Hypothalamic Pituitary Dysfunction

Question 1

What is it?

Answer 1

85% of ovulatory disorders (most common)
Normal oestrogen, normal gonadotrophins (though can get excess LH)
Oligo/amenorrhoea
Anovulation due to PCOS
Mainly PCOS, PCOS occurs in 5-15% women of reproductive age [oligomenorrhoea > amenorrhoea]

Question 2

what are the hormonal indications seen in PCOS

Answer 2

Insulin resistance is seen in 50-80% PCOS,
insulin acts as a co-gonadotrophin to LH so there’s an increase in LH levels,
insulin also lowers SHBG levels increasing free testosterone leading to hyperandrogenism

Question 3

how is PCOS managed?

Answer 3

weight loss, 
stop smoking/alcohol, 
folic acid (400 mcg daily), 
check prescribed drugs, 
check rubella immunity (vaccine), 
normal semen analysis, 
patent fallopian tube, 
ovulation induction

Question 4

how is ovulation induced in PCOS

Answer 4

• Clomifene citrate
• Gonadotrophin therapy (daily injections), risk of multiple pregnancy and overstimulation
• Laparoscopic ovarian diathermy, risk of ovarian destruction

Question 5

metformin ovulation induction in PCOS

Answer 5

Use with lifestyle modifications
It improves insulin resistance, reduction in androgen production (and increase in SHBG)
Causes restoration of menstruation and ovulation, may increase pregnancy rate
DOES NOT help in weight loss
May improve sensitivity to clomifene

Question 6

what are the risks of ovulation induction?

Answer 6

Ovarian hyperstimulation (affects 10% IVF, ranges from mild to severe, there is an increased risk if under 35 or if they have PCOS)
Multiple pregnancy
Potential ovarian cancer

Question 7

risks of multiple pregnancy

Answer 7

• Increased maternal pregnancy complications (hyperemesis, anaemia, hypertension, pre- eclampsia, gestational diabetes, postnatal depression/stress)
• Increased risk of both early and late miscarriage
• Increased risk of low birth weight
• Increased risk of prematurity (premature can affect brain, development, sight, heart, breathing)
• Increased risk of disability
• Increased risk of stillbirth/neonatal death (higher in twins, even higher in triplets)
• Twin-twin transfusion syndrome [TTTS]

Question 8

what are monochorionic twins?

Answer 8

T sign on scan
2 foetuses sharing one placenta
have increased perinatal mortality compared to dichorionic (lambda sign on scan)
Chorionicity - refers to the number of outer membranes around the baby in multiple pregnancies

Question 9

pathophysiology of twin-twin transfusion syndrome?

Answer 9

unbalanced vascular communications within placental bed so the recipient develops polyhydramnios (excess amniotic fluid in the amniotic sac)
while the donor develops oliguria, oligohydramnios and growth restriction)

Question 10

how is twin-twin transfusion syndrome managed?

Answer 10

fatal if left untreated,
later division of placental vessels,
amnioreduction,
septostomy

Question 11

what effect does being a twin have?

Answer 11

biggest risk to child’s health and welfare

biggest risk factor = prematurity and low birth weight

Question 12

what is the history of hyperprolactinaemia?

Answer 12

amenorrhoea

galactorrhoea

Question 13

examination and investigation for hyperprolactinaemia?

Answer 13

visual fields 
low oestrogen, 
raised serum prolactin (>1000 iu/l on 2 or more occasions), 
normal TFT, 
MRI to diagnose micro/macro prolactinoma

Question 14

how is prolactinemia managed?

Answer 14

dopamine agonist [should be stopped when pregnancy occurs]