Reproduction: Ovulation Disorders Flashcards
Oligomenorrhoea
Cycle lasts >35 days
Amenorrhoea
Absent menstruation
Primary: Never had a period
Secondary : Period has stopped
Gonadotrophin Releasing Hormone
Synthesised by neurons in hypothalamus Pulsatile release Stimulates synthesis/ release of - FSH (low frequency) -LH (high frequency)
Follicular Stimulating Hormone
Secreted by anterior pituitary
Stimulates follicular development
Thicken endometrium
luteinising hormone
Secreted by anterior pituitary
Peak (LH surge) stimulates ovulation
Stimulates corpus luteum developement
Thickens endometrium
Hormone Peaks during Menstrual Cycle
Estradoil peaks before ovulation
LH surge triggers ovulation
Progesterone peak follows ovulation
Estrogen
Secreted primarily by ovaries (follicles) and adrenal cortex
Stimulates thickening of endometrium
Responsible for fertile cervical mucus
High oestrogen concentration inhibits secretion of FSH and prolactin
(-ve feedback)
Progesterone
Secreted by corpus luteum to maintain early pregnancy
Inhibits secretion of LH
Responsible for infertile (thick) cervical mucosa
Maintains thickness of endometrium
Has thermogenic effect
- increases basal body temp
Relaxes smooth muscles
Assessing Ovulation
Regular cycles very suggestive of ovulation
- Confirm by midluteal (day 21) serum progesterone (>30nmol/l)
Irregular cycles: probably anovulatory: needs further hormone evaluation
Ovulatory Disorders Classifications
Group 1: Hypothalamic Pituitary Failure
Group 2: Hypothalamic Pituitary Dysfunction
Group 3 : Ovarian Failure
Group 1 ovulatory Disorders
hypogonadotrophic hypogonadism
Group 1 Ovulatory Disorders Finding
Low levels LH/ FSH Oestrogen deficiency - negative progesterone challenge test Normal prolactin Amenorrhoea
Group 1 Ovulatory Disorders Aetiology
Stress Excessive exercise Anorexia/low BMI Brain/ pituitary tumours Head trauma kallmanns syndrome Drugs (steroid, opiates)
Group 1 Disorder : Pre-treatment
Stabilise weight Lifestyle modification (smoking, alcohol) Folic acid (400mcg daily) Check prescribed drugs Rubella Immune Normal semen analysis
Group 1 Disorder: Medical Management
Pulsatile GnRH
- SC or IV pump worn continuously
- Pulsatile administration every 90 mins
Gonadotrophin (LH and FSH) daily injections
Pulsatile GnRH and gonadotrophin injections both need US monitoring of response
–> follicle tracking
Group 2 Ovulatory Disorder
Hypothalamic Pituitary Dysfunction
Group 2 Disorders Findings
Normal gonadotrophins
- possible excess LH
normal oestrogen levels
Oligomenorrhoea or Amenorrhoea
Group 2 Disorders Example
PCOS
PCOS
heterogenous disease characterised by hyperandrogegism and ovarian dysfunction which results in oligomenorrhoea or amenorrhoea and is associated with subfertility
PCOS Presentation
Oligomenorrhoea (80- 90%)
Amenorrhoea (10-20%)
PCOS Diagnosis
Requires 2 out of 3
Oligomenorrhoea or Amenorrhoea
polycystic Ovaries (US appearance)
- 12 or more 2-9mm follicles
- Increased ovarian volume (>10ml)
- Uni or bilateral
Chemical +/- biochemical signs of hyperandrogegism (acne, hirsutism)
PCOS and insulin resistance
Insulin resistance seen in 50 to 80%
Diminished biological response to a given level of insulin
Normal pancreatic reserve
- hyperinsulinaemia
Insulin acts as co-gonadotrophin to LH
- 60% elevated LH
- 955 altered LH: FSh ratios
Insulin lowers SHBG levels: increased free testosterone leads to hyperandrogegism
Group 2 (PCOS) Management
Treat patients symptoms/ needs
pre-treatment (lifestyle etc)
Subfertility: Ovulation Induction
Ovulation Induction
1st Line: Clomiferene Citrate
2nd : Gonadotrophin Therapy (daily injections)
3rd: Laparoscopic Ovarian Diathermy
Ovulation Induction Risks
Ovarian hyperstimulation
- affects 10% IVF
-Ranges from mild to severe
Multiple pregnancy
Risks of multiple pregnancy
Increased maternal pregnancy complications
- hyperemesis, anaemia, hypertension, pre-eclampsia, gestational diabetes, postnatal depression/ stress
Increased risk of miscarriage
Risk of low birth weight and prematurity
Risk of still birth
Monochorionic
Chorionicity
The number of chorionic (outer) membranes that surround babies in a multiple pregnancy
Monochorionic
- Fetus share a chorion
- Increased perinatal mortality
- T sign on US
Dichorionic
- Two placenta masses
- Lambda sign on US
Twin Twin Transfusion
Unbalanced vascular communications with placental bed
Recipient develops polyhydramnios
Donor develops oliguria, oligohydramnios and growth restriction
80-100% fatal if untreated
Treatment
- laser division of placenta vessels
- Amnioreduction
- Septostomy
Group 3 Ovarian Failure Findings
high level gonadotrophins
- Raised FSH >30IU/L
Low oestrogen levels
Amenorrhoea
menopausal
Premature Ovarian failure
Menopause before age 40
Premature Ovarian failure Aetiology
Genetic -Turner syndrome. -XX gonadal Genesis - Fragile X Autoimmune ovariaan failure Bilateral oophorectomy Pelvic chemotherapy/ radiotherapy
Premature Ovarian Failure Management
Hormone replacement therapy
Counselling/ Support network
Ovarian Failure; Gynaecological History
Details of menstrual cycle Amenorrhoea Hirsutism Acne Galactorrhoea Headaches Visual symptoms PMH and DHx
Ovarian Failure Biochemistry
Mid luteal progesterone (day 21)
Early follicular phase(day 2 to 5)
- serum TSH, oestradiol & LH
- serum testosterone/ SHBG
- prolactin
Gold Standard: Progesterone Challenge test
(menstrual bleeding in response to a 5 day course of progesterone: indicates oestrogen levels normal)
Ovarian Failure Ultrasound
Transvaginal
Routine part of infertility consultation
Examines pelvic anatomy
- uterus
- ovarian morphology
Scan to look for follicular growth/ monitor ovulation induction
Ovarian Failure Tests
Karyotype
ute-antibody screen
MRI of pituitary fossa
Bone density scan
hyperprolactinaemia
Raised prolactin
Can cause ovulatory disorder
hyperprlactinaemia history and exam
AAmenorrhoea
Oligomenorrhoea
Current medication
Examine visual fields
Hyperproolactinaemia Investigations
Normal LH/FSH
Low oestrogen
Raised serum prolactin
- >1000iu/l on 2 or more occasions
TFT normal
MRI
- Diagnose micro/macro prolactinoma
Hyperprolactinaemia management
Dopamine agonist
- cabergoline (2x weekly)
- stop when pregnancy occurs
