Anovulation

Aka: Anovulation, Ovulatory Dysfunction

1. History in evaluation of Anovulation
   1. Confirm Anovulation
      1. See Ovulation
      2. See Anovulatory Bleeding
      3. Plot Menstrual Cycle pattern
   2. Pituitary adenoma history
      1. Galactorrhea
      2. Visual changes
   3. Hyperandrogenism history (e.g. Hirsutism, HAIR-AN)
   4. Lifestyle factors (e.g. emotional stress)
   5. Weight change (excessive gain or loss)
   6. Exposure to Teratogens
2. Examination
   1. Hyperandrogenism (e.g. Polycystic Ovary Syndrome)
      1. Obesity
      2. Hirsutism
   2. Assess for syndromes
      1. Altered sense of smell
      2. Altered Breast development
   3. Assess for pituitary adenomas
      1. Visual field defects
      2. Galactorrhea
   4. Pelvic exam
      1. Evaluate for pelvic mass
      2. Cervical Mucus (increased amount or thickness)
      3. Hormonal effects
3. Differential Diagnosis
   1. See Infertility and Infertility Causes
   2. Pregnancy
   3. Menopause or Premature Ovarian Failure
4. Labs
   1. See Ovulation
   2. Day 3 FSH, LH, Estradiol
   3. Day 21 Progesterone
   4. Consider Day 25 Endometrial Biopsy
      1. Will show no secretory effect in Anovulation
   5. Consider Testosterone and DHEA levels if virilization
   6. Consider 17-Hydroxyprogesterone
5. Management: Inducing Ovulation for Fertility
   1. Treat specific underlying diseases
      1. Thyroid disease
      2. Pituitary adenoma
   2. Clomiphene Citrate (Clomid) alone
   3. If no Ovulation with Clomiphene
      1. Consider 8 day course of Clomid
      2. Consider with HCG if no Ovulation occurs
         1. HCG 10,000 units IM or 250 mcg SC
         2. Monitor follicle with Ultrasound
            1. Give when follicle 20 mm
            2. Monitor follicle on days 10-12
            3. Anticipate 2 mm/day growth
      3. Consider with Metformin (Polycystic ovarian syndrome)
      4. Consider with Glucocorticoids (adrenal hyperfunction)
         1. Indicated for adrenal suppression
         2. Obtain AM Cortisol for baseline
         3. Dosing: Prednisone 10 mg or Dexamethasone 500 mcg
         4. Protocol
            1. Cycle for days 3-7 with Clomid or
            2. Continuous glucocorticoid alone
      5. Consider with Gonadotropins (e.g. Parlodel)
         1. Clomid given 1-2 amps IM or SC and
         2. Gonadotropin given on day 9-10
      6. Consider Progesterone
         1. Indicated in Luteal Phase defect