Ovulatory Dysfunction Flashcards
Review menstral cycle
A menstrual cycle begins with the first day of genital bleeding (day 1; menses) and ends just before the next menstrual period. The median menstrual cycle length is 28 days but ranges from 21 to 35 days.
What happens when a woman doesn’t get pregnant to hormones and endometrium
No hCG gets secreated from luteum, thus progesterone drops and we slough off the lining
What are key hormones during the Follicular phase?
See rise in estradiol leading to the LH surge and peak
this is the proliferative phase of the uterine endometrium
What occurs during the luteal phase?
see LH and FSH go down and Progesterone rise
this is the secreatory phase of the endometrium and build up of lining till sloughing at day 28
The diagnosis of anovulation or ovulatory dysfunction can commonly be made ________ Menstrual bleeding occurring at regular intervals between 21 and 35 days, particularly in the presence of premenstrual moliminal (i.e., breast tenderness, abdominal bloating, mood disturbance) is suggestive of ovulation; bleeding at longer or irregular intervals generally reflects anovulation.
solely on the basis of history.
If the estrogen status of the patient is unclear from the physical examination, a ________ test can be arranged at the same time as the initial blood work.
progestin challenge
Medroxyprogesterone acetate (5 to 10 mg) is adminsted to asses
is administered daily for 7 to 14 days, after which a menstrual bleed should ensue in normally estrogenized patients. Any amount of spotting or bleeding in the 2 weeks after progestin withdrawal is considered a positive progestin challenge.
Your pt has irregular menses and you adminster the progestin challenge. She has no bleeding in the next two weeks. What’s going on?
Most likely hypothalamic amenorrhea leading to ovulatory dysfunction
You are seeing a pt that hasn’t had her period and she is 20 years old. What are the key hormone tests you want to run on top of getting a thorough history?
Get TSH, Prolactin, day 3 FSH and BhCG
You have a pt with amenorrhea and run her FSH levels which are elevated, you run them again one month later and confirm she does have elevated FSH. What is the diagnosis?
Premature Ovarian Failure
Your pt has lack of menstral cycles, you asses her hormone levels and they are normal, you perfrom a progestin challenge and she has spontaneous menses or a + test. What path does this lead us down?
Ovulatory dysfunction
Your patient responded + to the progestin challenge leading you to believe there is ovulatory dysfunction. What would lead you to believe she has PCOS?
Look at biochemical androgen levels or she would have bad acne, hirutism, signs of androgen excess
What do we seen to look at when evalulating for oligo/amenhorrhea
- History and physical exam
- Pregnancy test
- Baseline (day 3) Follicle Stimulating Hormone, Estradiol
- Thyroid stimulating hormone
- Prolactin
Role of the TRH in ovulation dysfunciton
TRH will also stimulate secreation of prolactin which in turn can inhibit GnRH
Thyroid is key for metabolism, devo and steroidogenesis
Beside the progestin challenge, what else can we look at to assess adequate estrogen exposure?
Pelvic ultrasound to demonstrate endometrial thickness
Your pt has withdrawl bleed to progesterone and her FSH, estradiol and prolacint and thryoid levels are normal. ON pelvic ultrasound, her ovaries look like they have cycts all over, Dx?
Polycystic ovarian syndrome
A 30 year old woman with eplilepsy and seizures partially controlled by carbamensepine presents for contraception counseling. What is the best method for her?
Copper IUD bc helps with seizure control
The most common endocrine cause of infertility and irregular menstrual cycles
Polycystic Ovarian Syndrome
What do you need to have to be dx with PCOS?
Need to have 2 of the 3
• Polycystic-like ovaries on ultrasound
- Oligomenorrhea
- Hyperandrogenism
You are working up a pt you expect has PCOS, what causes of hyperandrogenism and oligomenorrhea need to be excluded
- Testosterone secreting tumor
- Congenital adrenal hyperplasia • Thyroid disease
- Hyperprolactinemia
- Cushings’ disease
- Hypothalamic amenorrhea
- Premature ovarian insufficiency
Pt with PCOS needs treatement and is not intersted in getting pregant at this time. what tx do you recommend?
Counsel regarding health risks
• Treatment for endometrial protection: Cyclic progestin and OCP
Your pt was just dx with PCOS and is trying to concieve with her partner. What tx is recommend for her?
- Weight loss recommended as first line therapy in obese women with PCOS seeking pregnancy
- Weight loss is associated with improved ovulation rates in women with PCOS
***Clomiphene
What medical tx is recommend for pt with PCOS who are trying to concieve?
Clomiphene
- First line of treatment in PCOS
- Low cost
- Patient-friendly oral route
- Relatively few adverse effects
- Abundant clinical data regarding safety