Ovulation Disorders Flashcards
what is the normal range of menstrual cycle?
28-35 days
what is counted as day 1 of the menstrual cycle?
first day of bleeding
how long does bleeding usually last and how is this expressed>
3-8 days
annotated as 7/28 or 5-6/35 etc
what does FSH do?
females - stimulates follicular development - thickens endometrium males - stimulates Sertoli cells - spermatogenesis
what does LH do?
secretd by anterior pituitary stimulates development of corpus luteum LH surge triggers ovulation thickens endometrium males - stimulates Leydig cells - testosterone secretion -spermatogenesis
how do ovulation predictor kits work?
detects LH surge (36 hrs before ovulation)
not always reliable in everyone
when do estradiol and progesterone peak?
estradiol = peaks before ovulation progesterone = peaks following ovulation
where is estrogen secreted from?
primarily secreted by ovaries (follicles) and adrenal cortex (and placenta in pregnancy)
what does oestrogen do?
stimulates thickening of the endometrium
responsible for fertile cervical mucous
+ve feedback stimulates gonadotrophin secretion in follicular phase
inhibits secretion of FSH and prolactin in luteal phase via -ve feedback
where is progesterone secreted from and what does it do?
secreted from corpus luteum maintains early pregnancy inhibits LH secretion responsible for thick infertile cervical mucous maintains thickness of endometrium has thermogenic effect relaxes smooth muscles
how can ovulation be assessed in a regular, 28 day cycle?
confirm by midluteal (day 21) serum progesterone
ovulation = when >30nmol/L
how is ovulation confirmed in irregular cycle?
probably anovulatory
needs further hormone testing
what are the features of ovulatory disorders?
oligomenorrhoea (cycle >35 days)
amenorrhoea (absent menstruation)
what are the 3 groups of ovulatory disorders?
1 = hypothalamic pituitary failure 2 = hypothalamic pituitary dysfunction 3 = ovarian failure
what are the features of hypothalamic pituitary failure?
hypogonadotrophic hypogonadism low FSH/LH oestrogen deficiency (-ve progesterone challenge test) normal prolactin amenorrhoea
what can cause hypothalamic pituitary failure?
stress excessive exercise anorexia/low BMI brain/pituitary tumours head trauma Kallman's syndrome drugs (steroids, opiates)
how is group 1 anovulation (hypothalamic pituitary failure) managed?
stabilise weight
hormone therapy
- needs US monitoring of response (follicle tracking)
what hormone therapy is used in hypothalamic pituitary failure?
pulsatile GnRH - 90% ovulation rate - multiple pregnancy rates not really increased gonadotrophin (FSH and LH) injections - higher multiple pregnancy rates
what are the features of hypothalamic pituitary dysfunction?
normal gonadotrophins/excess LH normal oestrogen levels (progesterone challenge test) oligo/amenorrhoea PCOS - 10-20% have amenorrhoea - 80-90% have oligomenorrhoea
how is PCOS diagnosed?
2 out of 3 of
- oligo/amenorrhoea
- polycystic ovaries (US appearance)
- clinical and/or biochemical signs of hyperandrogenism (acne, hirsutism) - free androgen index (testosterone, sex hormone binding globulin)
how is PCOS managed?
depends on symptoms subfertility = ovulation induction oligo/amenorrhoea = risk of endometrial hyperplasia hirsuitism manage obesity manage acne/alopecia
how can PCOS affect glucose metabolism?
can cause insulin resistance in 50-80%
normal pancreas so results in hyperinsulinaemia
- insulin acts as co-gonadotrophin to LH leading to elevated LH and altered LH/FSH ratios
- insulin lowers SHBG levels causing increased testosterone and therefore hyperandrogenism
pre-treatment for PCOS?
weight loss to optimise results stop smoking/drinking folic acid 400mcg/5mg daily check prescribed drugs rubella immune normal semen analysis patent fallopian tube
how can ovulation be induced in PCOS?
clomifene citrate (clomid) gonadotrophin therapy (daily injections) laparoscopic ovarian diatherapy
what is clomid?
estogenic/anti-estrogenic properties
what do gonadotrophin injections do?
directly stimulate ovaries
what is first line for ovulation induction?
clomid
what can be used if clomid doesn’t cause ovulation?
metformin
gonadrtrophin injections
laproscopic ovarian drill
IVF
how can metformin affect ovulation?
improves insulin resistance causing reduction in androgen production and increase in SHBG
restores menstruation and ovulation
can improve sensitivity to colifene
what are the risks of ovulation induction/IVF?
ovarian hyperstimulation
multiple pregnancy
small risk of ovarian cancer
what causes an increases risk of ovarian hyperstimulation?
<35 years old
PCOS
why is multiple pregnancy a problem?
increased risk of complications
- hyperemesis
- anaemia
- hypertension/pre-eclampsia
- gestational diabetes
- postnatal depression/stress
- mode of delivery/PPH
what are the risks to the foetuses in multiple pregnancy?
early and late miscarriage low birth weight prematurity disability stillbirth/neonatal death twin-twin transfusion syndrome (MCDA twins only)
what is twin-twin transfusion syndrome?
where both twins share a placenta in the womb
abnormal blood vessels form meaning blood can travel between both foetuses
monochorionic twins?
monozygotic twins which share the same placenta
what are the main/most common problems in twins?
prematurity
low birth weight
what are the early problems with prematurity?
need for neonatal intensive care and respiratory support
some suffer from respiratory distress syndrome
what are the long term complications of prematurity?
at least one twin affected with disability in some births (cerebral palsy, vision, congenital heart disease etc)
how can ovulation induction/IVF cause ovarian cancer?
small risk if used for over 12 months
what are the features of prolactinaemia?
amen/galactorrhoea normal FSH/LH low oestrogen raised serum prolactin (>1000) TFT normal micro/macro prolactinoma on MRI
what are the features of ovarian failure?
high gonadrtrophins (FSH>30)
low oestrogen
amenorrhoea
menopause <40 yrs
what can cause premature ovarian failure?
genetic (turners, fragile X) autoimmune ovarian failure bilateral oophorectomy pelvic radiotherapy/chemotherapy family history of early menopause
how is premature ovarian failure managed?
hormone replacement therapy
egg/embryo donation
cryopreservation of ovary/egg/embryo prior to chemo/radiotherapy
what biochemistry tests may be done in a couple attending infertility clinic?
mid luteal progesterone
progesterone challenge test
serum FSH, LH, estradiol, prolactin, TSH, serum testosterone (in males) during early follicular phase (day 2-5)
how is an ultrasound used in fertility clinic?
routine part of infertility consultation
transvaginal
examines pelvic anatomy (uterus, ovaries)
looks for follicular growth/monitors ovulation induction
how is hyperprolactinaemia managed?
dopamine agonist
- cabergoline
- should be stopped when pregnancy occurs
what can cause testicular failure/non-obstructive azoospermia?
genetic (klinefelters, Y chromosome deletion) orchidectomy/undescended testes testicular trauma/torsion/mumps orchitis testicular cancer pelvic radiotherapy,chemotherapy autoimmune disease
