B8.008 Prework 1: Female Infertility: Secondary Amenorrhea

Question 1

what is infertility

Answer 1

unprotected intercourse for 12 mo if a female is < 35 or 6 mo if a female is > 35

Question 2

broad categories of female infertility

Answer 2

tubal
uterine
ovarian
unexplained (20%)

Question 3

tubal causes of infertility

Answer 3

blockage: prior ligation, scarring, prior infection
hydrosalpinx
endometriosis

Question 4

uterine causes of infertility

Answer 4

submucosal fibroids

intrauterine scarring: prior procedures, scarring

Question 5

ovarian causes of infertility

Answer 5

anovulation

low ovarian reserve

Question 6

prevalence of infertility

Answer 6

12%

Question 7

what is amenorrhea

Answer 7

absence of menses

Question 8

primary amenorrhea

Answer 8

no menarche by age 15

Question 9

secondary amenorrhea

Answer 9

absence of menses for > 3 mo in females with prior regular cycles
absence of menses for > 6 mo in females with prior irregular cycles

Question 10

anatomic locations of amenorrhea etiologies

Answer 10

hypothalamus (35%)
pituitary (17%)
ovary (40%, most common)
uterus (7%)

Question 11

hypothalamic causes of amenorrhea

Answer 11

suppression due to systemic illness, radiation, low energy states

Question 12

pituitary causes of amenorrhea

Answer 12

any hormone secreting tumor
hyperprolactinemia (13%)
empty sella syndrome (1.5%)
sheehan syndrome (1.5%)
cushing's syndrome (1%)

Question 13

empty sella syndrome

Answer 13

rare

enlargement of sella tunica in pituitary

Question 14

sheehan syndrome

Answer 14

pituitary infarct, usually due to post partum hemorrhage

Question 15

ovarian causes of amenorrhea

Answer 15

PCOS (30%)

primary ovarian insufficiency (10%)

Question 16

general “cause” of secondary amenorrhea

Answer 16

inappropriate hormone signaling in HPA

prohibits cyclic oocyte release

Question 17

follicular phase HPA

Answer 17

hypothalamus secretes GnRH
anterior pituitary stimulated to secrete FSH and LH
ovary is stimulated to release estradiol due to production by rapidly maturing oocytes
estradiol has an inhibitory effect at the level of the hypothalamus and the anterior pituitary

Question 18

midcycle HPA

Answer 18

hypothalamus secretes GnRH
anterior pituitary stimulated to secrete FSH and LH
LH surge
ovary is stimulated to release estradiol
estradiol has stimulatory effect at level of hypothalamus and the anterior pituitary

Question 19

luteal phase HPA

Answer 19

hypothalamus secretes GnRH
anterior pituitary stimulated to secrete FSH and LH
ovary contains corpus luteum (remnant of follicle) which secretes progesterone from glandular endometrium
progesterone has inhibitory effect at the level of the hypothalamus and anterior pituitary

Question 20

GnRH pulsatility for LH release

Answer 20

increasing amplitude, high frequency

Question 21

GnRH pulsatility for FSH release

Answer 21

decreased amplitude, low frequency

Question 22

effect of estrogen on GnRH

Answer 22

increases pulse frequency

Question 23

effect of progesterone on GnRH

Answer 23

decreases pulse frequency

Question 24

WHO 1 amenorrhea

Answer 24

hypothalamic

decreased FSH, LH, E2

Question 25

WHO 2 amenorrhea

Answer 25

PCOS normal levels can have increased LH and T (but not necessary for diagnosis)

Question 26

WHO 3 amenorrhea

Answer 26

ovarian failure increased FSH, LH decreased E2

Question 27

what needs to be excluded in hypothalamic amenorrhea

Answer 27

``` craniopharyngioma radiation of sellar tumor infiltrative disease systemic illness do an MRI to rule out tumor ```

Question 28

risk factors for hypothalamic amenorrhea

Answer 28

excess exercise stress nutritional deficiency (hypoleptinemia) **low energy states**

Question 29

rotterdam criteria for PCOS

Answer 29

need 2/3: 1. PCO - >12 antral follicles on US 2. hyperandrogenism 3. irregular menstrual cycles

Question 30

signs of hyperandrogenism

Answer 30

hirsutism acne elevated T

Question 31

irregular menstrual cycles

Answer 31

< 21 days | > 35 days

Question 32

why does PCOS lead to infertility

Answer 32

increased ratio of LH:FSH induces thecal proliferation | follicles continue to grow but done mature and rupture, thus ovulation does not occur

Question 33

characteristics of primary ovarian insufficiency (POI)

Answer 33

< 40 years of age | FSH > 30 on 2 occasions

Question 34

etiology of POI

Answer 34

``` iatrogenic (radiation, chemo) immunologic chromosomal -turners -galactosemia -fragile x -perrault ```

Question 35

treatment for WHO 1 amenorrhea

Answer 35

decrease stress increase energy intake gonadotropins

Question 36

treatment for WHO 2 amenorrhea

Answer 36

decrease energy intake letrozole (aromatase inhibitor) clomid, gonadotropins, ovarian drilling (last resorts)

Question 37

mechanism of action of letrozole

Answer 37

inhibits aromatase in ovaries and peripheral tissues, reducing estrogen levels estrogen reduction stimulates HPA to produce more FSH FSH mediated follicle stimulation, which causes estrogen to rise once estrogen begins to rise again, FSH is suppressed leaving a single dominant follicle

Question 38

treatment for WHO 3 amenorrhea

Answer 38

donor oocytes