female repro disorders Flashcards
(36 cards)
- Describe the anatomy and physiology of the reproductive axis in the female.
GnRH-induced LH signal in the female is dynamic. LH and FSH are equal for day 1-5 of follicular phase. During mid cycle, pulse generator speeds up and LH and FSH rise. During luteal phase, progesterone slows pulse resulting in infrequent high amplitude LH pulses and lower FSH levels
which cells make estradiol vs androgens/ progesteron
Granulosa cells make estradiol and the luteal cells make the androgens: DHEA, androstenedione and testosterone, and also produce progesterone.
Why are female ovaries more sensitive to toxic effects of chemo and radiation than testis
Progenitor cells are already committed to the primary follicle stage at birth
functions of inhibin A and B
Inhibins inhibit FSH. the Inhibin A (α and ßA) is important in the luteal phase; the inhibin B (α and ßB) is active in the follicular phase of the menstrual cycle
- Describe and apply a general approach to disorders of the hypothalamic-pituitary-ovarian axis.
exclude pregnancy, Rule out an elevated prolactin, Androgen levels are usually not indicated in the absence of hirsutism and/or acne, A GnRH stimulation test is not helpful except in the evaluation children with precocious puberty, Draw LH and FSH levels in the first 5 days after menses starts: normally LH=FSH at that time. TSH, cortisol, IGF-1,
hypogonadotropic hypogonadism labs
low LH, FSH and estradiol with amenorrhea
Causes of hypogonadotropic hypogonadism
- GnRH deficiency- Kallmans syndrome when associated with anosmia. 2. Hypothalamic amenorrhea- disorder of GnRH secretion (defects in amount or frequency) usually due to stress, exercise or poor nutrition. 3. Pituitary amenorrhea- prolactinoma, GH tumor, infiltrative dz (hemochromatosis, sarcoidosis, lymphocytic hypophysitis)
treatment of stress induced hypothalamic amenorrhea
no treatment is option but bone loss occurs with subtle deficits in estrogen deficiency and as early as 6 months after onset
Hypergonadotropic hypogonadism labs
High FSH and/or LH with low estradiol and amenorrhea
Causes of Hypergonadotropic hypogonadism
- Turners syndrome or gonadal dysgenesis (XO, XX/XO)- menopause before menarche. Require lifelong hormonal replacement. 2. Premature ovarian insufficiency- ovarian failure before 40. Autoimmune so look for other autoimmune dz, or srugical.
Signs/Sx of early gonadal failure
irregular menses without molimal symptoms (breast tenderness, bloating and cramping that are signs of an ovulatory cycle). FSH levels rise before LH levels (due to loss of inhibin); there is often a waxing and waning course
List the causes of hyperandrogenic anovulation
Congenital adrenal hyperplasia, PCOS, tumors causing hirsutism, obesity induced anovulation, prolactinoma, Cushings
Attenuated congenital adrenal hyperplasia Sx, treatment
Hx of early pubarche, hirsutism, irregular menses. Family hx. Treatment: OCPs and spironolactone. Use to be glucocorticoids
Polycystic ovarian syndrome Symptoms
begins in adolescence with irregular menses, anovulation, hirsutism and acne. 60% of patients are overweight but all are insulin resistant, and many have acanthosis nigicans
PCOS labs
during day 1-5 of menstrual cycle: HIGH ratio of LH/FSH > 2.5/1, increased androgens, both testosterone (ovarian) and DHEAS (adrenal). Also, estrogen does not fluctuate throughout cycle as normally would. Low sex hormone binding globulin.
PCOS etiology
GnRH pulse generator is turned up too high. Ovulation rarely occurs and progesterone levels don’t rise as they normally would in the luteal phase. Defect in ovarian steroidogenesis. Insulin resistance
Risks associated with PCOS
risk of developing endometrial cancer due to the effect of estrogen unopposed by progesterone, as well as insulin resistance causing glucose intolerance and frank diabetes, hypertension and premature cardiac disease. Also central obesity, low HDL, high triglycerides,
PCOS treatment
If no pregnancy desired: OCPs with nonandrogenic progestin or cyclic progesterone. Treat hirsutism with spironolcatone. Metformin for insulin resistance. If pregnancy desired: clomiphene citrate +/- metformin, Letrozole (aromatase inhibitor). Stop spironolactone 3 months before conception
What kinds of tumors can cause hyperandrogenic anovulation
ovarian: sertoli-leydig cell, hilar cell, lipoid cell. Adrenal: adrenocortical adenoma or carcinoma, virilizing T secreting tumor (rare)
Tumors causing hirsutism- clinical course
Patients with virilizing tumors of the ovary (makes testosterone) or adrenal (makes DHEA-S) are distinguishable from those with PCOS by the rapid onset and pace and the severity of the clinical symptoms, i.e. male pattern balding, hair on upper chest and back and clitorromegaly
Virilizing tumors labs
Testosterone levels >200 ng/dl or DHEAS levels >800 ng/dl suggest TUMOR
Obesity induced anovulation- clinical course and cause
Normal puberty until they exceed their weight set point. Then cycles become irregular, acne, hirsutism. US shows cysts in ovary secondary to anovulation. Excessive activity of aromatase and 5a-reductase in fat tissue.
Obesity induced anovulation labs
In early follicular phase: normal and equal LH and FSH, with mild elevations in androgens
Treatment of female hypogonadism
- no treatment- stress induced hypothalamic amenorrhea. 2. Estrogen therapy. 3. Clomiphene citrate (Clomid). 4. Gonadotropin therapy. 5. Pulsatile GnRH.
