Ovulation disorders yet again Flashcards by Robyn Baxter

What is the average length of a full menstrual cycle?

28 days

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Name the two phases of the menstrual cycle

Follicular

Luteal

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What is oligomenorrhea?

Less than 9 cycles in a year (i.e prolonged cycles)

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What is amenorrhea? How can it be classified?

Absence of menstruation. Primary (no menarche) or secondary

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Oligomenorrhea and amenorrhea are linked to what?

Anovulation (failure of egg to be released from the ovaries)

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Describe the hypothalamic pituitary ovarian axis

Hypothalamus - gonadotrophic releasing hormone
Pituitary - follicular stimulating hormone and lutenizing hormone
Ovaries - oestradiol + progesterone

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Where is gonadotrophic releasing hormone produced?

Neurones in the hypothalamus

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How is gonadotrophic releasing hormone secreted?

Pulsatile

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How does secretion of GnRH affect secretion of FSH and LH?

Low frequency secretion - FSH

High frequency secretion - LH

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What secretes FSH?

Anterior pituitary

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What does FSH do?

Stimulates follicular development

Thickens endometrium

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What secretes LH?

Anterior pituitary

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What does LH do?

Peak secretion stimulates ovulation
Corpus luteum development
Thickens endometrium

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What hormone triggers ovulation?

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What does an ovulation detector kit detect?

Surge of LH 1.5 days before ovulation

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How do the ovarian hormones vary with ovulation?

Oestradiol - high before ovulation

Progesterone - high after ovulation

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What produces progesterone?

Corpus luteum

Placenta during pregnancy

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What produces oestrogen?

Ovaries
Adrenal glands
Placenta during pregnancy

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What does oestrogen do?

Thickens endometrium

Induces production of fertile cervical mucus

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Describe the effects of high oestrogen

Inhibits FSH and prolactin

Stimulates LH

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What does progesterone do?

Inhibits LH
Maintains endometrial thickness
Induces production of infertile (thick) cervical mucus 
Increases basal body temperature
Relaxes smooth muscle

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How do you determine whether ovulation is taking place?

Regular cycles suggest ovulation ; irregular cycles suggest anovulation

Confirm via mid luteal (day 21) serum progesterone (raised) in two samples
Further hormone testing may be needed

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Why is the presence of absence of ovulation a big deal?

Can affect fertility

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Where is the pathology in hypogonadorophic hypogonadism?

Hypothalamus or pituitary

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How does hypogonadotrophic hypogonadism present?

Low LH/FSH Oestrogen deficiency Normal prolactin Amenorrhea

How is oestrogen deficiency tested for?

Serum oestradiol | Progesterone challenge test

What are the hypothalamic/pituitary causes of amenorrhea?

``` Stress Inc exercise Low BMI Tumour Kallman's Drugs (steroids, opiates) Trauma ```

How is hypogonadotrophic hypogonadism managed?

``` Weight stabilisation Pulsatile GnRH (subcutaneous or IV) OR Gonadotrophic daily injections ```

What are the benefits of both pulsatile GnRH and gonadotrophic daily injections? How are these treatments monitored?

Pulsatile GnRH - high conception rate Gonadotrophic injections - higher multiple pregnancy rates Ultrasound (follicular tracking)

How does hypothalamic pituitary dysfunction (NOT failure) present?

Normal oestrogen Normal gonadotrophs Oligo/amenorrhea Often polycystic ovarian syndrome

What is the diagnostic criteria for polycystic ovarian syndrome?

Oligo/amenorrhea Polycystic ovaries on USS Clinical/biochemical signs of hyperandrogenism

What are signs of hyperandrogenism?

Male pattern baldness Acne Hirsutism

How do people with polycystic ovaries react to insulin?

Resistant - normal pancreatic reserves but impaired efficacy to hyperinsulinaemia (may nave type 2 diabetes as result)

How does hyperandrogenism arise in patients with polycystic ovaries?

Insulin lowers sex hormone binding globulin (SHBG) levels causing increases in free testosterone

Insulin acts as a co-gonadotroph to LH. T/F

True

How is PCOS managed?

Patient dependent | Sub fertility managed by ovulation induction

What should be done pre ovulation induction for fertility treatment?

Weight loss (BMI

How is ovulation induction carried out?

Clomefine citrate/tamoxifen/letrozole OR (if resistant) Gonadotrophin (recombinant FSH) daily injection OR Laproscopic ovarian diathermy

What risks are associated with gonadotrophin daily injection?

Multiple pregnancies | Overstimulation

What risks are associated with laproscopic ovarian

Ovarian destuction

What can be used as an alternative to clomefine citrate? Why?

Metformin Increases insulin sensitivity, decreases androgens (& thus hyperandrogenism) and raises SHBG Restores menstruation and ovulation

What does metformin not do?

Help with weight loss

What is ovarian hyperstimulation? What are the risk factors?

Follicles produce increased growth factors --> fluid shift --> dehydration and thick blood

What are the symptoms of ovarian hyperstimulation?

Depends on severity: ``` Abdo pain Ascites Nausea & vomiting Oliguria Hypoproteinaemia Thromboembolism Large ovaries ```

Are single or multiple pregnancies higher risk? Higher risk of what?

Multiple ``` Hyperemesis Pre/eclampsia Gestational diabetes Stillbirth Intra-uterine death Anaemia Post-natal depression Post partum haemorrhage Prematurity Low birth weight Twin to twin transfusion syndrome ```

Are monochronic or dichronic twins at most risk of perinatal mortality?

Monochronic

What ultrasound sign indicates dichronicity? Which ultrasound sign indicates monochronicity?

Lambda | T sign

What is twin to twin transfusion syndrome? Which type of twins are at risk?

Unbalanced vascular communications within placental bed results in recipient of increased blood developing polyhydraminos and donor developing oliguria, oligohydraminos and growth restriction Monochronic diamniotic

How can twin to twin transfusion syndrome be managed? What happens if its not treated?

Laser division of placental vessels Amnioreduction Septostomy Death

What are the early and long term problems of prematurity?

``` Early - Intensive care admission - Respiratory distress syndrome Late - Cerebral palsy - Sight impairment - Congenital heart disease - Lower IQ - ADHD - Language development problems ```

How does hyperprolactinemia present?

Amenorrhoea | Galactorrhea

What medications are linked with hyperprolactinaemia?

Anti-emetic | Anti-psychotic

What must be clinically tested when a patient presents with hyperprolactinemia?

Visual fields

How should hyperprolactinaemia be investigated?

``` FSH/LH (should be normal) Low oestrogen Raised serum prolactin over 1000 (>2 occasions) Thyroid function tests (normal) MRI ```

How is hyperprolactinaemia treated? What is it important to remember?

Dopamine antagonist - Cabergoline twice weekly - Bromocriptine STOP treatment during pregnancy

How does ovarian failure present?

High gonadotrophins (raised FSH in two samples) Low oestrogen Amenorrhea Menopause

How is premature ovarian failure defined?

Menopause before the age of forty

List the causes of premature ovarian failure

``` Genetic (turner's, fragile X, XX gonadal agenesis) Radiotherapy Chemotherapy Oophrectomy (bilateral) Autoimmune ```

How is premature ovarian failure managed?

Hormone replacement therapy Assisted conception Cryopreservation of gametes prior to cancer therapy Counselling

What are the key features of a gynaecological history?

``` Details of menstrual cycle Amenorrhea (pregnancy test) Acne Galactorrhea Headaches Visual symptoms Past medical history Drug history ```

What biochemical investigations should be performed with ovarian irregularities?

Mid luteal progesterone (day 21) Early follicular tests (day 2-5) - FSH, LH, oestradiol - serum testosterone / SHBG (free androgens) - prolactin - TSH (hypothyroid) Progesterone challenge test (bleeding indicates normal oestrogen)

Which type of ultrasound is used in infertility testing/monitoring treatment response?

Transvaginal

What tests may be indicated in infertility testing?

Autoantibodies Karyotype MRI Bone density (oestrogen)