Week 5 - E - WHO classification of ovulatory disorders

Question 1

What hormone made in the hypothalamus causes the release of GnRH and the sequence of events following?

Answer 1

The kisspeptin hormone causes the release of GnRH from the hypothalamus

Question 2

What hormone can be used to check if a female is ovulating or not? Checked on day 21 of the menstrual cycle

Answer 2

The hormone progesterone

Its levels rise after ovulation as the corpus luteum forms from the remnant follicular cells after ovulation

Question 3

What is the moment in which the developing oocyte is released? What is it known as when the period becomes and why does this happen?

Answer 3

Ovulation is when the developing oocyte is released

Menses is when the uterus lining sheds causing bleeding

Question 4

What is defined as oligomenorrhea in woman?

Answer 4

reduction in frequency of periods to less than 9/year

Question 5

What is the failure of menarche by age 16 known as?

Answer 5

Primary amenorrhea

Question 6

What is secondary amenorrhea defined as?

Answer 6

cessation of periods for >6 months in an individual who has previously menstruated

Question 7

What are two physiological causes of amenorrhea?

Answer 7

Pregancny and post-menopause

Question 8

Primary amenorrhea is ually thought to be a congenital disorder (can be causes by something else eg prolactinoma from a young age) What are the two congenital disorders?

Answer 8

Turner’s syndrome Kallman’s syndrome

Question 9

Which congenital disorder is caused by having the 45X cromosome where there is a full missing Xchromosome? Is this disorder in males or females?

Answer 9

Tuner’s syndrome Only in females

Question 10

What are features of tuner’s syndrome found in women?

Answer 10

Short stature infertility – due to underdeveloped ovaries Puberty failing to arrive Congenital heart defects in 50% of females

Question 11

is a form of hypogonadotropic hypogonadism (HH). Congeneital condition that is a form of hypogonadotropic hypogonadism (HH) and therefore children cannot go through puberty?

Answer 11

Anosmia and isolated GnRH deficiency → Kallmann’s syndrome

Question 12

What are four causes of secondary amenorrhea? what can cause hypothalamic dysfunction? this causes amenorrhea also

Answer 12

Polycyctic ovarian syndrome (PCOS) Premature ovarian failure Hyperprolactinaemia Hypopituitarism Hypothalamic dysfuntion - weigh loss, stress, over exercise

Question 13

What are symptoms of oestrogen deficicency? (give name for the difficult/painful sex)

Answer 13

Flushing Libido Dysparenuia - difficult or painful sexual intercourse

Question 14

In all patients with amenorrhea, what hormone levels should be investigated?

Answer 14

LH, FSH Prolactin Oestradiol Thyroid function

Question 15

When should the patients karyotype be investigated?

Answer 15

In cases of primary amenorrhea or suspected turner’s syndroem

Question 16

Primary hypogonadism causing amenorrhea is to do with a problem due to the ovaries What are the hormone levels in primary hypogonadism? (clue - it is hypergonadotropic hypogonadism)

Answer 16

the ovaries have stopped working characterized by a high LH/FSH in combination with low oestogen

Question 17

Primary ovarian problem is the usual cause of hypergonadotropic hypogonadism What are the primary ovarian problem causes?

Answer 17

Premature ovarian failure

Question 18

What is secondary hypogonadism usually due to? WHat are the hormone levels in this? (LH,FSH and oestradiol levels)

Answer 18

Is a hypothalamic or pituitary problem LH, FSH and oestradiol are all low

Question 19

What are three potential causes of secondary hypogonadism causing amenorrhea?

Answer 19

Kallman’s syndrome Hyperprolactinaemia Hypopituitarism

Question 20

Condition, with amenorrhea, oestrogen deficiency and elevated gonadotrophins <40 years of age as a result of loss of ovarian function What is this condition?

Answer 20

Premature ovarian failure

Question 21

Is premature ovarian failure a cause of primary or secondary hypogonadism? What are the FSH levels to diagnose premature ovarian failure? (2 readings)

Answer 21

Causes of primary hypogonadism as it is an ovarian problem that causes secondaru amenorrhea Also the high LH/FSH with low oestrogen FSH >30 on 2 separate occasions > 1 month apart Below the age of 40

Question 22

So, menopause before the age of 40 can indicate premature ovarian failure This condition is usually idiopathic however what are some causes? (congenital, gene mutations, autoimmune)

Answer 22

Congenital - Turner’s Autoimmune - Addison’s and thyroid Gene mutations - FSH/LH receptor mutation Can also be iatrogenic due to radio or chemo therapy

Question 23

Hypothalamic dysfunction due to eg stress, weight loss causing amenorrhea is called functional hypothalamic amenorrhea What does this do to the GnRH? Why is amenorrhea associated with people who lose increase amounts of weight?

Answer 23

Causes loss of pulsatile GnRH decreasing the gonadotrophins Basically the hypothalamus decreases gonadotrophic production decreasing gonad production as it is saying the body is an unsuitable environment to host a foetus

Question 24

What is is an upstream regulator of GnRH secretion produced in a specific subset of hypothalamic neurons ?

Answer 24

Kisspeptin

Question 25

A genetic disorder characterised by a loss of GnRH secretion + anosmia or hyposmia Normal rest of pituitary function What is this condition? Aka - idiopathic hypogonadotropin hypogonadism + anosmia

Answer 25

Kallman’s syndrome

Question 26

On MRI in kallmans, what bulbs may be absent accounting for the lack of smell?

Answer 26

The olfactory bulbs

Question 27

Syndrome where the pituitary gland shrinks or becomes flattened, filling the sella turcica, or “Turkish Saddle”, with cerebrospinal fluid on imaging instead of the normal pituitary? Where is the sella turcica depression?

Answer 27

Empty sella syndrome Depression in the sphenoid bone

Question 28

Is pituitary dysfunction eg empty sella syndrome a cause of primary or secondary hypogonadism causing amenorrhea?

Answer 28

Cause of secondary hypogonadism

Question 29

What can metaclopramide cause that may cause secodnary hypogonadism?

Answer 29

Can inhibit dopamine receptors causing increased prolactin Hyperprolactinaemia can cause secondary hypogonadism leading to amenorrhea

Question 30

Polycystic ovarian syndrome is another ovarian cause of amenorrhea What are the hormone levels in PCOS? What does the genetic predisposition cause the ovaries to produces in excess in PCOS leading to some of the associated features?

Answer 30

Excess LH, androgens/testosterone, oestrogen Low FSH (remember oestrogen has a negative feedback on FSH (and prolactin) however stimulates secretion of LH) Causes the production of excess androgen

Question 31

What is the rotterdam criteria for diagnosing PCOS?

Answer 31

2 of: Menstrual irregularity Hyperandrogenism (hirsutism, elevated free testosterone) Polycystic ovaries

Question 32

What can the elevated free testosterone/oestrogen levels cause in PCOS?

Answer 32

The cystic appearance of the ovaries results from several follicles failing to mature properly without development of a dominant follicle. The multiple follicles produce large amounts of estradiol, which inhibits FSH release thereby preventing further follicle development

Question 33

What are common laboratory findings in PCOS?

Answer 33

Common laboratory findings with PCOS include elevated LH, androgens, and estrogen, with normal or low FSH.

Question 34

What is the adrenal insufficiecny cause that can classically presents in childhood with virilization and low salt? WHat enzyyme causes this?

Answer 34

Congenital adrenal hyperplasia Due to 21-OH deficiecny causing low aldosterone, cortisol and high androgen levels

Question 35

What is the form of congenitl adrenal hyperplasia that presents in adolescence with hirsituism and infertitility due to anovulatin?

Answer 35

Non-classic congenital adrenal hyperplasia (CAH) Causes by a partial 21-OH deficiency

Question 36

As ACTH is driven to androgens by the diversion since there is a 21-OH deficiecny What enzyme is there a massive increase in?

Answer 36

Increase in 17alpha OH progesterone after synacthen test

Question 37

Hirsituism and menstraul irregularity are associated symptoms of acromegaly in women What other 4 conditions can hyperandrogenism be associated with?

Answer 37

Cushing’s syndrome Addison’s disease Congenital adrenal hyperplasia Polycystic ovarian syndrome

Question 38

In the treatment of PCOS, it depends on the symptoms What is the first line treatment of PCOS? What can be given for the menstraul irregularity?

Answer 38

Weight loss - reduces hyperinsulinsim and hyperandrogenism * For menstrual irregularity can give oral contriceptrive pill * For the infertiity - give clompiphen citrate - 1st line (Clomifene is a non-steroidal anti-oestrogen that inhibits oestrogen negative feedback on the hypothalamus/pituitary, which in turn leads to an increase in FSH secretion that may allow follicular maturation and ovulation)

Question 39

Diagnosis? (this is a female)

Answer 39

Turner’s syndrome

Question 40

Turner’s syndrome can cause different heart disease eg coarctation of the aorta or bicuspid aortic valve What is the tetralogy of fallot?

Answer 40

1. Pulmonary Stenosis 2. Hypertrophy of Right Ventricle 3. VSD 4. Over-riding Aorta