Ovulatory Disorders

Question 1

what are ovulatory disorders associated with?

Answer 1

oligomenorrhoea

amenorrhoea

Question 2

define oligomenorrhoea

Answer 2

cycle lasting more than 35 days

Question 3

define amenorrhoea

Answer 3

absent menstruation

Question 4

two types of amenorrhoea

Answer 4

primary- never had a period

secondary- used to have periods but have now stopped

Question 5

three groups of anovulatory disorders

Answer 5

1. hypothalamic pituitary failure (hypogonadotropic hypogonadism)
2. hypothalamic pituitary dysfunction
3. ovarian failure

Question 6

describe hypothalamic pituitary failure

Answer 6

no GnRH secretion leading to no FHS/LH and oestrogen
normal prolactin
amenorrhoea

Question 7

diagnosis of hypothalamic pituitary failure (using a challenge test)

Answer 7

negative progesterone challenge

Question 8

causes of hypothalamic pituitary failure

Answer 8

stress
excessive exercise
low BMI
tumours
trauma
Kallman's syndrome
drugs (steroids and opiates)

Question 9

pre-treatment management of hypothalamic pituitary failure

Answer 9

stabilise weight
lifestyle (smoking and alcohol)
folic acid
check prescribed drugs
rubella immunity (IgG)
chlamydia analysis (azithromycin)
normal semen analysis
patent Fallopian tubes

Question 10

management of hypothalamic pituitary failure

Answer 10

pulsatile GnRH via SC/IV pump worn continuously (90minutes)
gonadotrophin daily injection (FSH/LH): higher risk of multiple pregnancies
both need USS monitoring of response (follicle tracking)

Question 11

define hypothalamic pituitary dysfunction

Answer 11

ovary does not respond to LH and FSH

Question 12

diagnosis of hypothalamic pituitary dysfunction

Answer 12

high LH
high FSH
normal oestrogen
oligo/amenorrhoea
PCOS associated

Question 13

define PCOS

Answer 13

inherited condition where females produce more than normal male hormones, it is a condition exacerbated by weight gain

Question 14

presentation of PCOS

Answer 14

obesity
hirsutism/acne
cycle abnormalities
infertility

Question 15

diagnosis of PCOS (biochemically)

Answer 15

high LH
high free androgens
impaired glucose tolerance

Question 16

diagnosis of PCOS 2/3 must be present

Answer 16

oligo/amenorrhoea
polycystic ovaries on USS with 12 or more 2-9mm follicles and increased ovarian volume
hyperandrogenism biochemically or clinically

Question 17

what is commonly seen in PCOS

Answer 17

insulin resistance

Question 18

how does insulin resistance occur in PCOS?

Answer 18

normal pancreatic reserve so hyperinsulinaemia, but sensitivity is decreased as insulin acts on the same receptor as LH and lowers SHBG levels so there is increased free testosterone (hyperandrogenism)

Question 19

management of PCOS

Answer 19

weight loss, lifestyle
folic acid 400mcg/5mg
reverse excess androgens
ovulation induction

Question 20

how can excess androgens be reduced in PCOS?

Answer 20

oral contraceptive pill
anti-androgen e.g. cyproterone acetate
cosmetic e.g. laser hair removal and creams

Question 21

three ways to do ovulation induction in PCOS

Answer 21

clomifene citrate (alternatives are tamoxifen and letrozole)
gonadotrophin daily injections
laparoscopic ovarian diathermy

Question 22

describe clomifene citrate

Answer 22

increases FSH
conception in first few months, if resistant consider metformin (improves insulin resistance, reduces androgens and increases SHBG) and other therapies

Question 23

what do gonadotrophin daily injections risk?

Answer 23

multiple pregnancies

overstimulation

Question 24

what does laparoscopic ovarian diathermy risk?

Answer 24

ovarian destruction

Question 25

adverse effects of ovulation induction

Answer 25

``` ovarian overstimulation (below 35 and PCOS) multiple pregnancies (USS lambda sign dichorionic, T sign monochorionic) twin-twin transfusion syndrome in monozygotic ovarian cancer ```

Question 26

what does hyperprolactinaemia present with?

Answer 26

amenorrhoea (inhibits GnRH) galactorrhea visual fields (macro)

Question 27

diagnosis of hyperprolactinaemia

Answer 27

``` normal FSH/LH low oestrogen raised prolactin TFT normal MRI ```

Question 28

management of hyperprolactinaemia

Answer 28

dopamine agonist e.g. cabergoline (stopped when pregnancy occurs)

Question 29

define ovarian failure

Answer 29

ovaries have no eggs left

Question 30

presentation of ovarian failure

Answer 30

hot flushes night sweats atrophic vaginitis

Question 31

diagnosis of ovarian failure (biochemically)

Answer 31

high FSH/LH low oestrogen amenorrhoea

Question 32

causes of ovarian failure

Answer 32

menopause

Question 33

causes of premature ovarian failure

Answer 33

- genetic= Turner's, XX gonadal genesis, fragile X - AI ovarian failure - bilateral oophorectomy - pelvic radiotherapy/chemotherapy

Question 34

management of premature ovarian failure

Answer 34

hormone replacement egg/embryo donation cryopreservation counselling

Question 35

define progesterone challenge testing

Answer 35

menstrual bleed in response to a 5-day course of progesterone indicates normal oestrogen