Ovulation disorders yet again Flashcards
What is the average length of a full menstrual cycle?
28 days
Name the two phases of the menstrual cycle
Follicular
Luteal
What is oligomenorrhea?
Less than 9 cycles in a year (i.e prolonged cycles)
What is amenorrhea? How can it be classified?
Absence of menstruation. Primary (no menarche) or secondary
Oligomenorrhea and amenorrhea are linked to what?
Anovulation (failure of egg to be released from the ovaries)
Describe the hypothalamic pituitary ovarian axis
Hypothalamus - gonadotrophic releasing hormone
Pituitary - follicular stimulating hormone and lutenizing hormone
Ovaries - oestradiol + progesterone
Where is gonadotrophic releasing hormone produced?
Neurones in the hypothalamus
How is gonadotrophic releasing hormone secreted?
Pulsatile
How does secretion of GnRH affect secretion of FSH and LH?
Low frequency secretion - FSH
High frequency secretion - LH
What secretes FSH?
Anterior pituitary
What does FSH do?
Stimulates follicular development
Thickens endometrium
What secretes LH?
Anterior pituitary
What does LH do?
Peak secretion stimulates ovulation
Corpus luteum development
Thickens endometrium
What hormone triggers ovulation?
LH
What does an ovulation detector kit detect?
Surge of LH 1.5 days before ovulation
How do the ovarian hormones vary with ovulation?
Oestradiol - high before ovulation
Progesterone - high after ovulation
What produces progesterone?
Corpus luteum
Placenta during pregnancy
What produces oestrogen?
Ovaries
Adrenal glands
Placenta during pregnancy
What does oestrogen do?
Thickens endometrium
Induces production of fertile cervical mucus
Describe the effects of high oestrogen
Inhibits FSH and prolactin
Stimulates LH
What does progesterone do?
Inhibits LH Maintains endometrial thickness Induces production of infertile (thick) cervical mucus Increases basal body temperature Relaxes smooth muscle
How do you determine whether ovulation is taking place?
Regular cycles suggest ovulation ; irregular cycles suggest anovulation
Confirm via mid luteal (day 21) serum progesterone (raised) in two samples
Further hormone testing may be needed
Why is the presence of absence of ovulation a big deal?
Can affect fertility
Where is the pathology in hypogonadorophic hypogonadism?
Hypothalamus or pituitary
How does hypogonadotrophic hypogonadism present?
Low LH/FSH
Oestrogen deficiency
Normal prolactin
Amenorrhea
How is oestrogen deficiency tested for?
Serum oestradiol
Progesterone challenge test
What are the hypothalamic/pituitary causes of amenorrhea?
Stress Inc exercise Low BMI Tumour Kallman's Drugs (steroids, opiates) Trauma
How is hypogonadotrophic hypogonadism managed?
Weight stabilisation Pulsatile GnRH (subcutaneous or IV) OR Gonadotrophic daily injections
What are the benefits of both pulsatile GnRH and gonadotrophic daily injections? How are these treatments monitored?
Pulsatile GnRH - high conception rate
Gonadotrophic injections - higher multiple pregnancy rates
Ultrasound (follicular tracking)
How does hypothalamic pituitary dysfunction (NOT failure) present?
Normal oestrogen
Normal gonadotrophs
Oligo/amenorrhea
Often polycystic ovarian syndrome
What is the diagnostic criteria for polycystic ovarian syndrome?
Oligo/amenorrhea
Polycystic ovaries on USS
Clinical/biochemical signs of hyperandrogenism
What are signs of hyperandrogenism?
Male pattern baldness
Acne
Hirsutism
How do people with polycystic ovaries react to insulin?
Resistant - normal pancreatic reserves but impaired efficacy to hyperinsulinaemia (may nave type 2 diabetes as result)
How does hyperandrogenism arise in patients with polycystic ovaries?
Insulin lowers sex hormone binding globulin (SHBG) levels causing increases in free testosterone
Insulin acts as a co-gonadotroph to LH. T/F
True
How is PCOS managed?
Patient dependent
Sub fertility managed by ovulation induction
What should be done pre ovulation induction for fertility treatment?
Weight loss (BMI
How is ovulation induction carried out?
Clomefine citrate/tamoxifen/letrozole OR (if resistant)
Gonadotrophin (recombinant FSH) daily injection OR
Laproscopic ovarian diathermy
What risks are associated with gonadotrophin daily injection?
Multiple pregnancies
Overstimulation
What risks are associated with laproscopic ovarian
Ovarian destuction
What can be used as an alternative to clomefine citrate? Why?
Metformin
Increases insulin sensitivity, decreases androgens (& thus hyperandrogenism) and raises SHBG
Restores menstruation and ovulation
What does metformin not do?
Help with weight loss
What is ovarian hyperstimulation? What are the risk factors?
Follicles produce increased growth factors –> fluid shift –> dehydration and thick blood
What are the symptoms of ovarian hyperstimulation?
Depends on severity:
Abdo pain Ascites Nausea & vomiting Oliguria Hypoproteinaemia Thromboembolism Large ovaries
Are single or multiple pregnancies higher risk? Higher risk of what?
Multiple
Hyperemesis Pre/eclampsia Gestational diabetes Stillbirth Intra-uterine death Anaemia Post-natal depression Post partum haemorrhage Prematurity Low birth weight Twin to twin transfusion syndrome
Are monochronic or dichronic twins at most risk of perinatal mortality?
Monochronic
What ultrasound sign indicates dichronicity? Which ultrasound sign indicates monochronicity?
Lambda
T sign
What is twin to twin transfusion syndrome? Which type of twins are at risk?
Unbalanced vascular communications within placental bed results in recipient of increased blood developing polyhydraminos and donor developing oliguria, oligohydraminos and growth restriction
Monochronic diamniotic
How can twin to twin transfusion syndrome be managed? What happens if its not treated?
Laser division of placental vessels
Amnioreduction
Septostomy
Death
What are the early and long term problems of prematurity?
Early - Intensive care admission - Respiratory distress syndrome Late - Cerebral palsy - Sight impairment - Congenital heart disease - Lower IQ - ADHD - Language development problems
How does hyperprolactinemia present?
Amenorrhoea
Galactorrhea
What medications are linked with hyperprolactinaemia?
Anti-emetic
Anti-psychotic
What must be clinically tested when a patient presents with hyperprolactinemia?
Visual fields
How should hyperprolactinaemia be investigated?
FSH/LH (should be normal) Low oestrogen Raised serum prolactin over 1000 (>2 occasions) Thyroid function tests (normal) MRI
How is hyperprolactinaemia treated? What is it important to remember?
Dopamine antagonist
- Cabergoline twice weekly
- Bromocriptine
STOP treatment during pregnancy
How does ovarian failure present?
High gonadotrophins (raised FSH in two samples)
Low oestrogen
Amenorrhea
Menopause
How is premature ovarian failure defined?
Menopause before the age of forty
List the causes of premature ovarian failure
Genetic (turner's, fragile X, XX gonadal agenesis) Radiotherapy Chemotherapy Oophrectomy (bilateral) Autoimmune
How is premature ovarian failure managed?
Hormone replacement therapy
Assisted conception
Cryopreservation of gametes prior to cancer therapy
Counselling
What are the key features of a gynaecological history?
Details of menstrual cycle Amenorrhea (pregnancy test) Acne Galactorrhea Headaches Visual symptoms Past medical history Drug history
What biochemical investigations should be performed with ovarian irregularities?
Mid luteal progesterone (day 21)
Early follicular tests (day 2-5)
- FSH, LH, oestradiol
- serum testosterone / SHBG (free androgens)
- prolactin
- TSH (hypothyroid)
Progesterone challenge test (bleeding indicates normal oestrogen)
Which type of ultrasound is used in infertility testing/monitoring treatment response?
Transvaginal
What tests may be indicated in infertility testing?
Autoantibodies
Karyotype
MRI
Bone density (oestrogen)
