Ovulation Disorders- Types 2 and 3

Question 1

What is the main type 2 ovulation disorder?

Answer 1

PCOS

Question 2

What type of gonadotrophin gonadism is type 2?

Answer 2

Normogonadotrophic hypogonadism

Question 3

Do type 2 ovulation disorders present with amenorrhoea, oligomenorrhoea or either?

Answer 3

Can be either

Question 4

What are the oestrogen levels like in type 2 ovulation disorders?

Answer 4

Normal

Question 5

PCOS is an inherited syndrome, exacerbated by what?

Answer 5

Weight gain

Question 6

PCOS is diagnosed by having 2/3 of the Rotterdam criteria, what are these?

Answer 6

Oligo/amenorrhoea, polycystic ovaries, biochemical or clinical signs of hyperandrogenism

Question 7

What are the two main clinical signs of hyperandrogenism?

Answer 7

Acne, hirsutism

Question 8

What test is most useful to visualise ovarian cysts?

Answer 8

Ultrasound

Question 9

What defines polycystic ovaries?

Answer 9

Increased ovarian volume (> 10ml), more than 12 follicles between 2-8mm in diameter, unilateral or bilateral

Question 10

What are the levels of testosterone in PCOS? This feeds back on the pituitary which can lead to what?

Answer 10

High testosterone, can lead to insulin resistance

Question 11

What are the levels of insulin in PCOS? What effect does this have on sex-hormone binding globulin?

Answer 11

High insulin- decreases SHBG

Question 12

Decreased SHBG in PCOS results in what?

Answer 12

Increased free testosterone and hyperandrogenism

Question 13

What are the 5 main symptoms of PCOS?

Answer 13

Obesity, hirsutism, acne, cycle abnormalities, infertility

Question 14

Symptoms of PCOS get worse as weight increases. What are the first line treatments?

Answer 14

Weight loss and metformin

Question 15

What are the levels of LH/FSH in PCOS?

Answer 15

High LH, normal FSH

Question 16

What will the levels of progesterone be in PCOS?

Answer 16

Low

Question 17

What are some ways to manage symptoms in a patient with PCOS?

Answer 17

Anti-androgens, contraceptive pill

Question 18

When can anti-androgens cause a problem?

Answer 18

If the patient gets pregnant and the foetus is male

Question 19

What should be given to women with PCOS who do not want to get pregnant?

Answer 19

Endometrial protection 4 times a year

Question 20

What lifestyle modifications are used for pre-treatment to aid fertility in women with PCOS?

Answer 20

Weight loss, stop smoking, decrease alcohol

Question 21

What supplement should be given in women with PCOS trying to get pregnant? What should you make sure they are immunised against?

Answer 21

Folic acid 5mg. Immunise against rubella.

Question 22

What is the first line treatment for ovulation induction in PCOS?

Answer 22

Clomifene citrate: 50/100/150mg tablets day 2-6

Question 23

If clomifene citrate treatment fails in PCOS, what can be used instead?

Answer 23

Metformin, gonadotrophin therapy, laparoscopic ovarian diathermy

Question 24

What is given as gonadotrophic therapy if required in PCOS? What are the risks of this?

Answer 24

Daily injections of recombinant FSH. Risks include multiple pregnancy and ovarian hyper stimulation.

Question 25

What is the main risk of laparoscopic ovarian diathermy? What is the advantage of this?

Answer 25

Ovarian destruction. The main advantage is singleton pregnancies.

Question 26

Along with lifestyle modification, what are the advantages of metformin in PCOS?

Answer 26

Improve insulin resistance, reduced androgen production, restore menstruation and ovulation

Question 27

What are the downsides of metformin in PCOS?

Answer 27

Does not help weight loss and may increase pregnancy rate

Question 28

What are the 3 main risks of ovarian induction?

Answer 28

Hyperstimulation, multiple pregnancies and increased risk of ovarian cancer

Question 29

When are you more likely to have ovarian hyper stimulation?

Answer 29

< 35 or if you have PCOS

Question 30

What are the main risks associated with multiple pregnancies?

Answer 30

Increased risk of maternal complications, increased risk of foetus complications, risk of disability, increased postnatal depression, twin twin transfusion syndrome

Question 31

When is the risk of ovarian cancer greatest in ovarian induction?

Answer 31

If fertility treatment is used for more than 12 months

Question 32

If the problem is pituitary dysfunction, what will be the levels of LH/FSH/oestrogen?

Answer 32

LH and FSH = low/normal, oestrogen = low

Question 33

What are some causes of loss of LH/FSH stimulation?

Answer 33

Non-functioning pituitary adenoma, empty sella or pituitary infarction

Question 34

What will be the main presenting features of hyperprolactinaemia?

Answer 34

Amenorrhoea and galactorrhoea

Question 35

What is a really important cause of hyperprolactinaemia which should be considered?

Answer 35

Drugs

Question 36

What exams/tests should be done in a case of hyperprolactinaemia?

Answer 36

Visual fields, hormone levels and pituitary MRI

Question 37

What will be the levels of LH/FSH/oestrogen in hyperprolactinaemia?

Answer 37

LH/FSH = normal, oestrogen = low

Question 38

How should hyperprolactinaemia be managed? When should this be stopped?

Answer 38

Dopamine agonist- stop if patient becomes pregnant

Question 39

What type of gonadotrophic gonadism is type 3 ovarian disorder?

Answer 39

Hypergonadotrophic hypogonadism

Question 40

What is the main issue in group 3 ovarian disorders?

Answer 40

Premature ovarian failure

Question 41

What are group 3 ovarian disorders?

Answer 41

Ovarian failure

Question 42

What will the level of oestrogen be in premature ovarian failure?

Answer 42

Low

Question 43

What will the levels of LH/FSH be in premature ovarian failure?

Answer 43

High

Question 44

What is premature ovarian failure?

Answer 44

The menopause aged < 40

Question 45

What FSH is diagnostic of premature ovarian failure?

Answer 45

> 30 on two separate occasions, more than 1 month apart

Question 46

What are some causes of premature ovarian failure?

Answer 46

Idiopathic, chromosomal, autoimmune, iatrogenic

Question 47

How can a mosaic of Turner's syndrome present?

Answer 47

Secondary amenorrhoea (premature ovarian failure)

Question 48

What are some symptoms of premature ovarian failure?

Answer 48

Hot flushes, night sweats, atopic vaginitis

Question 49

As well as hormone levels, what are some other tests which may be useful in premature ovarian failure?

Answer 49

Karyotyping, DEXA scan, pituitary MRI

Question 50

How do you treat premature ovarian failure?

Answer 50

Counselling, hormone replacement, oocyte donation, prevention of osteoporosis

Question 51

Group 3 ovarian disorders can also be caused by what, as well as premature ovarian failure? Give examples.

Answer 51

Congenital problems: absence of a uterus or vaginal atresia. Also Turner's, CAH, testicular feminisation.