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Endocrine > ovulatory disorders > Flashcards

ovulatory disorders Flashcards

1
Q

What are the causes of physiological amenorrhea?

A
  • pregnancy

- post-menopausal

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2
Q

What is primary amenorrhea? What are the causes of primary amenorrhea?

A

-failure menses by age 16

consider congenital problems (turners/kallmans syndrome)

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3
Q

What is secondary amenorrhea and what are the causes?:

  • ovarian problem
  • uterine problem
  • hypothalamic dysfunction
  • pituitary problem
A

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

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4
Q

What is oligomenorrhea?

A

reduction in the frequency of periods <9 a year

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5
Q

What is the WHO classification of anovulation?

A

Group 1: hypothalamic-pituitary failure
Group 2: hypothalamic-pituitary dysfunction
Group 3: ovarian failure

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6
Q

What are the causes for WHO group 1 anovulation? What hormone levels are seen?

A

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
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7
Q

What are the causes for WHO group 2 anovulation? What hormone levels are seen?

A

MOST COMMON

Hypothalamic-pituitary dysfunction: PCOS

  • gonadotrophin (LH/FSH) normal
  • estrogen normal
  • anovulation
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8
Q

What are the causes for WHO group 3 anovulation? What hormone levels are seen?

A

Ovarian failure

Causes:

  • premature ovarian failure
  • autoimmune ovarian failure
  • pelvic radio/chemo therapy
  • gonadotrophin high
  • low estrogen
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9
Q

What tests are done to distinguish between the different groups of anovulation?

A

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

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10
Q

What is included in the history for amenorrhea?

A
  • 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)
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11
Q

What is included in the examination for amenorrhea?

A
  • body habitus (turners)
  • visual fields/anosmia
  • breast development
  • hisutism/acne
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12
Q

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?

A

Probably is ovulating

-confirmation of ovulation by 2 midluteal (day 21) progesterone levels, if this is >30nmol/L = normal

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13
Q

A woman comes in querying whether she is ovulating, she says she is having irregular menstrual periods, what tests are offered?

A

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

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14
Q

What additional test is needed for a pt with primary amenorrhea?

A

-karyotype for turners

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15
Q

What radiological tests can be offered for amenorrhea?

A
  • transvaginal USS of ovaries
  • MRI pituitary fossa
  • Bone density scan
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16
Q

Hypothalamic-pitutary failure:

  • what is kallmans syndrome?
  • M:F
  • pituitary function?
  • inheritance?
A

=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)
17
Q

Describe the management of hypothalamic anovulation

A

-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)

18
Q

What is the pathophysiology of PCOS?

A

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

19
Q

What is the revised rotterdam criteria of PCOS?

A

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
20
Q

What are the biochemical signs of hyperandrogenism?

A
  • Elevated serum LH
  • LH/FSH ratio >2
  • normal E2
  • low progesterone
  • normal/mildly elevated PRL
  • raised testosterone
21
Q

Insulin resistance in PCOS:

  • is this common?
  • how does insulin interact with LH?
A

50-80% patients

  • insulin acts as a co-gonadotrophin to LH
  • it also lowers sex hormone binding globulin levels = increased free testosterone = hyperandrogenism
22
Q

What are the clinical features of PCOS?

A
  • hirsutism
  • acne
  • oily skin
  • central obesity
23
Q

What is management of PCOS based on?

A

patient need

24
Q

What is the management of PCOS:

  • subfertility
  • oligo/amenorrhea
  • hirsutism/acne/alopecia/central obesity
A
  • subfertility: ovulation induction
  • oligo/amenorrhea: COCP - use diannette to combat both sx
  • hirsutism/acne/alopecia/central obesity
25
Q

What is the ‘pre-treatment’ of PCOS?

A

optimises results of definitive treatment

  • weight loss (BMI<30)
  • lifestyle (smoking and alcohol)
  • folic acid (400micrograms/5mg)
  • rubella immunity
  • normal semen analysis
26
Q

Describe the 1st line treatment of PCOS

A 
Clomifene citrate (anti-estrogen thus increasing LH/FSH)
-50-100mg tab days 2-6 for 5 days, max dose 150

Alternatively tamoxifen or letrozole

Tamoxifen (similar mechanism to CC):
-20mg days 2-6

Letrozole (aromatase inhibitor decreasing estrogen)

All drugs = similar results
-70% ovulate, 40-60% concieve

Add metformin to increase sensitivity (improves insulin resistance)

27
Q

What are the adverse effects of clomifene citrate?

A

Peripheral anti-estrogen side effects e.g. breast tenderness

Multiple preg. rate <10%

28
Q

What are the adverse effects of tamoxifen?

A

estrogen effect on endometrium -

29
Q

What is the second line treatment for PCOS?

A

Gonadotrophin therapy: daily injections

  • hMG: (LH/FSH) fFSH
  • 80% ovulate, 60-70% concieve
  • risks multiple preg., overstimulation
30
Q

What is third line treatment of PCOS?

A

Laparoscopic ovarian diathermy

  • laser/electrocautery drills holes in stroma of ovary (helpes to reduce steroid production)
  • 80% ovulate, 34% concieve
  • risks overian destruction/adhesion
31
Q

What is premature ovarian failure? what is the aetiology? how is this diagnosed?

A

menopause before the age 40
-unclear aetiology: x chromosome defects, turners syndrome, FH

Diagnosis:

  • two X FSH >30IUL samples
  • low E2
32
Q

What is turners syndrome?

A

only one X chromosome
-other genotype less common

Syndrome:

  • webbed neck
  • short stature
  • shield chest
  • wide spaced nipples
  • cubitus valgus
33
Q

What is involved in the treatment for prem. ovarian failure?

A
  • HRT
  • egg/embryo donation
  • ovary/egg/embryo cryopreservation before chemo/radio therapy when POF predicted
  • counselling
34
Q

What is reduced ovarian reserve?
how is this diagnosed?
how is this managed?

A

Prematurely reduced Oocyte number

Diagnosis:

  • raised FSH
  • low anti-mullerian hormone
  • reduced antral follicle count on USS

Management:
-assisted conception

35
Q

Wha are the causes of hirsutism?

A

Long history, no virilisation, testosterone not dramatically increased:

  • PCOS
  • familial esp. mediterranean population
  • idiopathic
  • congenital adrenal hyperplasia

Short history, virilisation signs:
-adrenal/ovarian tumour

Endocrine (18 decks)

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