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Year 2 Clinical > Ovulatory disorders > Flashcards

Ovulatory disorders Flashcards

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1
Q

Describe a regular menstrual cycle

A

Lasts 28-35 days and has 2 phases:
• Follicular
• Luteal

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2
Q

Define oligomenorrhea?

A

Cycle >35 days

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3
Q

Define amenorrhea?

A

Absent menstruation of a cause:
• Primary
• Secondary

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4
Q

Symptoms of anovulation?

A

Oligomenorrhea and amenorrhea

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5
Q

Describe the HPO (hypothalamic-pituitary-ovarian) axis

A

Hypothalamus produces GnRH, which stimulates the pituitary gland to produce LH and FSH

These stimulate the ovaries to produce:
• Oestradol - -vely feedbacks to the pituitary gland
• Progesterone - -vely feedbacks to the hypothalamus

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6
Q

Production, release and function of GnRH?

A

Synthesised by neurons in the hypothalamus and is released in a pulsatile manner

Stimulates FSH (low frequency pulses) and LH (high frequency pulses) synthesis/release from the anterior pituitary gland

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7
Q

Functions of FSH?

A

Stimulates follicular development and thickens the endometrium

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8
Q

Functions of LH?

A
  1. Peak of LH stimulates ovulation
  2. Stimulates corpus luteum development
  3. Thickens endometrium
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9
Q

What does the ovulation predictor kit do and what is its downfall?

A

Detects LH surge (which occurs 36 hours before ovulation)

Beware: for 3/100 women, this is not reliable as LH is not always in the urine

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10
Q

Which hormones peak before and after ovulation?

A

Oestradiol - peaks before ovulation

Progesterone - peaks after ovulation (it is produced by the corpuc luteum)

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11
Q

Production and functions of oestrogen?

A

Secreted primarily by the ovaries (follicles) and the adrenal cortex; also secreted by the placenta during pregnancy

Functions:
• Stimulates endometrial thickening
• Responsible for fertile cervical mucous
• High oestrogen conc. inhibits FSH and prolactin secretion (-ve feedback) and stimulates LH secretion (+ve feedback)

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12
Q

Production and functions of progesterone?

A

Secreted by the corpus luteum, to maintain early pregnancy; also secreted by the placenta during pregnancy

Functions:
• Inhibition of LH secretion
• Responsible for infertile (thick) cervical mucous
• Maintains endometrial thickness
• Has a thermogenic effect (increases basal body temp)
• Relaxes smooth muscles

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13
Q

What does a regular cycle say about ovulation?

A

Very suggestive of ovulation and this can be confirmed with mid-luteal (day 21) serum progesterone measurements with 2 samples

> 30 nmol/L is normal

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14
Q

What does an irregular cycle say about ovulation?

A

Likely anovulatory and requires further hormone evaluation

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15
Q

WHO classification for the 3 groups of ovulatory disorders?

A

Group 1 - hypothalamic pituitary failure

Group 2 - hypothalamic pituitary dysfunction

Group 3 - ovarian failure

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16
Q

Consequence of hypothalamic pituitary failure?

A

Hypogonadotrophic hypogonadism - there are low FSH/LH levels

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17
Q

Features of hypothalamic pituitary failure (group 1)?

A

Oestrogen deficiency (progesterone challenge test is -ve)

Normal prolactin

Amenorrhea

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18
Q

Causes of hypothalamic pituitary failure?

A

Stress, excessive exercise (athletes), anorexia/low BMI

Brain/pituitary tumours and head trauma

Kallman’s syndrome

Drugs, e.g: steroids, opiates

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19
Q

Mx of hypothalamic anovulation

A

Stabilise weight (BMI >18.5 is the aim)

Pulsatile GnRH if they continue to have hypogonadotrophic hypogonadism

Gonadotrophin (LH + FSH) daily injections

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20
Q

Monitoring of hypothlamaic anovulation treatment?

A

Both of the treatment required USS monitoring of response (follicle tracking)

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21
Q

Risk with gonadotrophin (LH +FSH) daily injections?

A

Higher rate of multiple pregnancy

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22
Q

Features of hypothalamic pituitary dysfunction (group 2)?

A

Normal gonadotrophins OR there can be excess LH

Normal oestrogen levels

Oligo/amenorrhea

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23
Q

Most common cause of hypothalamic pituitary dysfunction?

Study These Flashcards
A

Polycystic Ovarian Syndrome (PCOS)

24
Q

Rotterdam criteria for the diagnosis of PCOS?

Study These Flashcards
A

Oligo/amenorrhea

  1. Polycystic ovaries (USS appearance):
    • 12/more 2-9mm follicles
    • Increased ovarian volume (>10ml)
    • Unilateral/bilateral
  2. Clinical and/or biochemical signs of hyperandrogenism, e.g:
    • Hirsutism
    • Acne
25
Symptoms of PCOS?
Sub-fertility Oligo/amenorrhea Hirsutism Obesity Acne
26
Describe the insulin resistance in PCOS
They have a normal pancreatic reserve so they have hyperinsulinaemia Some develop frank glucose intolerance or NIDDM
27
Effects of insulin in PCOS?
Acts as a co-gonadotrophin to LH Also lowers SHBG (sex-hormone binding globulin) so there is increased free testosterone, leading to hyperandrogenism
28
What does Mx of PCOS depend on?
Depends on symptoms and patient needs
29
Pre-treatment of anovulation in PCOS?
Weight loss optimises results (BMI>30 = poor outcome) Lifestyle modification (smoking and alcohol <5 units) Folic acid 400mcg / 5mg daily Check prescribed drugs Ensure Rubella immunity Ensure serum analysis is normal and that fallopian tubes are patent
30
Treatments that cause ovulation induction in PCOS?
1. Clomifene citrate (days 2-6) is the 1ST-LINE treatment 2. Gonadotrophin therapy (recombinant FSH) daily injections 3. Laparoscopic ovarian diathermy
31
Alternatives to clomifene citrate?
Tamoxifen Letrozole
32
Risks with gonadotrophin therapy?
Multiple pregnancy Over-stimulation
33
Risks with laparoscopic ovarian diathermy?
Ovarian destruction
34
Options for those who do not ovulate on Clomifene?
Metformin (+ clomifene citrate) - can induce ovulation for those where clomifene citrate was not effective alone; it is used alongside lifestyle modifications Gonadotrophic therapy (FSH injections) Laparoscopic ovarian drilling Assisted conception treatment
35
Effects of metformin in ovulation induction?
Improves insulin resistance, reduces androgen production and increases SHBG Restores menstruation and ovulation May increase pregnancy rate IT DOES NOT AID WEIGHT LOSS
36
Risks with ovulation induction?
Ovarian hyperstimulation (most serious consequence) - formation of many follicles and the end result is fluid shift; risk increases if aged <35 years and if patient has PCOS Multiple pregnancy (twins, etc) May increase ovarian cancer risk
37
Types of ovarian hyperstimulation?
Mild - abdominal bloating/pain Moderate - moderate abdominal pain, N&V, USS evidence of ascites, etc Severe - clinical ascites, oliguria, etc Critical - tense ascites, thromboembolism, ARDS, etc
38
Risks assoc. with multiple pregnancy for the mother?
Increased maternal pregnancy complications: • Hyperemesis • Anaemia • Hypertension and pre-eclampsia • Gestational diabetes (assoc. increase risk IUD / SB) • Mode of delivery (caesarian) / PPH • Post-natal depression / stress
39
Risks assoc. with multiple pregnancy for the neonate?
``` Increased risk of: • Early and late miscarriage • Low birth weight (<2.5kg) • Prematurity • Disability • Stillbirth / neonatal death • Twin-twin transfusion syndrome (TTTS) - affects identical twin pregnancies and causes unequal blood supply ```
40
Which types of twins have a higher peri-natal mortality?
Monochorionic (monozygotic and shared the same placenta) twins NOTE: monoamniotic means that the twins shared the same amniotic sac
41
What sign on USS suggests a dichorionic pregnancy?
Lambda sign (twin peak) - triangular appearance of the chorion insinuating between the layers of the inter-twin membrane
42
What sign on USS suggests a monochorionic pregnancy?
T-sign - absence of a twin peak sign
43
Pathophysiology of twin-twin transfusion syndrome?
Unbalanced vascular communications within the placental bed Recipient develops polyhydramnios (too much amniotic fluid) Donor develops oliguria, oligohydramnios and growth restriction
44
Treatment options for twin-twin transfusion syndrome?
Laser division of placental vessels Amnioreduction Septostomy
45
Early problems that occur with prematurity?
Neonatal intensive care required, help with breathing and some suffer from neonatal respiratory distress syndrome
46
Long-term problems that occur with prematurity?
Higher risk of a child being affected with disability, e.g: cerebral palsy, impaired sight, congenital heart disease Lower IQ Attention Deficit Hyperactivity Disorder (ADHD) and long-lasting behavioural difficulties Problems with language development
47
Another cause of hypothalamic pituitary dysfunction (group 2), other than PCOS?
Hyperprolactinaemia (raised serum prolactin >1000 iu/l on 2/more occasions)
48
Treatment of hyperprolactinaemia?
Dopamine agonist (cabergoline); these must be stopped when pregnancy occurs
49
Features of ovarian failure (group 3)?
High levels of gonadotrophins (raised FSH >30 iu/l with 2 samples) Low oestrogen Amenorrhea Menopausal
50
What is premature ovarian failure?
Menopause before 40 years of age
51
Causes of premature ovarian failure?
Genetic: • Turner syndrome (46 XO) • XX gonadal agenesis • Fragile X Autoimmune ovarian failure Bilateral oophrectomy Pelvic radio/chemotherapy Cause can be unclear
52
Treatment of premature ovarian failure?
HRT (hormone replacement therapy) Egg/embryo donation (assisted conception) Ovary/egg/embryo cryopreservation prior to chemo/radiotherapy where premature ovarian failure is anticipated Counselling/support
53
Points to cover in a gynaecological history?
``` Details of menstrual cycle Amenorrhoea (do a pregnancy test) Hirsutism and acne Galactorrhea Headaches Visual symptoms PMH and DH ```
54
Biochemical tests for anovulation?
Mid-luteal progesterone (day 21) ``` In the early follicular phase (day 2-5): • Serum FSH, LH, oestradiol • Serum testosterone, SHBG • Prolactin • TSH (hypothyroidism) ```
55
Use of a progesterone challenge test?
Menstrual bleeding in response to a 5-day course of progesterone indicates normal oestrogen levels
56
Other Ix for anovulation?
USS scan Karyotype Auto-Ab screen MRI of pituitary fossa Bone density scan for BMD (risk of osteoporosis if oestrogen is low)

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