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Year 2 Clinical > Ovulatory disorders > Flashcards

Ovulatory disorders Flashcards

1
Q

Describe a regular menstrual cycle

A

Lasts 28-35 days and has 2 phases:
• Follicular
• Luteal

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2
Q

Define oligomenorrhea?

A

Cycle >35 days

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3
Q

Define amenorrhea?

A

Absent menstruation of a cause:
• Primary
• Secondary

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4
Q

Symptoms of anovulation?

A

Oligomenorrhea and amenorrhea

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5
Q

Describe the HPO (hypothalamic-pituitary-ovarian) axis

A

Hypothalamus produces GnRH, which stimulates the pituitary gland to produce LH and FSH

These stimulate the ovaries to produce:
• Oestradol - -vely feedbacks to the pituitary gland
• Progesterone - -vely feedbacks to the hypothalamus

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6
Q

Production, release and function of GnRH?

A

Synthesised by neurons in the hypothalamus and is released in a pulsatile manner

Stimulates FSH (low frequency pulses) and LH (high frequency pulses) synthesis/release from the anterior pituitary gland

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7
Q

Functions of FSH?

A

Stimulates follicular development and thickens the endometrium

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8
Q

Functions of LH?

A
  1. Peak of LH stimulates ovulation
  2. Stimulates corpus luteum development
  3. Thickens endometrium
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9
Q

What does the ovulation predictor kit do and what is its downfall?

A

Detects LH surge (which occurs 36 hours before ovulation)

Beware: for 3/100 women, this is not reliable as LH is not always in the urine

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10
Q

Which hormones peak before and after ovulation?

A

Oestradiol - peaks before ovulation

Progesterone - peaks after ovulation (it is produced by the corpuc luteum)

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11
Q

Production and functions of oestrogen?

A

Secreted primarily by the ovaries (follicles) and the adrenal cortex; also secreted by the placenta during pregnancy

Functions:
• Stimulates endometrial thickening
• Responsible for fertile cervical mucous
• High oestrogen conc. inhibits FSH and prolactin secretion (-ve feedback) and stimulates LH secretion (+ve feedback)

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12
Q

Production and functions of progesterone?

A

Secreted by the corpus luteum, to maintain early pregnancy; also secreted by the placenta during pregnancy

Functions:
• Inhibition of LH secretion
• Responsible for infertile (thick) cervical mucous
• Maintains endometrial thickness
• Has a thermogenic effect (increases basal body temp)
• Relaxes smooth muscles

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13
Q

What does a regular cycle say about ovulation?

A

Very suggestive of ovulation and this can be confirmed with mid-luteal (day 21) serum progesterone measurements with 2 samples

> 30 nmol/L is normal

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14
Q

What does an irregular cycle say about ovulation?

A

Likely anovulatory and requires further hormone evaluation

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15
Q

WHO classification for the 3 groups of ovulatory disorders?

A

Group 1 - hypothalamic pituitary failure

Group 2 - hypothalamic pituitary dysfunction

Group 3 - ovarian failure

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16
Q

Consequence of hypothalamic pituitary failure?

A

Hypogonadotrophic hypogonadism - there are low FSH/LH levels

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17
Q

Features of hypothalamic pituitary failure (group 1)?

A

Oestrogen deficiency (progesterone challenge test is -ve)

Normal prolactin

Amenorrhea

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18
Q

Causes of hypothalamic pituitary failure?

A

Stress, excessive exercise (athletes), anorexia/low BMI

Brain/pituitary tumours and head trauma

Kallman’s syndrome

Drugs, e.g: steroids, opiates

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19
Q

Mx of hypothalamic anovulation

A

Stabilise weight (BMI >18.5 is the aim)

Pulsatile GnRH if they continue to have hypogonadotrophic hypogonadism

Gonadotrophin (LH + FSH) daily injections

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20
Q

Monitoring of hypothlamaic anovulation treatment?

A

Both of the treatment required USS monitoring of response (follicle tracking)

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21
Q

Risk with gonadotrophin (LH +FSH) daily injections?

A

Higher rate of multiple pregnancy

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22
Q

Features of hypothalamic pituitary dysfunction (group 2)?

A

Normal gonadotrophins OR there can be excess LH

Normal oestrogen levels

Oligo/amenorrhea

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23
Q

Most common cause of hypothalamic pituitary dysfunction?

A

Polycystic Ovarian Syndrome (PCOS)

24
Q

Rotterdam criteria for the diagnosis of PCOS?

A

Oligo/amenorrhea

  1. Polycystic ovaries (USS appearance):
    • 12/more 2-9mm follicles
    • Increased ovarian volume (>10ml)
    • Unilateral/bilateral
  2. Clinical and/or biochemical signs of hyperandrogenism, e.g:
    • Hirsutism
    • Acne
25
Q

Symptoms of PCOS?

A

Sub-fertility

Oligo/amenorrhea

Hirsutism

Obesity

Acne

26
Q

Describe the insulin resistance in PCOS

A

They have a normal pancreatic reserve so they have hyperinsulinaemia

Some develop frank glucose intolerance or NIDDM

27
Q

Effects of insulin in PCOS?

A

Acts as a co-gonadotrophin to LH

Also lowers SHBG (sex-hormone binding globulin) so there is increased free testosterone, leading to hyperandrogenism

28
Q

What does Mx of PCOS depend on?

A

Depends on symptoms and patient needs

29
Q

Pre-treatment of anovulation in PCOS?

A

Weight loss optimises results (BMI>30 = poor outcome)

Lifestyle modification (smoking and alcohol <5 units)

Folic acid 400mcg / 5mg daily

Check prescribed drugs

Ensure Rubella immunity

Ensure serum analysis is normal and that fallopian tubes are patent

30
Q

Treatments that cause ovulation induction in PCOS?

A
  1. Clomifene citrate (days 2-6) is the 1ST-LINE treatment
  2. Gonadotrophin therapy (recombinant FSH) daily injections
  3. Laparoscopic ovarian diathermy
31
Q

Alternatives to clomifene citrate?

A

Tamoxifen

Letrozole

32
Q

Risks with gonadotrophin therapy?

A

Multiple pregnancy

Over-stimulation

33
Q

Risks with laparoscopic ovarian diathermy?

A

Ovarian destruction

34
Q

Options for those who do not ovulate on Clomifene?

A

Metformin (+ clomifene citrate) - can induce ovulation for those where clomifene citrate was not effective alone; it is used alongside lifestyle modifications

Gonadotrophic therapy (FSH injections)

Laparoscopic ovarian drilling

Assisted conception treatment

35
Q

Effects of metformin in ovulation induction?

A

Improves insulin resistance, reduces androgen production and increases SHBG

Restores menstruation and ovulation

May increase pregnancy rate

IT DOES NOT AID WEIGHT LOSS

36
Q

Risks with ovulation induction?

A

Ovarian hyperstimulation (most serious consequence) - formation of many follicles and the end result is fluid shift; risk increases if aged <35 years and if patient has PCOS

Multiple pregnancy (twins, etc)

May increase ovarian cancer risk

37
Q

Types of ovarian hyperstimulation?

A

Mild - abdominal bloating/pain

Moderate - moderate abdominal pain, N&V, USS evidence of ascites, etc

Severe - clinical ascites, oliguria, etc

Critical - tense ascites, thromboembolism, ARDS, etc

38
Q

Risks assoc. with multiple pregnancy for the mother?

A

Increased maternal pregnancy complications:
• Hyperemesis
• Anaemia
• Hypertension and pre-eclampsia
• Gestational diabetes (assoc. increase risk IUD / SB)
• Mode of delivery (caesarian) / PPH

• Post-natal depression / stress

39
Q

Risks assoc. with multiple pregnancy for the neonate?

A 
Increased risk of:
• Early and late miscarriage
• Low birth weight (<2.5kg)
• Prematurity
• Disability
• Stillbirth / neonatal death 
• Twin-twin transfusion syndrome (TTTS) - affects identical twin pregnancies and causes unequal blood supply
40
Q

Which types of twins have a higher peri-natal mortality?

A

Monochorionic (monozygotic and shared the same placenta) twins

NOTE: monoamniotic means that the twins shared the same amniotic sac

41
Q

What sign on USS suggests a dichorionic pregnancy?

A

Lambda sign (twin peak) - triangular appearance of the chorion insinuating between the layers of the inter-twin membrane

42
Q

What sign on USS suggests a monochorionic pregnancy?

A

T-sign - absence of a twin peak sign

43
Q

Pathophysiology of twin-twin transfusion syndrome?

A

Unbalanced vascular communications within the placental bed

Recipient develops polyhydramnios (too much amniotic fluid)

Donor develops oliguria, oligohydramnios and growth restriction

44
Q

Treatment options for twin-twin transfusion syndrome?

A

Laser division of placental vessels

Amnioreduction

Septostomy

45
Q

Early problems that occur with prematurity?

A

Neonatal intensive care required, help with breathing and some suffer from neonatal respiratory distress syndrome

46
Q

Long-term problems that occur with prematurity?

A

Higher risk of a child being affected with disability, e.g: cerebral palsy, impaired sight, congenital heart disease

Lower IQ

Attention Deficit Hyperactivity Disorder (ADHD) and long-lasting behavioural difficulties

Problems with language development

47
Q

Another cause of hypothalamic pituitary dysfunction (group 2), other than PCOS?

A

Hyperprolactinaemia (raised serum prolactin >1000 iu/l on 2/more occasions)

48
Q

Treatment of hyperprolactinaemia?

A

Dopamine agonist (cabergoline); these must be stopped when pregnancy occurs

49
Q

Features of ovarian failure (group 3)?

A

High levels of gonadotrophins (raised FSH >30 iu/l with 2 samples)

Low oestrogen

Amenorrhea

Menopausal

50
Q

What is premature ovarian failure?

A

Menopause before 40 years of age

51
Q

Causes of premature ovarian failure?

A

Genetic:
• Turner syndrome (46 XO)
• XX gonadal agenesis
• Fragile X

Autoimmune ovarian failure

Bilateral oophrectomy

Pelvic radio/chemotherapy

Cause can be unclear

52
Q

Treatment of premature ovarian failure?

A

HRT (hormone replacement therapy)

Egg/embryo donation (assisted conception)

Ovary/egg/embryo cryopreservation prior to chemo/radiotherapy where premature ovarian failure is anticipated

Counselling/support

53
Q

Points to cover in a gynaecological history?

A 
Details of menstrual cycle 
Amenorrhoea (do a pregnancy test)
Hirsutism and acne
Galactorrhea
Headaches
Visual symptoms
PMH and DH
54
Q

Biochemical tests for anovulation?

A

Mid-luteal progesterone (day 21)

In the early follicular phase (day 2-5):
• Serum FSH, LH, oestradiol
• Serum testosterone, SHBG
• Prolactin
• TSH (hypothyroidism)
55
Q

Use of a progesterone challenge test?

A

Menstrual bleeding in response to a 5-day course of progesterone indicates normal oestrogen levels

56
Q

Other Ix for anovulation?

A

USS scan

Karyotype

Auto-Ab screen

MRI of pituitary fossa

Bone density scan for BMD (risk of osteoporosis if oestrogen is low)

Year 2 Clinical (119 decks)

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