ovulatory disorders Flashcards
What are the causes of physiological amenorrhea?
- pregnancy
- post-menopausal
What is primary amenorrhea? What are the causes of primary amenorrhea?
-failure menses by age 16
consider congenital problems (turners/kallmans syndrome)
What is secondary amenorrhea and what are the causes?:
- ovarian problem
- uterine problem
- hypothalamic dysfunction
- pituitary problem
Cessation periods >6mths in an individual who has previously menstruated
Ovarian problem: PCOS, premature ovarian failure
Uterine problem: uterine adhesions
Hypothalamic dysfunction: weight loss, over exercise, stress, infiltrative
pituitary problem: high prolactin or hypopituitarism
What is oligomenorrhea?
reduction in the frequency of periods <9 a year
What is the WHO classification of anovulation?
Group 1: hypothalamic-pituitary failure
Group 2: hypothalamic-pituitary dysfunction
Group 3: ovarian failure
What are the causes for WHO group 1 anovulation? What hormone levels are seen?
Hypothalamic-pituitary failure: (failure of hypothalamus to secrete GNRH or pituitary to secrete FSH/LH)
Causes:
- Pituitary problems
- functional hypothalamic disorders (weight change/stress/exercise/anabolic steroids/systemic illness/surgery/radiotherapy/recreational drugs/head trauma/infiltrative e.g. sarcoid)
- brain/pit. tumours
- kallman’s syndrome
- idiopathic hypogonadal hypogonadism
- Miscellaneous (prader-willi, haemochromotosis)
Hormone levels:
- Low FSH, low estrogen
- normal PRL
- -ve progesterone challenge
What are the causes for WHO group 2 anovulation? What hormone levels are seen?
MOST COMMON
Hypothalamic-pituitary dysfunction: PCOS
- gonadotrophin (LH/FSH) normal
- estrogen normal
- anovulation
What are the causes for WHO group 3 anovulation? What hormone levels are seen?
Ovarian failure
Causes:
- premature ovarian failure
- autoimmune ovarian failure
- pelvic radio/chemo therapy
- gonadotrophin high
- low estrogen
What tests are done to distinguish between the different groups of anovulation?
Amenorrhea and low estrogen - measure LH/FSH
If high = primary ovarian problem: group 3
-hypergonadotrophic hypogonadism
If low = group 1
-hypogonadotrophic hypogonadism
If innapropriately normal = group 2
What is included in the history for amenorrhea?
- menstrual cycle
- amenorrhea
- headaches (pit. tumour)
- estrogen deficiency (flushing/libido/dysparaunia)
- hypothalamic problem (stress/exercise/wt loss)
- PCOS or androgen excess (hirsutism/acne)
- anosmia (kallman’s syndrome)
- hyperprolactinaemia (drugs/galactorrhea)
- PMH (chemo/radio therapy)
What is included in the examination for amenorrhea?
- body habitus (turners)
- visual fields/anosmia
- breast development
- hisutism/acne
A woman comes in querying whether she is ovulating (she thinks she could be infertile), she says she is having regular menstrual periods, what tests are offered?
Probably is ovulating
-confirmation of ovulation by 2 midluteal (day 21) progesterone levels, if this is >30nmol/L = normal
A woman comes in querying whether she is ovulating, she says she is having irregular menstrual periods, what tests are offered?
Probably is not ovulating
- measure serum progesterone 7 days prior to the end of her cycle (e.g. day 28 of a 35 day cycle) (day 1 of cycle is menstruation) = midluteal progesterone
- also additional FSH and LH tests (days 2-5 cycle)
- other hormone tests: E2, testosterone, FAI, PRL, TSH) days 2-5 cycle
If suspect hypothalamic-pit problem:
-pituitary function test
also autoantibody screen
What additional test is needed for a pt with primary amenorrhea?
-karyotype for turners
What radiological tests can be offered for amenorrhea?
- transvaginal USS of ovaries
- MRI pituitary fossa
- Bone density scan
Hypothalamic-pitutary failure:
- what is kallmans syndrome?
- M:F
- pituitary function?
- inheritance?
=loss GnRH secretion +/- anosmia (anosmia in 75%)
- M:F 4:1
- remainder of pit. function normal, normal MRI pit (see absence of olfactory bulbs)
- demonstrates variable patterns of inheritance (may be assoc. with FH)
Describe the management of hypothalamic anovulation
-stabilise weight/advise on exercise
Either:
-pulsatile GnRH if hypog hypog (s/c IV pump worn continuously and pumps every 90mins) = up to 90% ovulation rate
-LH/FSH daily injections (but more multiple pregnancy rates)
(for both of these need US monitoring of response)
What is the pathophysiology of PCOS?
ovaries are stimulated to produces excessive amounts of androgens, usually from excessive release of LH, although hyperinsulinaemia also has a similar effect and plays a role in many cases
-cysts are actually immature follicles
What is the revised rotterdam criteria of PCOS?
Presence of 2+:
-oligo/amenorrhea (oligo in 80-90%/amen 30%)
- polycystic ovaries on USS (increased ovarian volume >10mls, 12+ 2-9mm follicles, unilateral or bilateral)
- Clinical (acne/hirsutism/acanthosis nigrans) +/- biochemical signs of hyperandrogenism
What are the biochemical signs of hyperandrogenism?
- Elevated serum LH
- LH/FSH ratio >2
- normal E2
- low progesterone
- normal/mildly elevated PRL
- raised testosterone
Insulin resistance in PCOS:
- is this common?
- how does insulin interact with LH?
50-80% patients
- insulin acts as a co-gonadotrophin to LH
- it also lowers sex hormone binding globulin levels = increased free testosterone = hyperandrogenism
What are the clinical features of PCOS?
- hirsutism
- acne
- oily skin
- central obesity
What is management of PCOS based on?
patient need
What is the management of PCOS:
- subfertility
- oligo/amenorrhea
- hirsutism/acne/alopecia/central obesity
- subfertility: ovulation induction
- oligo/amenorrhea: COCP - use diannette to combat both sx
- hirsutism/acne/alopecia/central obesity
