Ovulatory Disorders Flashcards
what are ovulatory disorders associated with?
oligomenorrhoea
amenorrhoea
define oligomenorrhoea
cycle lasting more than 35 days
define amenorrhoea
absent menstruation
two types of amenorrhoea
primary- never had a period
secondary- used to have periods but have now stopped
three groups of anovulatory disorders
- hypothalamic pituitary failure (hypogonadotropic hypogonadism)
- hypothalamic pituitary dysfunction
- ovarian failure
describe hypothalamic pituitary failure
no GnRH secretion leading to no FHS/LH and oestrogen
normal prolactin
amenorrhoea
diagnosis of hypothalamic pituitary failure (using a challenge test)
negative progesterone challenge
causes of hypothalamic pituitary failure
stress excessive exercise low BMI tumours trauma Kallman's syndrome drugs (steroids and opiates)
pre-treatment management of hypothalamic pituitary failure
stabilise weight lifestyle (smoking and alcohol) folic acid check prescribed drugs rubella immunity (IgG) chlamydia analysis (azithromycin) normal semen analysis patent Fallopian tubes
management of hypothalamic pituitary failure
pulsatile GnRH via SC/IV pump worn continuously (90minutes)
gonadotrophin daily injection (FSH/LH): higher risk of multiple pregnancies
both need USS monitoring of response (follicle tracking)
define hypothalamic pituitary dysfunction
ovary does not respond to LH and FSH
diagnosis of hypothalamic pituitary dysfunction
high LH high FSH normal oestrogen oligo/amenorrhoea PCOS associated
define PCOS
inherited condition where females produce more than normal male hormones, it is a condition exacerbated by weight gain
presentation of PCOS
obesity
hirsutism/acne
cycle abnormalities
infertility
diagnosis of PCOS (biochemically)
high LH
high free androgens
impaired glucose tolerance
diagnosis of PCOS 2/3 must be present
oligo/amenorrhoea
polycystic ovaries on USS with 12 or more 2-9mm follicles and increased ovarian volume
hyperandrogenism biochemically or clinically
what is commonly seen in PCOS
insulin resistance
how does insulin resistance occur in PCOS?
normal pancreatic reserve so hyperinsulinaemia, but sensitivity is decreased as insulin acts on the same receptor as LH and lowers SHBG levels so there is increased free testosterone (hyperandrogenism)
management of PCOS
weight loss, lifestyle
folic acid 400mcg/5mg
reverse excess androgens
ovulation induction
how can excess androgens be reduced in PCOS?
oral contraceptive pill
anti-androgen e.g. cyproterone acetate
cosmetic e.g. laser hair removal and creams
three ways to do ovulation induction in PCOS
clomifene citrate (alternatives are tamoxifen and letrozole) gonadotrophin daily injections laparoscopic ovarian diathermy
describe clomifene citrate
increases FSH
conception in first few months, if resistant consider metformin (improves insulin resistance, reduces androgens and increases SHBG) and other therapies
what do gonadotrophin daily injections risk?
multiple pregnancies
overstimulation
what does laparoscopic ovarian diathermy risk?
ovarian destruction
adverse effects of ovulation induction
ovarian overstimulation (below 35 and PCOS) multiple pregnancies (USS lambda sign dichorionic, T sign monochorionic) twin-twin transfusion syndrome in monozygotic ovarian cancer
what does hyperprolactinaemia present with?
amenorrhoea (inhibits GnRH)
galactorrhea
visual fields (macro)
diagnosis of hyperprolactinaemia
normal FSH/LH low oestrogen raised prolactin TFT normal MRI
management of hyperprolactinaemia
dopamine agonist e.g. cabergoline (stopped when pregnancy occurs)
define ovarian failure
ovaries have no eggs left
presentation of ovarian failure
hot flushes
night sweats
atrophic vaginitis
diagnosis of ovarian failure (biochemically)
high FSH/LH
low oestrogen
amenorrhoea
causes of ovarian failure
menopause
causes of premature ovarian failure
- genetic= Turner’s, XX gonadal genesis, fragile X
- AI ovarian failure
- bilateral oophorectomy
- pelvic radiotherapy/chemotherapy
management of premature ovarian failure
hormone replacement
egg/embryo donation
cryopreservation
counselling
define progesterone challenge testing
menstrual bleed in response to a 5-day course of progesterone indicates normal oestrogen
