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Endocrine > Ovulation Disorders & PCOS > Flashcards

Ovulation Disorders & PCOS Flashcards

1
Q

Define ovulation disorders, include the four subgroups outlined by FIGO classification

A

Spectrum of conditions that affect a women’s hormones and affect her ovulation patterns/cycle.

1) Hypothalamic
2) Pituitary
3) Ovarian
4) PCOS

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2
Q

Hypothalamic ovulatory disorders (hypogonadotrophic hypogonadism) presentation

A
  • Amenorrhoea
  • Low FSH/LH & Oestrogen
  • Negative progesterone challenge test
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3
Q

Hypothalamic ovulatory disorders (hypogonadotrophic hypogonadism) Aetiology

A

Neoplasm - pituitary tumour
Drugs - steroids, opiates
Congenital - Kallman’s syndrome
Trauma - Brain trauma

Physiological - excessive exercise, anorexia, stress

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4
Q

Hypothalamic ovulatory disorders (hypogonadotrophic hypogonadism) Infertility Management

A
  • Pulsatile GnRH pump OR
  • FSH/LH daily injections

+ US monitoring for both

NOTE: Gonadrotrophin daily injections have higher multiple pregnancy rates

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5
Q

Pituitary ovulatory disorders presentation

A
  • Amenorrhoea
  • Low FSH/LH & Oestrogen
  • Negative progesterone challenge test

& co-existent anterior pituitary abnormality

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6
Q

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
A
  • Galactorrhea
  • MRI prolactinoma
  • Highly raised serum prolactin
  • Dopamine agonist treatment which should be stopped as soon as the individual becomes pregnant
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7
Q

Ovarian ovulatory disorders (premature ovarian insufficiency) presentation

A
  • Amenorrhea
  • Menopausal
  • High FSH +/- LH
  • Low oestrogen
  • Hot flushes
  • Night sweats
  • Atrophic vaginitis
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8
Q

Premature ovarian insufficiency vs early menopause vs menopause

A

Age <40 - Premature ovarian insufficiency
40< age <45 - Early menopause
Age > 45 - Menopause

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9
Q

Ovarian ovulatory disorders (premature ovarian insufficiency) aetiology

A

Iatrogenic - Pelvic radiotherapy, chemotherapy
Iatrogenic - Bilateral oophorectomy
Congenital - Turner Syndrome
Autoimmune - Autoimmune ovarian failure

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10
Q

Ovarian ovulatory disorders (premature ovarian insufficiency) infertility management

A
  • Hormone replacement therapy
  • Egg/embryo donation
  • Ovary/egg/embryo cryopreservation prior to chemo/radiotherapy where POF anticipated
  • Counselling/support network
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11
Q

When assessing ovulation of an individual with regular periods how can you confirm regular cycles

A
  • Midluteul D21 serum progesterone
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12
Q

When assessing ovulation of an individual with irregular periods what tests would you want to carry out first.

A

Hormonal evaluation
- FSH, LH, TSH, prolactin, oestrogen, testosterone, SHBG, FAI

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13
Q

Before treating any ovulatory disorder, would actions/ lifestyle change/ tests would you want to carry out

A
  • 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
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14
Q

What standard tests would you carry out on an individual presenting with ovulatory disorder

A
  • Hormonal ovulation assessment
  • Progesterone challenge test
  • USS for follicular development, ovulation induction
  • Aetiology focused tests e.g. MRI, karyotyping, autoantibody screen
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15
Q

What is a progesterone challenge test and what would a positive or negative test indicate

A
  • 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
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16
Q

PCOS presentation

A
  • Oligio/amenorrhoea, infertility
  • Normal FSH/LH (or excess LH)
  • Normal oestrogen
  • Hyperandrogenism (raised testosterone)
    - hirsutism, acne, weight gain, alopecia
17
Q

PCOS diagnostic criteria

A

2 out of the following 3…

1) Oligo/amenorrhoea
2) USS polycystic ovaries
3) Hyperandrogenism (acne, hirsutism)

18
Q

PCOS definition

A

Polycystic ovary syndrome (PCOS) is a hetrogenous disorder characterised by hyperandrogenism, oligoovulation/anovulation and/or the presence of polycystic ovaries

19
Q

PCOS general advice

A
  • Encourage weight loss & exercise
  • Educate on risk of CV disease, diabetes & endometrial cancer
20
Q

PCOS pharmacological treatment for women not planning pregnancy

A
  • 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)
21
Q

PCOS pharmacological treatment for women wishing to conceive

A

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)

22
Q

Why is PCOS associated with an increased risk of endometrial cancer

A

Oligomenorrhoea/amenorrhoea =>
Increased risk of endometrial hyperplasia =>
Increased risk of endometrial cancer

23
Q

Describe the relationship between PCOS & insulin resistance and the effect this has on LH, FSH & testosterone levels

A

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

Endocrine (22 decks)

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