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Endocrine > Ovulation Disorders > Flashcards

Ovulation Disorders Flashcards

1
Q

How long do regular menstrual cycles last?

A

28-35 days

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2
Q

What is day one of the menstrual cycle?

A

When bleeding starts = bleeding typically lasts 3-8 days

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3
Q

What are the phases of the menstrual cycle?

A

Follicular and luteal phases = defined by ovulation

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4
Q

What are ovulatory disorders associated with?

A 
Oligomenorrhoea = cycle >35 days
Amenorrhoea = absent menstruation
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5
Q

What produces GnRH?

A

Synthesised by neurons in the hypothalamus

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6
Q

How is GnRH released?

A

Pulsatile release = low frequency pulses stimulate FSH release, high frequency pulses stimulate LH release

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7
Q

Where are FSH and LH secreted from?

A

The anterior pituitary

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8
Q

What are the functions of FSH?

A

Stimulates follicular development and thickens endometrium

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9
Q

What triggers ovulation?

A

LH surge (peak LH levels)

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10
Q

What are the functions of LH?

A

Stimulates corpus luteum development and thickens endometrium

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11
Q

What do ovulation predictor kits detect?

A

The LH surge = 36hrs before ovulation, successful in 97%

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12
Q

When does oestradiol peak?

A

Before ovulation

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13
Q

When does progesterone peak?

A

Following ovulation

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14
Q

Where is progesterone produced?

A

By the corpus luteum to maintain early pregnancy (also by placenta during pregnancy)

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15
Q

Where is oestrogen secreted from?

A

Primarily by the ovaries (follicles) and adrenal cortex (and the placenta during pregnancy)

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16
Q

What is the function of oestrogen?

A

Stimulates the thickening of the endometrium and is responsible for the fertile cervical mucus

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17
Q

What do high oestrogen levels cause?

A

Inhibits secretion of FSH and prolactin (by negative feedback)

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18
Q

What are the functions of progesterone?

A

Inhibits secretion of LH, responsible for infertile (thick) cervical mucus, maintains thickness of endometrium and relaxes smooth muscle

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19
Q

How does progesterone have a thermogenic effect?

A

Increases basal body temperature

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20
Q

What are regular cycles very suggestive of?

A

ovulation = confirm by midluteal (D21) serum progesterone (>30nmol/L) x 2 samples

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21
Q

What are some methods not recommended for assessing ovulation?

A

BBT, cervical mucus and ovulation predictors

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22
Q

What are irregular cycles suggestive of?

A

Anovulatory cycles = needs further hormone evaluation

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23
Q

What is the WHO classification of ovulatory disorders?

A

Group 1 = hypothalamic pituitary failure
Group 2 = hypothalamic pituitary dysfunction
Group 3 = ovarian failure

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24
Q

How common is hypothalamic pituitary failure

A

Account for 10% of ovulatory disorders = often hypogonadotrophic hypogonadism

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25
Q

What are some features of hypothalamic pituitary failure?

A

Low levels of FSH/LH, normal prolactin, oestrogen deficiency (negative progesterone challenge test), amenorrhoea

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26
Q

What are some causes of hypothalamic pituitary failure?

A

Stress, excessive exercise, anorexia/low BMI, brain/pituitary tumours, head trauma, Kallman’s syndrome, steroids/opiates

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27
Q

What is used to treat hypogonadotrophic hypogonadism?

A

Pulsatile GnRH = SC or IV, pump worn continuously, pulsatile administration every 90mins, 90% ovulation rate

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28
Q

How should hypothalamic pituitary failure be treated?

A 
Stabilise weight (BMI >18.5)
Gonadotrophin (FSH/LH) daily injections = higher multiple pregnancy rates
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29
Q

How is response to treatment for hypothalamic pituitary failure monitored?

A

Using ultrasounds (follicle tracking)

30
Q

How common are hypothalamic pituitary dysfunctions?

A

Accounts for 85% of ovulatory disorders (includes PCOS)

31
Q

What are some features of hypothalamic pituitary dysfunction?

A

Normal gonadotrophins/excess LH, normal oestrogen levels, oligo/amenorrhoea

32
Q

How common is polycystic ovary syndrome (PCOS)?

A

Affects 5-15% of women of reproductive age = 10-20% have amenorrhoea, 80-90% have oligomenorrhoea

33
Q

What is the Revised Rotterdam diagnostic criteria for PCOS?

A

Presence of 2 of = oligo/amenorrhoea, clinical and/or biochemical signs of hyperandrogenism (acne/hirsutism), polycystic ovaries on US

34
Q

What is the appearance of polycystic ovaries on US?

A

12 or more 2-9mm follicles, increased ovarian volume >10ml, unilateral/bilateral

35
Q

How common is insulin resistance in PCOS?

A

Seen in 50-80% = normal pancreatic reserve (hence hyperinsulinaemia), 20% have frank glucose intolerance or type 2 diabetes

36
Q

How does insulin affect sex hormones?

A

Acts as co-gonadotrophin to LH = 60% have elevated LH, 95% have altered LH/FSH ratios
Lowers SHBG levels = increased free testosterone leads to hyperandrogenism

37
Q

What does the management of PCOS depend on?

A

The patient’s symptoms and needs (ie subfertility should be treated with ovulation induction)

38
Q

What are some symptoms of PCOS?

A

Oligo/amenorrhoea, hirsutism, obesity, acne, alopecia

39
Q

What are the pre-treatment interventions for PCOS?

A

Weight loss to optimise results (BMI <30), stop smoking and alcohol, folic acid 400mcg/5mg daily, check prescribed drugs, rubella immunity

40
Q

What are some ways to cause ovulation induction in patients with PCOS?

A

Clomifene citrate, gonadotrophin daily injections, laparoscopic ovarian diathermy

41
Q

What are some features of clomifene citrate?

A

First line, 50/100/150mg orally, days 2-6, 70% ovulate, 40-60% conceive alternatively on tamoxifen/letrozole (all three are anti-oestrogens)

42
Q

What are some features of gonadotrophin daily injections?

A

Recombinant FSH, 80% ovulate, 60-70% conceive

Risks = multiple pregnancies, overstimulation

43
Q

What is the risk of laparoscopic ovarian diathermies?

A

Ovarian destruction

44
Q

What are alternative treatments for patients resistant to clomifene citrate?

A

15-20% of cases = metformin, gonadotrophin injections, laparoscopic ovarian drilling, assisted conception treatment

45
Q

What must metformin be used alongside?

A

Lifestyle modifications

46
Q

What are the effects of metformin as a treatment for PCOS?

A

Improves insulin resistance, reduces androgen production, restores menstruation and ovulation, doesn’t help weight loss, may increase pregnancy rate

47
Q

What are the risks of ovulation induction?

A

Ovarian hyperstimulation, multiple pregnancies, risk of ovarian cancer

48
Q

What are some features of ovarian hyperstimulation?

A

Affects 10% of IVF patients, ranges from mild to severe, increased risk in PCOS or if age<35

49
Q

What maternal pregnancy complications do multiple pregnancies increase the risk of?

A

Hyperemesis, anaemia, pre-eclampsia, hypertension. gestational diabetes, postnatal depression

50
Q

What are some risks associated with multiple pregnancies?

A

Early/late miscarriage, low birth weight (<2.5kg), prematurity, disability, stillbirth/neonatal death, twin-twin transfusion syndrome (TTTS)

51
Q

What is chorionicity?

A

Refers to type of placentation = number of membranes that surrounds babies in a multiple pregnancy

52
Q

What are some features of chorionicity?

A

Lambda sign on US for dichorionic, T sign on US for monochorionic, monochorionic twins 3x risk of perinatal mortality compared to dichorionic twins

53
Q

How common is twin-twin transfusion syndrome?

A

Complicates 10-15% of MCDA twin pregnancies, responsible for 15-17% of all perinantal mortality in twins

54
Q

What is twin-twin transfusion syndrome?

A

Unbalanced vascular communications within placental bed

55
Q

What occurs in twin-twin transfusion syndrome?

A

Recipient develops polyhydramnios, donor develops oliguria, oligohydramnios and growth restrictions, 80-100% fatal if untreated

56
Q

What are the treatment options for twin-twin transfusion syndrome?

A

Laser division of placental vessels, amnioreduction, septosectomy

57
Q

What are some early problems caused by prematurity?

A

40-60% require neonatal intensive care, 8% need help with breathing, 6% suffer from respiratory distress syndrome

58
Q

What are some late problems caused by prematurity?

A

Lower IQ, ADHD, behavioural difficulties, language development problems

59
Q

What is the history of hyperprolactinaemia?

A

Amenorrhoea, galactorrhoea, current medication important

Examine visual fields

60
Q

What do investigations for hyperprolactinaemia show?

A

Normal FSH/LH, low oestrogen, raised serum prolactin (>1000iu/L on 2 or more tests), TFT normal, MRI (to diagnose micro/macroprolactinoma)

61
Q

How are dopamine agonists used to treat hyperprolactinaemia?

A

Longer acting = cabergoline twice weekly
Conventional treatment with bromocriptine
Should be stopped when pregnancy occurs

62
Q

How common is ovarian failure?

A

5% of ovulatory disorders

63
Q

What are the features of ovarian failure?

A

High levels of gonadotrophins (raised FSH >30iu/L x 2 samples), low oestrogen levels, amenorrhoea

64
Q

What is premature ovarian failure?

A

Menopause before age 40

65
Q

What are some causes of premature ovarian failure?

A

Turner syndrome (46X0), XX gonadal agenesis, Fragile X, autoimmune ovarian failure, bilateral oophorectomy, pelvic radio/chemotherapy

66
Q

How can premature ovarian failure be treated?

A

Hormone replacement therapy, assisted conception treatment, freezing of ovum before chemo/radiotherapy where POF anticipated

67
Q

What should be included in a gynaecological history?

A

Details of menstrual cycle, amenorrhoea, hirsutism, acne, galactorrhoea, headaches, visual symptoms, PMH, drug history

68
Q

What are some biochemical tests that can be done to investigate ovarian disorders?

A

Midluteal progesterone (day 21), progesterone challenge tests, early follicular phase testing (days 2-5)

69
Q

What is tested for during the early follicular phase (days 2-5)?

A

Serum FSH/LH/oestradiol, serum testosterone/SHBG, prolactin, TSH

70
Q

What result of a progesterone challenge test indicates normal oestrogen levels?

A

Menstrual bleed in response to a five day course of progesterone

71
Q

How are ultrasounds used to investigate ovulatory disorders?

A

Transvaginal US, routine part of infertility consultation, examines normal pelvic anatomy, look for follicular growth and monitor ovulation induction

72
Q

What are some other tests that can be done to investigate ovulatory disorders?

A

Karotypes, auto-antibody screen, MRI of pituitary fossa, bone density scan

Endocrine (42 decks)

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