Reproduction and Ovulatory Disorders Flashcards by Kerry Hendrie

Define oligomenorrhoea

Reduced frequency of periods (less than 9/year)

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Define primary amenorrhoea

Failure of having a period before the age of 16

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Define secondary amenorrhoea

Cessation of periods for greater than 6mths in someone who has previously had a period

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What is the main cause of primary amenorrhoea?

Congenital abnormality

Turner’s, Kallman’s

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List ovarian causes of secondary amenorrhoea

Polycystic ovarian syndrome

Ovarian failure

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List pituitary causes of secondary amenorrhea?

High prolactin

Hypopituitarism

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What triad of symptoms are classic of amenorrhoea/oestrogen deficiency?

Flushing
Lack of libido
Dyspareunia (painful sex)

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List investigations that all patients with oligo-/amen- orrhoea get

LH, FSH, oestradiol leves
Thyroid function tests
Prolactin levels

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List additional investigations for oligo-/amen- orrhoea

Ovarian USS, endometrial thickness
Testosterone levels if hirsutism
Pituitary function/ MRI
Karyotype

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In primary hypogonadism in females, the problem is arising from where?

Ovaries

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In secondary hypogonadism in females, the problem is arising from where?

Pituitary/hypothalamus

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Describe LH and FSH levels in primary hypogonadism

High LH
High FSH
Low oestraidol
i.e. hypergonadotrophic hypogonadism

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Describe LH and FSH levels in secondary hypogonadism

Low LH
Low FSH
High oestradiol
i.e. hypogonadotrophic hypogonadism

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Give an example of a condition where primary hypogonadism occurs

Premature ovarian failure

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What happens in premature ovarian failure?

Loss of ovarian function causes amenorrhoea, low oestrogen and elevated gonadotrophins

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What is idiopathic hypogonadotrophic hypogonadism?

Absent/delayed sexual development assoc. with low levels of gonadotrophins in the absence of anatomical/functional defect in the H-P-gonadal axis

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Which syndrome is like idiopathic hypogonadotrophic hypogonadism but includes anosmia (inability to smell)?

Kalmann’s syndrome

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What is the major defect/identified cause of idiopathic hypogonadotrophic hypogonadism?

Mutated GnRH receptor (thus inability to sense GnRH from hypothalamus)

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What is the function of kisspeptin?

Regulates GnRH secretion and thus pubertyRegulates fertility

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What is Kallman’s syndrome? What is the characteristic sign on imaging?

Genetic disorder of loss of GnRH secretion characterised by anosmia and hyposmia
Absence of olfactory bulbs

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Males are more affected by Kallman’s syndrome. True/False?

True

4:1

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What causes hirsutism?

Excess androgen at the hair follicle

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What is the most common cause of hirsutism?

Polycystic ovarian syndrome

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Which chromosome is missing in Turner syndrome?

so women only have one X

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List clinical features of Turner syndrome

``` Short stature Failure/delayed puberty Coarctation of aorta Poor breast formation Infertility ```

Define primary hypogonadism in males in terms of testosterone and LH/FSH levels

Low testosterone | High FHS/LH

Define secondary hypogonadism in males in terms of testosterone and LH/FSH levels

Low testosterone | Low FSH/LH

What is the most common congenital form of primary hypogonadism?

Klinefelter's syndrome (XXY)

List clinical features of Klinefelter's syndrome

Reduced testicular volume Gynaecomastia Eunuchoidism (lack of reproductive organ development)

Infertility risk increases with chlamydia infections. True/False? How is it diagnosed and managed?

True Endocervical swab Azithromycin 1st line, doxycycline if allergic

List some male factors contributing to infertility

Decreased quality sperm Increased testicular cancer Cryptoorchidism Hypospadias

Define infertility

Failure to achieve pregnancy after 12 months of regular unprotected sex in a couple who have never had a child

What is the difference between primary + secondary infertility?

Primary: never conceived Secondary: unsuccessful pregnancy

List factors increasing the chance of conception

``` Women less than 30yrs Less than 3yrs trying to conceive Intercourse during 6 days before ovulation Women BMI 20-30 Non-smokers Low caffeine intake ```

What are the main causes of female infertility?

``` Ovulation failure (50%) Tubal damage (25%) Endometriosis (10%)Misc. (15%) ```

List hypothalamic causes of anovulatory infertility

Anorexia, bulimia | Excessive exercise

List pituitary causes of anovulatory infertility

Hyperprolactinaemia Sheehan syndrome Tumours

What is a hydrosalpinx?

Fallopian tube dilation by fluid (due to blockage)

What is endometriosis?

Condition where endometrial tissue grows outside of the womb/uterus

What is the characteristic sign of endometriosis on USS?

Chocolate cysts on ovary

What is the most common cause of male infertility?

Varicocele

What is a varicocele?

"varicose veins" of the testis

List endocrine disorders that can cause male infertility

``` Hypogonadotrophic hypogonadism (Kallman's) Testicular failure Klinefelter's syndrome (XXY) Hyperprolactinaemia Acromegaly Cushing's ```

List investigations for causes of infertility in females

``` Endocervical swab (chlamydia) Cervical smear Pelvic USS Bloods (rubella) Mid-luteal progesterone Hormone levels (PRL, FSH, LH) Hysterosalpingiogram (tubal patency) ```

List causes of WHO group I ovulatory disorders

``` FSH/ LH REDUCED (hypothalamic causes) Hypogonadotrophic hypogonadism Kallman's syndrome Anorexia, bulimia Excessive exercise ```

List causes of WHO group II ovulatory disorders

NORMAL FSH/ LH (pituitary dysfunction) Normogonadotrophic hypogonadism Polycystic ovarian syndrome Hyperprolactinaemia

List causes of WHO group III ovulatory disorders

FSH/ LH INCREASED Hypergonadotrophic hypogonadism Ovarian failure

List causes of amenorrhea

``` PHYSIOLOGICAL (pregnancy, post-menopause) CONGENITAL OVARIAN UTERINE (adhesions) HYPOTHALAMUS PITUITARY ```

List hypothalamic causes of secondary amenorrhea

Weight loss Over-exercise Stress

What age is the typical onset of premature ovarian failure?

<40 yo

How long is the normal menstrual cycle?

28-35 days

If someone has oligomenorrhoea, how long do menstrual cycles last?

Greater than 35 days

What is another name for an ovulatory disorder caused by hypothalamic pituitary failure?

Hypogonadotrophic hypogonadism

Outline management of hypogonadotrophic hypogonadism

``` Pulsatile GnRH Gonadotrophin injections Stabilise weight (BMI over 18.5) ```

What is the most common ovulatory disease caused by hypothalamic pituitary dysfunction?

Polycystic ovarian syndrome

What is the criteria for diagnosing polycystic ovarian syndrome?

2/3: Oligo/amen -orrhoea Polycystic ovaries on USS (12+ 2-9mm follicles) Hyperandrogenism

Insulin resistance is commonly seen alongside polycystic ovarian syndrome. True/False?

True

Outline management of polycystic ovarian syndrome

``` Ovulation induction Lifestyle modification (smoking, alcohol) Ovulation induction Folic acid 400mcg/5mg if BMI over 30 Check if rubella immunity ```

By what 3 methods can ovulation be induced in polycystic ovarian syndrome?

Clomifene citrate/tamoxifen/letrozole Gonadotrophin injection Laparoscopic ovarian diathermy

What type of drugs are clomifene citrate and tamoxifen?

Anti-oestrogens (thus help stimulate FSH)

Is metformin useful in ovulation induction? If so, why?

Yes | Improves insulin resistance, thus reducing androgen production

What are the main risks of ovulation induction?

Ovarian hyperstimulation Multiple pregnancy Possible ovarian cancer

What is another name for ovarian failure?

Hypergonadotrophic hypogonadism

Oestrogen levels are low in ovarian failure. True/False?

True

List some causes of premature ovarian failure (menopause before age of 40)

Turner syndrome XX gonadal agenesis Autoimmunity

What is involved in a progesterone challenge test?

Should menstrual bleed in response to a 5-day course of progesterone to indicate normal oestrogen levels

List clinical features of polycystic ovarian syndrome

``` Hirsutism Acne/oily skin Alopecia Central obesity Amenorrhoea/ infertility ```

What do aromatase inhibitors do? Give an example of one

Letrozole | Inhibit ovarian aromatase enzyme to inhibit oestrogen

In PCOS, oestrogen levels are ___

Normal

List clinical features of premature ovarian failure

Hot flushes Night sweats Atrophic vaginitis

What is the diagnostic criteria for premature ovarian failure?

FSH/LH >30u/l on two occasions 2 months apart

List causes of tubal disease

INFECTIVE: PID (chlamydia, gonorrhea, anerobes, syphillus, TB), trans-peritoneal spreas (appendicitis, abscess), following procedure NON-INFECTIVE: endometriosis, surgical, fibroids, polyps, congenital

List the clinical features of endometriosis

``` Dysmenorrhea Dysparenuia Menorrhagia Defecation pain Chronic pelvic pain ```

Outline management for premature ovarian failure/menopause

Counselling Oocyte donation Prevention of OP via HRT Cryopreservation of ovarian tissue

List the differential diagnoses of infertility from most to least likely

``` Pregnancy PCOS Premature ovarian failure PID (secondary to STI) Hyperprolactinaemia Anorexia/ bulimia ```

What are the clinical signs of hyperprolactinaemia?

Amenorrhea Galactorrhea Visual field defect (BTH)

Outline the drug used to manage hyperprolactinaemia

Dopamine antagonist (cabergoline)