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Year 2 > Ovulation disorders yet again > Flashcards

Ovulation disorders yet again Flashcards

1
Q

What is the average length of a full menstrual cycle?

A

28 days

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2
Q

Name the two phases of the menstrual cycle

A

Follicular

Luteal

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3
Q

What is oligomenorrhea?

A

Less than 9 cycles in a year (i.e prolonged cycles)

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4
Q

What is amenorrhea? How can it be classified?

A

Absence of menstruation. Primary (no menarche) or secondary

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5
Q

Oligomenorrhea and amenorrhea are linked to what?

A

Anovulation (failure of egg to be released from the ovaries)

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6
Q

Describe the hypothalamic pituitary ovarian axis

A

Hypothalamus - gonadotrophic releasing hormone
Pituitary - follicular stimulating hormone and lutenizing hormone
Ovaries - oestradiol + progesterone

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7
Q

Where is gonadotrophic releasing hormone produced?

A

Neurones in the hypothalamus

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8
Q

How is gonadotrophic releasing hormone secreted?

A

Pulsatile

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9
Q

How does secretion of GnRH affect secretion of FSH and LH?

A

Low frequency secretion - FSH

High frequency secretion - LH

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10
Q

What secretes FSH?

A

Anterior pituitary

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11
Q

What does FSH do?

A

Stimulates follicular development

Thickens endometrium

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12
Q

What secretes LH?

A

Anterior pituitary

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13
Q

What does LH do?

A

Peak secretion stimulates ovulation
Corpus luteum development
Thickens endometrium

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14
Q

What hormone triggers ovulation?

A

LH

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15
Q

What does an ovulation detector kit detect?

A

Surge of LH 1.5 days before ovulation

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16
Q

How do the ovarian hormones vary with ovulation?

A

Oestradiol - high before ovulation

Progesterone - high after ovulation

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17
Q

What produces progesterone?

A

Corpus luteum

Placenta during pregnancy

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18
Q

What produces oestrogen?

A

Ovaries
Adrenal glands
Placenta during pregnancy

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19
Q

What does oestrogen do?

A

Thickens endometrium

Induces production of fertile cervical mucus

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20
Q

Describe the effects of high oestrogen

A

Inhibits FSH and prolactin

Stimulates LH

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21
Q

What does progesterone do?

A 
Inhibits LH
Maintains endometrial thickness
Induces production of infertile (thick) cervical mucus 
Increases basal body temperature
Relaxes smooth muscle
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22
Q

How do you determine whether ovulation is taking place?

A

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

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23
Q

Why is the presence of absence of ovulation a big deal?

A

Can affect fertility

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24
Q

Where is the pathology in hypogonadorophic hypogonadism?

A

Hypothalamus or pituitary

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25
Q

How does hypogonadotrophic hypogonadism present?

A

Low LH/FSH
Oestrogen deficiency
Normal prolactin
Amenorrhea

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26
Q

How is oestrogen deficiency tested for?

A

Serum oestradiol

Progesterone challenge test

27
Q

What are the hypothalamic/pituitary causes of amenorrhea?

A 
Stress
Inc exercise
Low BMI
Tumour
Kallman's 
Drugs (steroids, opiates)
Trauma
28
Q

How is hypogonadotrophic hypogonadism managed?

A 
Weight stabilisation 
Pulsatile GnRH (subcutaneous or IV) OR Gonadotrophic daily injections
29
Q

What are the benefits of both pulsatile GnRH and gonadotrophic daily injections? How are these treatments monitored?

A

Pulsatile GnRH - high conception rate
Gonadotrophic injections - higher multiple pregnancy rates
Ultrasound (follicular tracking)

30
Q

How does hypothalamic pituitary dysfunction (NOT failure) present?

A

Normal oestrogen
Normal gonadotrophs
Oligo/amenorrhea

Often polycystic ovarian syndrome

31
Q

What is the diagnostic criteria for polycystic ovarian syndrome?

A

Oligo/amenorrhea
Polycystic ovaries on USS
Clinical/biochemical signs of hyperandrogenism

32
Q

What are signs of hyperandrogenism?

A

Male pattern baldness
Acne
Hirsutism

33
Q

How do people with polycystic ovaries react to insulin?

A

Resistant - normal pancreatic reserves but impaired efficacy to hyperinsulinaemia (may nave type 2 diabetes as result)

34
Q

How does hyperandrogenism arise in patients with polycystic ovaries?

A

Insulin lowers sex hormone binding globulin (SHBG) levels causing increases in free testosterone

35
Q

Insulin acts as a co-gonadotroph to LH. T/F

A

True

36
Q

How is PCOS managed?

A

Patient dependent

Sub fertility managed by ovulation induction

37
Q

What should be done pre ovulation induction for fertility treatment?

A

Weight loss (BMI

38
Q

How is ovulation induction carried out?

A

Clomefine citrate/tamoxifen/letrozole OR (if resistant)
Gonadotrophin (recombinant FSH) daily injection OR
Laproscopic ovarian diathermy

39
Q

What risks are associated with gonadotrophin daily injection?

A

Multiple pregnancies

Overstimulation

40
Q

What risks are associated with laproscopic ovarian

A

Ovarian destuction

41
Q

What can be used as an alternative to clomefine citrate? Why?

A

Metformin
Increases insulin sensitivity, decreases androgens (& thus hyperandrogenism) and raises SHBG
Restores menstruation and ovulation

42
Q

What does metformin not do?

A

Help with weight loss

43
Q

What is ovarian hyperstimulation? What are the risk factors?

A

Follicles produce increased growth factors –> fluid shift –> dehydration and thick blood

44
Q

What are the symptoms of ovarian hyperstimulation?

A

Depends on severity:

Abdo pain
Ascites
Nausea & vomiting 
Oliguria 
Hypoproteinaemia 
Thromboembolism
Large ovaries
45
Q

Are single or multiple pregnancies higher risk? Higher risk of what?

A

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
46
Q

Are monochronic or dichronic twins at most risk of perinatal mortality?

A

Monochronic

47
Q

What ultrasound sign indicates dichronicity? Which ultrasound sign indicates monochronicity?

A

Lambda

T sign

48
Q

What is twin to twin transfusion syndrome? Which type of twins are at risk?

A

Unbalanced vascular communications within placental bed results in recipient of increased blood developing polyhydraminos and donor developing oliguria, oligohydraminos and growth restriction

Monochronic diamniotic

49
Q

How can twin to twin transfusion syndrome be managed? What happens if its not treated?

A

Laser division of placental vessels
Amnioreduction
Septostomy

Death

50
Q

What are the early and long term problems of prematurity?

A 
Early 
 - Intensive care admission
 - Respiratory distress syndrome 
Late 
 - Cerebral palsy
 - Sight impairment
 - Congenital heart disease 
 - Lower IQ 
 - ADHD
 - Language development problems
51
Q

How does hyperprolactinemia present?

A

Amenorrhoea

Galactorrhea

52
Q

What medications are linked with hyperprolactinaemia?

A

Anti-emetic

Anti-psychotic

53
Q

What must be clinically tested when a patient presents with hyperprolactinemia?

A

Visual fields

54
Q

How should hyperprolactinaemia be investigated?

A 
FSH/LH (should be normal)
Low oestrogen
Raised serum prolactin over 1000 (>2 occasions)
Thyroid function tests (normal)
MRI
55
Q

How is hyperprolactinaemia treated? What is it important to remember?

A

Dopamine antagonist

  • Cabergoline twice weekly
  • Bromocriptine

STOP treatment during pregnancy

56
Q

How does ovarian failure present?

A

High gonadotrophins (raised FSH in two samples)
Low oestrogen
Amenorrhea
Menopause

57
Q

How is premature ovarian failure defined?

A

Menopause before the age of forty

58
Q

List the causes of premature ovarian failure

A 
Genetic (turner's, fragile X, XX gonadal agenesis)
Radiotherapy
Chemotherapy
Oophrectomy (bilateral)
Autoimmune
59
Q

How is premature ovarian failure managed?

A

Hormone replacement therapy
Assisted conception
Cryopreservation of gametes prior to cancer therapy
Counselling

60
Q

What are the key features of a gynaecological history?

A 
Details of menstrual cycle
Amenorrhea (pregnancy test)
Acne
Galactorrhea 
Headaches
Visual symptoms 
Past medical history
Drug history
61
Q

What biochemical investigations should be performed with ovarian irregularities?

A

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)

62
Q

Which type of ultrasound is used in infertility testing/monitoring treatment response?

A

Transvaginal

63
Q

What tests may be indicated in infertility testing?

A

Autoantibodies
Karyotype
MRI
Bone density (oestrogen)

Year 2 (72 decks)

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