Conception and Contraception for altered menstrual cycles

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Conception and Contraceptionfor altered
menstrual cycles

• Dr Gavin Sacks
• MA BM BCh PhD MRCOG FRANZCOG CCSST (UK)
• Staff Specialist Director of Gynaecology, St
  George Hospital
• VMO Prince of Wales Private Hospital
• Conjoint Senior Lecturer UNSW
• Fertility Specialist IVFAustralia

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Key Learning Objectives

• Understand the endocrinology of a normal
  menstrual cycle
• Understand how it can go wrong
• Approach with confidence
• Periods too heavy or frequent
• Periods infrequent or absent

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But firstwho is your patient?
Good news
Bad news
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What treatments are possible?
Good treatment
Bad treatment
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What does she want ?
Good treatment
Bad treatment
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How will you help her ?
Hope
Anxiety
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Critical questions when you meet any female
patient of reproductive age

• 2.

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Critical questions when you meet any female
patient of reproductive age

• 1. Is she pregnant ?
• 2.

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Critical questions when you meet any female
patient of reproductive age

• 1. Is she pregnant ?
• 2. If not, why not ?

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The normal menstrual cycle
FSH
LH
Oestradiol
Progesterone
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The normal menstrual cycle
FSH
LH
Oestradiol
Progesterone
Recruitment
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The normal menstrual cycle
FSH
LH
Selection
Oestradiol
Progesterone
Recruitment
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The normal menstrual cycle
FSH
LH
Selection
Oestradiol
Progesterone
Recruitment
X
X
X
X
X
X
X
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The normal menstrual cycle
FSH
LH
Oestradiol
Progesterone
Recruitment
X
X
X
X
X
X
X
15
The normal menstrual cycle
FSH
LH
Oestradiol
Progesterone
Recruitment
X
X
X
X
X
X
X
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The normal menstrual cycle
FSH
LH
Ovulation
Oestradiol
Progesterone
Recruitment
Selection
X
X
X
X
X
X
X
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The luteal phase
FSH
LH
Oestradiol
Progesterone
Selection
X
X
X
X
X
X
X
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Effects of luteolysis
FSH
LH
Oestradiol
Progesterone
Selection
X
X
X
X
X
X
X
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Effects of luteolysis
FSH
LH
Oestradiol
Progesterone
Selection
X
X
X
X
X
X
X
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Hormonal causes of altered cycles I
FSH
LH
Oestradiol
Progesterone
Inadequate signal from pituitary to stimulate
ovaries
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Hormonal causes of altered cycles II
FSH
LH
Oestradiol
Progesterone
Poor ovarian response to stimulation
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Hormonal causes of altered cycles III
FSH
LH
Oestradiol
Progesterone
Anovulation
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Hormonal causes of altered cycles IV
FSH
LH
Oestradiol
Progesterone
Anovulation / Luteal phase defect
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Common causes of altered cycles

• I Inadequate signal from pituitary
• Anorexia, excessive exercise, drugs, stress,
  tumours
• PCOS
• II Poor ovarian response
• Decreased ovarian reserve/ premature ovarian
  failure
• perimenopause
• III Anovulation
• PCOS, thyroid dysfunction
• IV Luteal phase defect
• PCOS
• Low progesterone production or endometrium
  tissue levels

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Hypothalamic-pituitary-ovarian-uterine axis
Hypothalamus
Pituitary
Ovaries
Uterus
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Management options for altered cycles

• Contraception agents
• Barriers
• Combined pill / ring
• Minipill
• Implanon
• Mirena
• Sterilisation
• Hysterectomy

• Conception agents
• Clomid
• Metformin
• FSH injection
• Intrauterine insemination (IUI)
• Laparoscopy
• IVF / ICSI

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Hypothalamic-pituitary-ovarian-uterine axis
contraceptive and conceptive agents
Hypothalamus
Clomid
Pituitary
Metformin
Ovaries
FSH (IVF)
Uterus
IUI
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Hypothalamic-pituitary-ovarian-uterine axis
contraceptive and conceptive agents
Hypothalamus
Combined pill
Clomid
Implanon
Pituitary
Metformin
Minipill
Ovaries
FSH (IVF)
Mirena
Uterus
IUI
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Indications for combined oral contraceptive

• Is she alive ?
• Are periods regular ?
• Medical contraindications
• Thrombophilia
• Hypertension
• Hepatic disease
• Check blood pressure prior to after starting

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Structure of oestrogens
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Oral contraceptive effects
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Progesterone-only contraceptive effects

• Different levels of suppression of FSH/LH
• Altered cervical mucous preventing sperm
  penetration
• Altered tubal function - preventing sperm/ embryo
  transport
• Altered endometrium preventing implantation

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Structure of progestogens
Levonorgestrel
3rd generation gestogens
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The levonorgestrel-containing intra-uterine
system (mirena)

• 2/3 women treated for menorrhagia cancelled their
  decision to undergo hysterectomy
• Wide variation between individual women
• Mirena improved general well being and work
  performance and physical, sexual, and leisure
  time activity
• Contraceptive better than sterilisation

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Infrequent or absent periods
Hypothalamo-pituitary
Anovulation/PCOS
Ovarian failure
Uterine
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The clues
Amenorrhoea Weight loss/Exercise/Stress Drug-induc
ed Other disease
Hypothalamo-pituitary
Anovulation/PCOS
Irregular menses Weight gain PCOS signs/symptoms
Ovarian failure
Hot flushes Irregular/absent periods Short cycle
Uterine
Uterine surgery
Period
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The tests What is missing ?

• Oestradiol
• Progesterone
• FSH/LH
• Testosterone
• Prolactin
• Thyroid function
• Pelvic ultrasound

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The tests What is missing ?

• HCG
• The commonest cause of amenorrhoea is pregnancy !!

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The results
FSH/LH low or normal Oestradiol low PRL or
Thyroid abnormal
Hypothalamo-pituitary
Anovulation/PCOS
LH raised Oestradiol normal No progesterone
Ovarian failure
FSH very high LH also raised Oestradiol low
Uterine
Normal
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Oligo/amenorrhoea
WHO Type I
Hypothalamo-pituitary
WHO Type 2
Anovulation/PCOS
Ovarian failure
WHO Type 3
Uterine
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Oligo/amenorrhoea
WHO Type I Nearly everyone conceives
Hypothalamo-pituitary
WHO Type 2 Most women conceive
Anovulation/PCOS
Ovarian failure
WHO Type 3 Conception remote chance without
donated oocytes
Uterine
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Treatment Fertility wanted
Gonadotrophin ovulation induction Outcome good
Hypothalamo-pituitary
Anovulation/PCOS
Clomiphene first Outcome reasonable
Ovulation induction not possible Donor oocytes
only
Ovarian failure
Uterine
Depends on cause
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Treatment No fertility needed
Oestrogen deficient HRT or oral contraceptive
Hypothalamo-pituitary
Anovulation/PCOS
Unopposed oestrogen Progestogen or oral
contraceptive
Oestrogen deficient HRT or oral contraceptive
Ovarian failure
Uterine
No treatment essential
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Frequent or heavy periods
Falling Progesterone
Menstruation
Prostaglandin release Spasm of spiral
arterioles Release of fibrinolysis inhibitors
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Irregular, frequent or heavy periods
Drug-induced Other disease
Hypothalamo-pituitary
Irregular menses Weight gain PCOS signs/symptoms
Ovarian cyst or PCOS
Hot flushes Irregular periods Short cycle Luteal
phase defect
Peri-Ovarian failure
Uterine
Uterine polyps/ fibroids Endometrial
hyperplasia Cervical lesions
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Aims of management

• Exclude malignancy
• Identify specific pathology
• Patient-centred treatment

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Initial assessment

• History of bleeding
• Intermenstrual / Postcoital / Postmenopausal
• Amount
• Cervical examination PAP smear
• Pelvic ultrasound
• FBC ( ? clotting screen for teens)
• Hormone profile
• LH,FSH,E2,Testosterone
• TSH,prolactin
• HCG

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Follow up management
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Follow up management
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Follow up management
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Managing irregular bleeding
1. Exclude malignancy 2. Define needs (eg.
Contraception/ fertility preservation/
compliance) 3. Treatment ladder for DUB eg.
Non-hormonal tablets (ponstan, tranexamic acid)
Hormonal tablets (combined pill,
progestagen) Hormonal devices (Mirena)
Minimal access surgery (endometrial
ablation) Major surgery (hysterectomy)
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Managing irregular bleeding infertility
1. Exclude malignancy 2. Define needs (eg.
Contraception/ fertility preservation/
compliance) 3. Treatment ladder for DUB eg.
Non-hormonal tablets (ponstan, tranexamic acid)
Hormonal tablets (clomid, metformin) Hormonal
therapy (timed intercourse, IUI) Minimal
access surgery (laparoscopy) ART (IVF/ ICSI)
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Conclusions - Golden rules

• Irregular periods trying to conceive early
  referral to fertility specialist
• Combined pill first line treatment for any
  menstrual disorder unless trying to conceive
• H-P-O-U axis outlines investigations
• Best time for hormone profile (LH,FSH,E2)
• Day 2-4
• Best time for ovulation test (progesterone)
• Day 21

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Is she pregnant ? If not, why not ?