen insensitivity syndrome

A
  • X linked condition.

- Male karyotype (46 XY).

35
Q

What are the consequences of androgen insensitivity

A
  • no pubic hair, facial hair or male type muscle development.
  • Patients are infertile and there is a risk of testicular cancer unless the testes are removed.
36
Q

What is the management of androgen insensitivity syndrome

A
  • Generally raised as female, but this is sensitive and tailored to the individual.
  • Oestrogen therapy.
  • Bilateral orchidectomy (removal of the testes)
37
Q

What causes pre-menstrual syndrome

A

Caused by fluctuation in hormones during the premenstrual period, particularly the fall in oestrogen and progesterone associated with the corpus luteum degenerating prior to menstruation.

38
Q

What are the features of pre-menstrual syndrome

A
  • Bloating
  • Headaches
  • Backaches
  • Anxiety
  • Low mood
  • Irritability
  • symptoms improve with the onset of the menstruation.
  • not present before menarche, during pregnancy or after menopause.
39
Q

What is premenstrual dysphoric disorder.

A

features of PMS are severe and have a significant effect on quality of life

40
Q

What is the management of pre-menstrual syndrome

A
  • symptom diary relating to the menstrual cycle.
  • General healthy lifestyle changes (e.g. diet, exercise, alcohol, stress, sleep etc)
  • Combined contraceptive pill
  • SSRIs
41
Q

What is premature ovarian failure

A
  • Defined as menopause before the age of 40 years.

- Hormonal analysis will reveal raised LH and FSH levels.

42
Q

What are the causes of premature ovarian failure

A
  • Idiopathic
  • Chemotherapy
  • Radiotherapy
  • Autoimmune
  • Turners Syndrome
43
Q

What are peri-menopausal symptoms

A 
Hot flushes
Emotional lability
Premenstrual syndrome
Irregular periods
Heavier or lighter periods
Vaginal dryness
Reduced libido
44
Q

How are peri-menopausal symptoms managed

A
  • Hormone Replacement Therapy: Tibolone (only when 12 months period free)
  • SSRIs (e.g. fluoxetine / citalopram)
  • Clonidine (act as agonists of alpha adrenergic and imidazoline receptors). Side effects are dizziness and dry mouth.
  • Cognitive Behavioural Therapy
45
Q

When can menopause be diagnosed

A
  • 12 months after the last menstrual period.

- Caused by a drop in oestrogen and progesterone.

46
Q

What advice regarding contraception is given to patients with the menopause

A
  • recommended for 2 years after the last mensural period

- women under 50, and 1 year in women over 50.

47
Q

What would LH/FSH hormones show in the menopause

A

LH and FSH are usually high, in response to the drop in the gonadal hormones.

48
Q

What non-hormonal treatments are available to woman going through the menopause

A

General lifestyle advice (diet, exercise, weight loss, less alcohol, less caffeine, less stress etc)
SSRIs (e.g. fluoxetine)
Venlafaxine (selective serotonin-norepinephrine reuptake inhibitor)
Clonidine (alpha-2 agonist)

49
Q

What types of HRT are there

A
  • Combined oestrogen + progesterone
  • Progesterone only
  • Cyclical
  • Continuous
  • Systemic
  • Local
50
Q

Who should get given cyclical treatment

A

Peri-menopausal

51
Q

Who should get given continuous treatment

A

post menopausal

52
Q

Who should get local vs systemic HRT

A

Local symptoms – give topical treatment (i.e. topical oestrogen cream)
Systemic symptoms – give systemic treatment

53
Q

Who should get given combined vs progesterone only

A

Has uterus – add progesterone

No uterus – don’t add progesterone

54
Q

What are the side effects of HRT

A

Bloating
Breast swelling and tenderness
Weight gain
Headaches

55
Q

What are the benefits of HRT

A

Reduces symptoms of menopause

Reduces osteoporosis

56
Q

What are the downsides of HRT

A
  • Increases risk of breast and endometrial cancer
  • Increases risk of stroke and thrombosis (and coronary artery disease in longer use)
  • These risks increase with longer duration of use
57
Q

Why do we combine progesterone with oestrogen

A
  • lower risk of endometrial cancer (unopposed oestrogen).
  • increases the risk of breast cancer.
  • No need to combine with progesterone when there is hysterectomy in past.
  • mirena coil can be used to provide the progesterone component of combined HRT.

O&G (13 decks)

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