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1st Repro > Ovulatory Dysfunction > Flashcards

Ovulatory Dysfunction Flashcards

1
Q

Review menstral cycle

A

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.

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2
Q

What happens when a woman doesn’t get pregnant to hormones and endometrium

A

No hCG gets secreated from luteum, thus progesterone drops and we slough off the lining

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3
Q

What are key hormones during the Follicular phase?

A

See rise in estradiol leading to the LH surge and peak

this is the proliferative phase of the uterine endometrium

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4
Q

What occurs during the luteal phase?

A

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

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5
Q

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.

A

solely on the basis of history.

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6
Q

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.

A

progestin challenge

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7
Q

Medroxyprogesterone acetate (5 to 10 mg) is adminsted to asses

A

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.

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8
Q

Your pt has irregular menses and you adminster the progestin challenge. She has no bleeding in the next two weeks. What’s going on?

A

Most likely hypothalamic amenorrhea leading to ovulatory dysfunction

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9
Q

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?

A

Get TSH, Prolactin, day 3 FSH and BhCG

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10
Q

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?

A

Premature Ovarian Failure

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11
Q

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?

A

Ovulatory dysfunction

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12
Q

Your patient responded + to the progestin challenge leading you to believe there is ovulatory dysfunction. What would lead you to believe she has PCOS?

A

Look at biochemical androgen levels or she would have bad acne, hirutism, signs of androgen excess

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13
Q

What do we seen to look at when evalulating for oligo/amenhorrhea

A
  • History and physical exam
  • Pregnancy test
  • Baseline (day 3) Follicle Stimulating Hormone, Estradiol
  • Thyroid stimulating hormone
  • Prolactin
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14
Q

Role of the TRH in ovulation dysfunciton

A

TRH will also stimulate secreation of prolactin which in turn can inhibit GnRH

Thyroid is key for metabolism, devo and steroidogenesis

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15
Q

Beside the progestin challenge, what else can we look at to assess adequate estrogen exposure?

A

Pelvic ultrasound to demonstrate endometrial thickness

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16
Q

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?

A

Polycystic ovarian syndrome

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17
Q

A 30 year old woman with eplilepsy and seizures partially controlled by carbamensepine presents for contraception counseling. What is the best method for her?

A

Copper IUD bc helps with seizure control

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18
Q

The most common endocrine cause of infertility and irregular menstrual cycles

A

Polycystic Ovarian Syndrome

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19
Q

What do you need to have to be dx with PCOS?

A

Need to have 2 of the 3

• Polycystic-like ovaries on ultrasound

  • Oligomenorrhea
  • Hyperandrogenism
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20
Q

You are working up a pt you expect has PCOS, what causes of hyperandrogenism and oligomenorrhea need to be excluded

A
  • Testosterone secreting tumor
  • Congenital adrenal hyperplasia • Thyroid disease
  • Hyperprolactinemia
  • Cushings’ disease
  • Hypothalamic amenorrhea
  • Premature ovarian insufficiency
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21
Q

Pt with PCOS needs treatement and is not intersted in getting pregant at this time. what tx do you recommend?

A

Counsel regarding health risks

• Treatment for endometrial protection: Cyclic progestin and OCP

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22
Q

Your pt was just dx with PCOS and is trying to concieve with her partner. What tx is recommend for her?

A
  • 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

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23
Q

What medical tx is recommend for pt with PCOS who are trying to concieve?

A

Clomiphene

  • First line of treatment in PCOS
  • Low cost
  • Patient-friendly oral route
  • Relatively few adverse effects
  • Abundant clinical data regarding safety
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24
Q

MOA of Clomiphene

A

• Reduces concentration of intracellular estrogen receptors

  • Diminishes negative feedback
  • Activates mechanism for GnRH secretion
25
Q

Indicated in:

(1) induction of ovulation in women with anovulatory infertility, and
(2) stimulation of multifollicular ovulation or enhancing ovulation in ovulatory infertile women (e.g., unexplained infertilit Clomiphene Citrate

A

Clomiphene Citrate

26
Q

Negative side effects of Clomiphene

A

hot flashes, bloating, cramping, nausea, mood swings, and rarely visual disturbances.

multiple pregnancy after CC is between 4-10%.

rare risk of Ovarian Hyperstimulation Syndrome

Anti estrogen: endometrial thinning and cervical mucus

27
Q

Non FDA approved method for ovulation induction with lower rates of multiples dt monofollicular ovulation induction

A

Aromatase inhibitors

28
Q

Patient comes in with normal prolactin and thyroid function. Her FSH is elevated and estradiol is LOW. What is the cause of this pts irregular menstral cycles?

A

Patient has premature ovarian insufficiency and is approaching menopause

29
Q

Pt is given the progestin challenge with Medroxyprogesterone acetate for 10 days: she did not have withdrawl bleed. This is most likely due to

A

Atrophic endometrium d/t lack fo ciruculating estradiol

30
Q

reasons for lack of withdrawal bleeding in response to progesterone therapy

A
  1. Lack of circulating Estradiol resulting in inadequate endometrial proliferation thus wont respond to increase in progestin
  2. Severe endometrial adhesions
  3. Pregnancy
31
Q

• Condition of low/normal FSH and low estradiol

  • Absence of sellar mass
  • May be Stress or weight related
A

Hypogonadotropic hypogonadism

32
Q

Pathophysiology of Hypogonadotropic hypogonadism

A

Condition of low/normal FSH and low estrodiol and absence of sellar mass

33
Q

Causes of hypogonadotropic hypogonadism

A
  • Kallman’s syndrome- congenital GnRH deficiency
  • GnRH receptor mutations
  • Treatable with injectable gonadotropins

or stress/weight releated

34
Q

defined as hypergonadotropic hypogonadism before age 40, commonly but not uniformly associated with depletion of ovarian follicles, as is seen in menopause. It results in cessation of regular menses. This condition affects approximately 1% of all women, with 90% of cases occurring between ages 30 and 40.

A

Premature ovarian failure (POF) or premature ovarian insufficiency (POI)

35
Q

can obliterate the endometrial cavity and produce secondary amenorrhea and most likely to result from procedures that can damage the endometrial cavity.

A

Intrauterine adhesions (IUAs) or synechiae (Asherman’s syndrome)

36
Q

What do we see with Intrauterine adhesions or Ashermans syndrome

A

Can obliterate the endometrial cavity and produce secondary amenorrhea

Can result in lack of withdrawal bleed in response to progesterone if patient is amenorrheic

• Most likely to result from procedures that can damage the endometrial cavity.

37
Q

Causes of Premature Menopause/ Prematuer ovarian Insufficiency (POI)

A
  • Genetic
  • Chromosomal number: 45X or 45X/XX (Turner’s syndrome and Turner’s mosaic)
  • Fragile X
  • Autoimmune
  • Iatrogenic (treatment-related) • Chemotherapy
  • Radiation

• Idiopathic

38
Q

What hormone triggers ovulation?

A

LH

39
Q

premutation carriers are at an increased risk for premature ovarian failure, with an incidence of 16% to 21%. Expansion of a triplet repeat within exon 1 of the FMR1 X-linked gene causes this syndrome. Expansions of between 50 and 200 repeats are premutations.

A

Fragile X syndrome

40
Q

Many individuals with POI (30-50%) also have an

A

autoimmune disease such as hypoparathyroidism, Hashimoto’s thyroiditis, Addison’s disease, vitiligo, myasthenia gravis, Sjögren syndrome, systemic lupus erythematosus, celiac disease, rheumatoid arthritis, or pernicious anemia.

41
Q

Reproductive option in pts with premature ovarian insufficiency

A

oocyte donation, adoption, extremely low likelihood of spontaneous conception

42
Q

Three most common causes of infertility in couples

A

Ovulatory, Tubal and Pelvic, Male factor

43
Q

Time table of expected pregnancy:

3 months:

6 months:

1 year

2 years

A

3 months: 57%

6 months: 72%

1 year: 85%

2 years: 95%

44
Q

• Usually determined by menstrual history

  • Anovulation
  • Oligoovulation
  • Early Ovulation/dysfunctional cycle
A

all ovulation disorders

45
Q

What happens to ovarian reserve with increasing age?

A

Acceleration of follicular loss, depleation of oocyte pool and decreased oocyte quality

46
Q

How do we test for ovarian reserve?

A

Perform a Day 3 FSH/Estradiol level

Antral follicle couts

Anti-Mullerian hormone level

47
Q

Day 2 or 3 Follicle Stimulating Hormone (FSH) and Estradiol

-An ____ FSH and/or estradiol is consistent with diminished ovarian reserve due to the hypothalamic-pituitary-ovarian feedback loop

A

elevated

48
Q

This beta-glycoprotein is synthesized by granulosa cells in small antral and preantral follicles in the ovary and is directly proportional to a woman’s ovarian reserve.

A

Antimullerian Hormone

49
Q

What tests can be done to eval uterine and tubal anatomy?

A
50
Q

Risk factors for tubal disease

A

• History of pelvic infections

  • Tubal or pelvic surgery
  • Endometriosis
51
Q

What three pt populations would benefit from Intrauterine insemination or IUI

A

Mild male factor infertility

Women with cervical mucus abnormalities

Couples with unexplained infertility

Patients often treated with ovulation induction medications prior to IUI

52
Q

What are indications for IVF?

A
  • Severe male factor
  • Tubal disease
  • Endometriosis
  • Diminished ovarian reserve
  • Unexplained infertility
  • Failed more conservative measures
53
Q

Overview of IVF

A
  • Ovarian stimulation with injectable gonadotropins :FSH, HMG (LH/FSH)
  • Oocyte retrieval
  • Fertilization
  • Embryo transfer
54
Q

is indicated for ovulation induction in

(1) Patients who have hypothalamic amenorrhea,
(2) Anovulatory patients who do not respond to Clomiphene citrate or aromatase inhibitors, or
(3) Patients undergoing hormonal stimulation for in vitro fertilization or less commonly for purposes of multifollicular recruitment to be paired with intrauterine insemination.

A

Gonadotropin therapy

55
Q

Pergonal, Humegon, Menopur are all examples of

A

Human menopausal Gonadotropin :

(1) Patients who have hypothalamic amenorrhea,
(2) Anovulatory patients who do not respond to Clomiphene citrate or aromatase inhibitors, or
(3) Patients undergoing hormonal stimulation for in vitro fertilization or less commonly for purposes of multifollicular recruitment to be paired with intrauterine insemination.

56
Q

are also approved for preventing the LH surge during controlled ovarian hyperstimulation.

A

The GnRH antagonists (ganirelix and cetrorelix )

57
Q

Bravelle, Metrodin,Gonal-F, Follistim

A

all examples of FSH

58
Q

s administered intramuscularly to induce follicular maturation and ovulation.

A

hCG

1st Repro (16 decks)

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