Ovulation Disorders & PCOS Flashcards
Define ovulation disorders, include the four subgroups outlined by FIGO classification
Spectrum of conditions that affect a women’s hormones and affect her ovulation patterns/cycle.
1) Hypothalamic
2) Pituitary
3) Ovarian
4) PCOS
Hypothalamic ovulatory disorders (hypogonadotrophic hypogonadism) presentation
- Amenorrhoea
- Low FSH/LH & Oestrogen
- Negative progesterone challenge test
Hypothalamic ovulatory disorders (hypogonadotrophic hypogonadism) Aetiology
Neoplasm - pituitary tumour
Drugs - steroids, opiates
Congenital - Kallman’s syndrome
Trauma - Brain trauma
Physiological - excessive exercise, anorexia, stress
Hypothalamic ovulatory disorders (hypogonadotrophic hypogonadism) Infertility Management
- Pulsatile GnRH pump OR
- FSH/LH daily injections
+ US monitoring for both
NOTE: Gonadrotrophin daily injections have higher multiple pregnancy rates
Pituitary ovulatory disorders presentation
- Amenorrhoea
- Low FSH/LH & Oestrogen
- Negative progesterone challenge test
& co-existent anterior pituitary abnormality
A common cause of a pituitary ovulatory disorder is a prolactinoma/ hyperprolactinaemia
- What additional symptoms & investigations findings would you expect
- How would you manage it
- Galactorrhea
- MRI prolactinoma
- Highly raised serum prolactin
- Dopamine agonist treatment which should be stopped as soon as the individual becomes pregnant
Ovarian ovulatory disorders (premature ovarian insufficiency) presentation
- Amenorrhea
- Menopausal
- High FSH +/- LH
- Low oestrogen
- Hot flushes
- Night sweats
- Atrophic vaginitis
Premature ovarian insufficiency vs early menopause vs menopause
Age <40 - Premature ovarian insufficiency
40< age <45 - Early menopause
Age > 45 - Menopause
Ovarian ovulatory disorders (premature ovarian insufficiency) aetiology
Iatrogenic - Pelvic radiotherapy, chemotherapy
Iatrogenic - Bilateral oophorectomy
Congenital - Turner Syndrome
Autoimmune - Autoimmune ovarian failure
Ovarian ovulatory disorders (premature ovarian insufficiency) infertility management
- Hormone replacement therapy
- Egg/embryo donation
- Ovary/egg/embryo cryopreservation prior to chemo/radiotherapy where POF anticipated
- Counselling/support network
When assessing ovulation of an individual with regular periods how can you confirm regular cycles
- Midluteul D21 serum progesterone
When assessing ovulation of an individual with irregular periods what tests would you want to carry out first.
Hormonal evaluation
- FSH, LH, TSH, prolactin, oestrogen, testosterone, SHBG, FAI
Before treating any ovulatory disorder, would actions/ lifestyle change/ tests would you want to carry out
- Stabilise weight (18.5<BMI<35)
- Stop smoking, reduce alcohol
- Start folic acid supplements
- Cervical smear
- Drug history
- Rubella immunity
- Semen analysis
- Patent fallopian tube
What standard tests would you carry out on an individual presenting with ovulatory disorder
- Hormonal ovulation assessment
- Progesterone challenge test
- USS for follicular development, ovulation induction
- Aetiology focused tests e.g. MRI, karyotyping, autoantibody screen
What is a progesterone challenge test and what would a positive or negative test indicate
- Administering progesterone to induce a period
- Positive test - Withdrawal bleed within ~7-10 days after progesterone. This would indicate that oestrogen levels are normal
- Negative test (no bleeding) - low oestrogen levels, uterine/endometrial abnormality or cervical stenosis
PCOS presentation
- Oligio/amenorrhoea, infertility
- Normal FSH/LH (or excess LH)
- Normal oestrogen
- Hyperandrogenism (raised testosterone)
- hirsutism, acne, weight gain, alopecia
PCOS diagnostic criteria
2 out of the following 3…
1) Oligo/amenorrhoea
2) USS polycystic ovaries
3) Hyperandrogenism (acne, hirsutism)
PCOS definition
Polycystic ovary syndrome (PCOS) is a hetrogenous disorder characterised by hyperandrogenism, oligoovulation/anovulation and/or the presence of polycystic ovaries
PCOS general advice
- Encourage weight loss & exercise
- Educate on risk of CV disease, diabetes & endometrial cancer
PCOS pharmacological treatment for women not planning pregnancy
- Co-cyprindrol: reduces hirsutism and promotes regular menstruation
- Combined oral contraceptive pill (COCP): decreases irregular bleeding and offers protection against endometrial cancer
- Metformin: aids in regularising menstruation, reducing androgens (hirsutism, acne) and reducing insulin resistance (but not in helping weight loss)
PCOS pharmacological treatment for women wishing to conceive
Clomiphene citrate (anti-oestrogen) (first line)
- induces ovulation and enhances conception rates
- Clomiphene alternatives: tamoxifen, letrozole
Metformin
- can be used alone or in combination with clomiphene
- helps restore ovulation & improves chance of pregnancy
Ovarian drilling (second line)
- laparoscopic ovarian diathermy
- damages thick outer layer of ovaries
- this reduces testosterone production
Gonadotrophins (second line)
- if clomiphene & metform ineffective
- daily recombinant FSH injections
- stimulates follicular growth induces ovulation
- risk of multiple pregnancy (overstimulation)
IVF (last line)
Why is PCOS associated with an increased risk of endometrial cancer
Oligomenorrhoea/amenorrhoea =>
Increased risk of endometrial hyperplasia =>
Increased risk of endometrial cancer
Describe the relationship between PCOS & insulin resistance and the effect this has on LH, FSH & testosterone levels
Insulin resistance seen in 50-80% PCOS =>
Diminished response to insulin but normal pancreas =>
Hyperinsulinaemia
- Insulin acts as a co-gonadotrophin to LH => excess LH
- Insulin lowers SHBG levels => increased free testosterone & hyperandrogenism
