How long is the standard menstrual cycle?
What consitutes oligomenorrhea?
24-32 days long; typical cycle is 28 days
A cycle that is longer than 35 days
What is the first test that should be done in a patient who presents with oligomenorrhea?
Since you'll probably run other tests at the same time, what other tests can be run concurrently?
TSH, prolactin, FSH
What are the four categories of ovulation disorders?
What hormonal results are seen with each?
- Hypothalamic- Pituitary Failure
- Failure of FSH release or FSH effect
- Low/normal FSH
- Secondary Hypothalamic-Pituitary Dysfunction
- Abnormalities in hormone levels outside of the normal feedback cycle
- EG tumors, thyroid disease, hyperprolactinemia
- Hypothalamic- Pituitary Dysfunction
- Normal FSH, estradiol; maybe hyperandrogenism
- EG PCOS, idiopathic
- Ovarian Failure
- Burn-out of the ovaries
- High FSH (but ovaries won't respond)
What is the point of the progesterone challenge?
What can it tell us about the etiology of infertility?
Progesterone challenge is done to females with low/normal FSH. The challenge tells us whether the ovary is developing a viable follicle.
If there is bleeding, there is initially a viable follicle, but there is a problem with ovulation (and therefore progesterone production); if there isn't bleeding, the hypothalamus is not stimulating follicle development.
What three symptoms are associated with PCOS?
How many are needed for a diagnosis of PCOS?
- Cysts on ovaries on ultrasound
Two out of the three symptoms are needed, plus tumors/CAH/thyroid disease/Cushing's must be ruled out
How is PCOS treated?
- Hormonal birth control
- Cyclic progesterone
- Weight loss
- Treat diabetes
- Clomiphene citrate (ovulation stimulant)
- Aromatase inhibitor (off-label use)
What mechanism does clomiphene citrate use?
What are some side effects?
Reduces translocation of estrogen receptors
Diminishes negative feedback on GnRH
Prompts increased FSH, LH release
Dry genital mucus
Thin endometrial lining
Ovarian hyperstimulation syndrome
What hormone tests might indicate hypogonadotropic hypogonadism?
What are some specific causes of HH?
Low/normal FSH, low estrogen, negative progesterone test
- Absence of a pituitary
- Stress (too much) or weight (too little)
- Kallman's (congenital GnRH deficiency)
- GnRH receptor mutations
What might cause amenorrhea in patients whose hormone levels are normal?
What sort of medical history would they have?
Physical obstruction from adhesions
History of endometrial/cervical procedures which might cause scarring
What hormone tests might indicate hypergonadotropic hypogonadism?
Who does it affect?
High levels of FSH, without menorrhea and no bleed in response to progesterone
(AKA premature menopause or Ovarian insufficiency)
Women between the ages of 30 and 40
What are some potential causes of Premature Ovarian Insufficiency/hypergonadotrophic hypogonadism?
- Turner's syndrome or Turner's Mosaic
- Fragile X syndrome
- Alkylating agents (chemo)
All things that would damage germ cells!
What are some options for patients with hypergonadotrophic hypogonadism who want to have kids?
- Oocyte donation
Unfortunately, conceiving, even with hormonal aids, is extremely unlikely
What is the definition of infertility?
Which partner should be examined?
>1 year trying to get pregnant; can treat at 6 months if older, special concerns
Both partners should be examined with blood panels, but specimen samples are less invasive for men
What is the ovarian reserve?
What tests can be done to determine the size of a patient's reserve?
Essentially time left until menopause; accelerated follicular loss, reduced oocyte pool, decreased oocyte quality
- Day 3 FSH/Estradiol levels
- Antral follicle counts
- Anti-Mullerian hormone (corresponds with egg reserve)
What are some indications for IUI (Intrauterine Insemination)?
What are some indications for IVF?
Anything that might prevent sperms from reaching the egg: mild male infertility (EG low number, low mobility) or cervical mucus abnormalities
Severe male infertility, tubal diseases, endometriosis, diminished ovarian reserve, failed IUI