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REPRODUCTIVE ENDOCRINOLOGY . . . CONT.

POLYCYSTIC OVARIAN DISEASE

Clinical Presentation average age 15-30 years anovulation hirsutism infertility obesity virilization

LH FSH

stimulation of ovarian stroma and theca

ovarian follicle maturation

estradiol (cyclic)

ovarian androgens

estrone (acyclic)

anovulation

peripheral aromatizationin adipose tissue

androgen excess

+

obesity Figure 4. Pathogenesis of PCO

adrenal androgens

most common pathologic finding: white, smooth, sclerotic ovary with a thick capsule, multiple follicular cysts in various stages of atresia, hyperplastic theca and stroma but ovarian pathology varies and none is pathognomonic so diagnosis is biochemical fundamental defect = bad signals to HPA; high androgens + obesity = increased formation of estrone (acyclic estrogen) ––> acyclic positive feedback on LH + negative feedback on FSH ––> high LH with plasma LH/FSH > 2 ––> hyperplasia of ovarian stroma and theca cells ––> increased androgen production ––> more substrate for peripheral aromatization ––> chronic anovulation increased incidence of endometrial cancer due to unopposed estrogen

Treatment interrupt the self-perpetuating cycle by: • decreasing ovarian androgen secretion: BCP (wedge resections used in past) • decreasing peripheral estrone formation: weight reduction • enhancing FSH secretion: clomiphene, hMG (Pergonal), LHRH, purified FSH to prevent endometrial hyperplasia: progesterone (Provera), BCP for pregnancy • medical induction of ovulation • clomiphene citrate (Clomid) • human menopausal gonadotropin (Pergonal)

DYSMENORRHEA

Primary menstrual pain not caused by organic disease may be due to prostaglandin-induced uterine contractions and ischemia begins 6 months - 2 years after menarche (ovulatory cycles) colicky pain in abdomen, radiating to the lower back, labia and inner thighs begins hours before onset of bleeding and persists for hours or days associated nausea, vomiting, altered bowel habits, headaches treatment • PG synthetase inhibitors (e.g. naproxen) • must be started before/at onset of pain • BCP to suppress ovulation and reduce menstrual flow

MCCQE 2000 Review Notes and Lecture Series

Notes

Gynecology 13

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