When an apparent abnormality in ovulation is detected, an organized
and cost effective plan of evaluation should be recommended.
* (1) a detailed menstrual history should be taken, including
The relative amount (spotting, light, moderate, heavy) and timing
of flow. A menstrual diary over several months provides a good
amount of information.
Changes in amount or duration of flow. Most studies report that
women do not usually have an accurate idea of the actual volume
of their flow but that women do know relatively precisely when
their flow volume changes
Age at menarche (the initial menstrual flow) and the regularity
of the menstrual intervals from menarche to date
Results of administration of any hormonal medication (oral contraceptive
pills to regulate the menstrual intervals, progesterone to bring
on a flow)
History of pregnancy and the outcome
* (2) a detailed medical history should be taken, including
Pelvic surgery especially those involving the ovaries or reproductive
organs
Cancer and any treatment with radiation or chemotherapy. Available
medical reports describing exactly which areas have been irradiated
(and the doses) or which chemotherapeutic agents were used (with
cumulative doses) are important
Pelvic inflammatory disease or pelvic infection, especially if
involving a pelvic abscess. Medical reports describing treatment
with antibiotics and the woman's response to treatment (as well
as any radiologic or other studies gathered) can be important
Cigarette, alcohol or elicit drug abuse. The amount of use and
timing with respect to the onset of the ovulatory dysfunction
should be discussed
Endometriosis (including operative reports describing the location
and depth of lesions)
Symptoms of decreased estrogen, including hot flashes, tightening
of the skin, insomnia, and fatigue
Symptoms of hypothyroidism or hyperthyroidism, including cold
or heat intolerance, tremor, palpitations, fatigue, change in
bowel habits
Galactorrhea (milky discharge from the breasts) or any source
for chronic breast stimulation (such as a thoracotomy or surgical
scar near the breast)
Neurologic symptoms including headaches, blurry or double vision,
dizziness, focal weakness.
History of severe (life threatening) hypotension either immediately
postpartum or otherwise
Stressful or catastrophic personal events around the onset of
the ovulatory problem
Exercise regimen (if serious or elite athlete)
Weight loss history, with height and weight measurements
Male pattern hair growth, acne or oily skin, obesity, history
of pelvic ultrasounds with multiple cysts within the ovaries
Medications
* (3) a physical exam should be performed including an examination
of
The skin for acne, excess oiliness, male pattern hair growth,
irregular dark velvety discoloration (acanthosis nigricans), stretch
marks from prior obesity or prior surgical scars in the abdomen
or around the breasts
The breasts for milky discharge (galactorrhea) or surgical scars
The abdomen and pelvis for masses or tenderness
The overall appearance of either Cushing's syndrome, acromegaly,
or anorexia nervosa
* (4) an initial laboratory evaluation may appropriately include
Review of documentation aimed at detecting ovulation
A pregnancy test (the number 1 reason for secondary amenorrhea
in reproductive age women)
Blood concentration of TSH and prolactin even if the patient is
asymptomatic, with appropriate followup if abnormal
Blood concentration of FSH, LH and estradiol (on cycle day 3 if
woman has a cycle) if there is a suspicion of ovarian failure,
hypothalamic or pituitary dysfunction (stress, exercise, weight
loss, weight extreme) or polycystic ovaries, with appropriate
followup if abnormal
Evaluation for Cushing's syndrome (either 24 hour urine for "urine
free cortisol" or overnight 1 mg Dexamethasone suppression
test with 8 A.M. blood cortisol concentration) if clinical appearance
is suggestive
Evaluation for acromegaly (either blood growth hormone concentration
both fasting and during an oral glucose tolerance test or an IGF-1
concentration) if clinical appearance is suggestive
In some situations, radiologic testing of the brain will be recommended.
The best radiologic exam is not always the most cost effective
one. There is a continuing debate among physicians concerning
the most appropriate screening test to radiologically examine
the pituitary region of the brain. MRI with gadolinium contrast,
CT with contrast, or lateral coned down x-ray views of the sella
turcica are frequently performed. In general, the MRI gives the
best detail and resolution (best picture) and the x-ray is the
least expensive with the least resolution (but adequate to see
tumors that are greater than 1 cm large).
For some women, a progesterone challenge test (after confirming
that the patient is not pregnant) will be recommended. This test
determines whether there is adequate estrogen production by the
ovaries to achieve growth of the endometrial lining of the uterus.
Medroxyprogesterone acetate (provera, 5-10 mg by mouth per day
for 5-10 days), micronized progesterone (100-200 mg by mouth two
to three times per day for 5-10 days), progesterone vaginal suppositories
(50-200 mg per vagina two to three times per day for 5-10 days),
and progesterone in oil (either sesame oil or peanut oil, 150-200
mg intramuscular injection once) are alternative appropriate progesterone
compounds. The natural compounds (all but provera) are safest
if treatment (rather than testing) is to be continued regularly
(such as monthly) and the woman is simultaneously trying to get
pregnant.
A withdrawal flow is expected a few days after the final progesterone
dose (or within 2 weeks of the injection). Uncommonly, the progesterone
taken may allow the woman to have a spontaneous (natural) ovulation.
If a spontaneous ovulation occurs the natural progesterone produced
from the resulting corpus luteum cyst will delay the withdrawal
flow for up to an additional 2 weeks. Therefore, you must wait
at least 2 weeks from the time of expected flow to see whether
a natural ovulation has occurred. The reason for an occasional
spontaneous ovulation is that small amounts of progesterone decrease
the threshold for ovulation (makes ovulation easier).
The results of this initial evaluation will provide a tremendous
amount of information and the physician will most likely be able
to readily advise a couple on the likely cause(s) for the ovulatory
dysfunction. Additional confirmatory testing will sometimes be
required. The available treatment options for these ovulatory
dysfunctions depend on the cause of the dysfunction and the goals
of the woman involved.
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