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WHO classification of ovulatory disorders

 
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Nick Raine-Fenning
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PostPosted: Thu Jan 25, 2007 7:35 pm    Post subject: WHO classification of ovulatory disorders Reply with quote

Classification of ovulatory disorders (21% of female fertility)

The World Health Organization classifies ovulation disorders into three groups:

Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism). 10%

Group II: hypothalamic pituitary dysfunction (predominately polycystic ovary syndrome). 85%

Group III: ovarian failure.5%
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Last edited by Nick Raine-Fenning on Thu Jan 25, 2007 8:09 pm; edited 1 time in total
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rpwalavalkar
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PostPosted: Thu Jan 25, 2007 7:42 pm    Post subject: Reply with quote

Treatments for Ov disorders....

Class 1 -- pulsatile GnRH OR gnodatrophins with LH activity.

Class 2 -- Clomiphene

if no response to clomiphene -

add metformin if BMI > 25 OR gonadotrophin induction OR ovarian drilling.

Class 3 -- Oocyte donation IVF

Very Happy
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Dr Miss. Raj Walavalkar MBBS MRCOG
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Nick Raine-Fenning
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PostPosted: Thu Jan 25, 2007 8:04 pm    Post subject: Reply with quote

Where does hyperprolactinaemia sit in the WHO criteria?

What is the first line treatment for idiopathic disease and small tumours?

N
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wolverine
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PostPosted: Thu Jan 25, 2007 8:25 pm    Post subject: Reply with quote

I think that Hyperprolactinaemia sits in class II as high levels of PRL interfere with pulsatile GnRH secretion therefore hypothalamic pitutary dysfunction. Agree?
Treatment for both I'd say cabergoline straight forward
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rpwalavalkar
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PostPosted: Thu Jan 25, 2007 8:27 pm    Post subject: Reply with quote

hyperprolactinaemia -- sits in Class II

Patients with hyperprolactinemia and no symptoms (idiopathic or microprolactinoma) can be monitored without treatment.

Consider treatment if amenorrhea develops, for -- effects on fertility and osteoporosis.

bromocriptine , is the first line drug of choice. cabergoline and quinagolide can also be used where side effects of bromocriptine are unacceptable. serial prolactin levels should be done to monitor response.

bromocriptine may alone be enough to induce ovulation, clomiphene may be added if the patient does not ovulate despite correction of prolactin levels.

also check TFTs and treat with thyroxine as required.
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wolverine
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PostPosted: Thu Jan 25, 2007 9:24 pm    Post subject: Reply with quote

Raj! Move on! Cabergoline is now the drug of choice! Better side effect profile, better compliance (twice weekly), faster and more effective restoration of ovulation (72% vs 52) and higher pregnancy rates! I don't know about cost but I'm sure that the advabtages outweigh anything
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Nick Raine-Fenning
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PostPosted: Fri Jan 26, 2007 10:35 am    Post subject: Reply with quote

wolverine wrote:
Raj! Move on!


There so cheeky this new bunch Wink

Actually I have revised my stance on this following the last EMQ Course.

Cabergoline is 1st line treatment for the reasons wolverine states - absolutely spot on - more effective and less side effects which outweigh the extra expense. However, and it is a big however there are better data available regading the safety of bromocriptine in women during pregnancy and the drug company advised against the use o cabergoline in the month preceding pregnancy - it would be inappropriate to use it for fertility treatment in women with ovulatory problems therefore Wink

Great question and that is why I asked!

Are we sure hyperprolactinaemia sits in class II? I agree this is the most appropriate class but I wonder whether it sits outside of the WHO group system.
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cpeedahsa
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PostPosted: Mon Sep 03, 2007 4:02 pm    Post subject: Reply with quote

Nick Raine-Fenning wrote:


Are we sure hyperprolactinaemia sits in class II? I agree this is the most appropriate class but I wonder whether it sits outside of the WHO group system.


Nick, I think you are right- hyperprolactinemia actually sits outside the WHO classification.


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cpeedahsa
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PostPosted: Mon Sep 03, 2007 4:11 pm    Post subject: Reply with quote

CLASSIFICATION OF ANOVULATION


WHO class 1: Hypogonadotropic hypogonadal anovulation — 5 to 10 % of anovulation, usually amenorrhea (although a range of gonadal compromise can be seen) . Low or low-normal FSH and low serum estradiol due to decreased hypothalamic secretion of GnRH or pituitary unresponsiveness to GnRH.
Causes of hypothalamic amenorrhea include stress- or exercise-related amenorrhea, anorexia nervosa, and Kallman's syndrome (isolated gonadotropin deficiency); approximately 5 to 10 percent have hypopituitarism.
Reversing the lifestyle factors that contribute to the anovulation (low weight, heavy exercise) should be attempted before considering intervention with medications.

WHO class 2: Normogonadotropic normoestrogenic anovulation -largest group of anovulatory women encountered in clinical practice -70-85%. FSH and estrogen levels are normal, whereas LH concentrations may either be normal or elevated. Includes women with polycystic ovary syndrome (PCOS). Some ovulate occasionally, especially those with oligomenorrhea.
In PCOS, weight loss, which restores spontaneous ovulation in many women, attempted before treatment with ovulation induction agents is considered. In PCOS-screen for type 2 diabetes before starting ovulation induction, because of the risk of fetal complications with untreated diabetes.

WHO class 3: Hypergonadotropic hypoestrogenic anovulation — 10-30% cases of anovulation. Primary causes Arrow POF(absence of ovarian follicles due to early menopause) or ovarian resistance (follicular form). Many, but not all, of these women have amenorrhea; they usually do not respond to therapy for anovulation.

Hyperprolactinemic anovulation -5-10% anovulation. Anovulatory because hyperprolactinemia inhibits gonadotropin and therefore estrogen secretion. Most have oligomenorrhea or amenorrhea. Their serum gonadotropin concentrations are usually normal or decreased.
Hyperprolactinemia always be confirmed by several measurements of serum prolactin. An MRI of the head should be done in whom the cause is not obvious (eg, neuroleptic drug therapy, primary hypothyroidism).

Reference- uptodate


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cpeedahsa
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PostPosted: Mon Sep 03, 2007 4:12 pm    Post subject: Reply with quote

http://humupd.oxfordjournals.org/cgi/reprint/10/4/295

This is an interesting and useful article to read
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cpeedahsa
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PostPosted: Mon Sep 03, 2007 4:19 pm    Post subject: Reply with quote

WHO-classification of anovulation: background, evidence and problems
Marc Dhont*
Ghent University Hospital, Department of Obstetrics an dGynaecology,
De Pintelaan 185, B-9000 Ghent, Belgium
Iternational Congress Series
Volume 1279, April 2005, Pages 3-9
Gynaecology, Obstetrics, and Reproductive Medicine in Daily Practice

This article describes in detail, the problems of the WHO classification.
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cpeedahsa
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PostPosted: Mon Sep 03, 2007 4:26 pm    Post subject: Reply with quote

1973 Arrow WHO Scientific Group proposed a classification of anovulatory patients which was meant to provide guidance for ovulation induction. This classification was based on the levels of gonadotropins and oestrogens and is still being used.

Although it was well-known that galactorrhoea is associated with ovulatory dysfunction it was only in the mid-seventies of the previous century that prolactin could be determined and the first dopaminergic prolactin-lowering drugs became available for clinical use in the early 1980s.
Taking into account these new developments and therapeutic possibilities, the WHO classification has been refined, but it still maintained the classification based on basal oestrogen and gonadotropin level while at the same time acknowledging that anovulation should be treated by the most appropriate and physiological way, i.e. anovulation due to hyperprolactinemia should, in the first place, be treated with prolactin-lowering drugs and Group I patients preferably should be treated by pulsatile GnRH treatment.


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cpeedahsa
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PostPosted: Mon Sep 03, 2007 4:28 pm    Post subject: Reply with quote

Problems with the WHO classification of anovulatory states.
1)The most trivial but practically important one is that the numerical denomination does not communicate anything about the underlying aetiology. For this reason, it is seldom if ever used in clinical practice. Given the vast array of pathophysiological mechanisms underlying anovulation, it also cannot satisfy the inquiring minds of students and thoughtful clinicians. In fact, the level of gonadotropins and oestrogens is only a peripheral reflection of what is going wrong within the principal actors involved in the regulation of the menstrual cycle.

2) Diagnostic procedures advocated are no longer up to the modern standards of investigation and the new insights in the physiopathology of anovulation. For example, the role of transvaginal ultrasound in the evaluation of the ovarian function and the endometrial development is not included.

3)Therapeutic flow chart that follows from it does not take into account the complex variety of etiologies of anovulation, particularly concerning Group II. Although, as advocated in the WHO Manual, the primary treatment of choice is clomiphene citrate in ascending doses depending on the response, it gives no guidance to ancillary treatment options such as weight loss in obese patients or insulin sensitizers.

4)It does not give guidance on the treatment of clomiphene resistant cases.

Reference- Reference:International Congress Series
Volume 1279, April 2005, Pages 3-9
Gynaecology, Obstetrics, and Reproductive Medicine in Daily Practice
Marc Dhont, Ghent University Hospital, Department of Obstetrics an dGynaecology, De Pintelaan 185, B-9000 Ghent, Belgium
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EMAK
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PostPosted: Mon Sep 03, 2007 5:44 pm    Post subject: Reply with quote

Indications and Usage for Cabergoline
Cabergoline tablets are indicated for the treatment of hyperprolactinemic disorders, either idiopathic or due to pituitary adenomas.

Postpartum Lactation Inhibition or Suppression
Cabergoline tablets are not indicated for the inhibition or suppression of physiologic lactation. Use of bromocriptine, another dopamine agonist for this purpose, has been associated with cases of hypertension, stroke, and seizures.[ precausion].

Fibrosis/Valvulopathy : As with other ergot derivatives, pleural effusion/pulmonary fibrosis and valvulopathy have been reported following long-term administration of Cabergoline. Some reports were in patients previously treated with ergotinic dopamine agonists. Therefore, Cabergoline should be used with caution in patients with a history of, or current signs and/or clinical symptoms of, respiratory or cardiac disorders linked to fibrotic tissue. Following diagnosis of pleural effusion/pulmonary fibrosis or valvulopathy, the discontinuance of Cabergoline has been reported to result in improvement of signs and symptoms.
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EMAK
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PostPosted: Mon Sep 03, 2007 5:47 pm    Post subject: Reply with quote

Doses:
The recommended dosage of Cabergoline tablets for initiation of therapy is 0.25 mg twice a week. Dosage may be increased by 0.25 mg twice weekly up to a dosage of 1 mg twice a week according to the patient’s serum prolactin level.

Dosage increases should not occur more rapidly than every 4 weeks.

After a normal serum prolactin level has been maintained for 6 months, Cabergoline may be discontinued, with periodic monitoring of the serum prolactin level to determine whether or when treatment with Cabergoline should be reinstituted. The durability of efficacy beyond 24 months of therapy with Cabergoline has not been established.
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EMAK
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PostPosted: Mon Sep 03, 2007 5:51 pm    Post subject: Reply with quote

Animal studies reveal ;
[list=]There was a slight increase in the incidence of [list=]cervical and uterine leiomyomas and uterine leiomyosarcomas[/list]
[/list]
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EMAK
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PostPosted: Mon Sep 03, 2007 5:51 pm    Post subject: Reply with quote

http://www.drugs.com/pro/Cabergoline.html
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