Hysterosalpinogram and Laparoscopy
Tubal Disease. Assessment of fallopian tube abnormalities is the next step if the semen analysisis normal and ovulation is confirmed.
• Hysterosalpingogram (HSG). In this imaging procedure, a catheter is placed insidethe uterine cavity, and contrast material is injected. The contrast material should be
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seen on x-ray images spilling bilaterally into the peritoneal cavity. It should be sched-uled during the week after the end of menses after prophylactic antibiotics to prevent causing a recurrent acute salpingitis. No further testing is performed if the HSG shows normal anatomy. If abnormal findings are seen, the extent and site of the pathology is noted and laparoscopy considered.
• Chlamydia antibody. A negative IgG Antibody test for chlamydia virtually rules outinfection induced tubal adhesions.
• Laparoscopy. If potentially correctible tubal disease is suggested by the HSG, the nextstep in management is to visualize the oviducts and attempt reconstruction if possible
(tuboplasty). If tubal damage is so severe surgical therapy is futile, then IVF should be planned.
Unexplained Infertility
Definition. This diagnosis is reserved for couples in which the semen analysis is normal, ovula-tion is confirmed, and patent oviducts are noted.
Outcome. Approximately 60% of patients with unexplained infertility will achieve a spontane-ous pregnancy within the next 3 years.
Management. Treatment consists of controlled ovarian hyperstimulation (COH) with clomi-phene, and appropriately timed preovulatory intrauterine insemination (IUI). The fecundity rates for 6 months are comparable with IVF with a significantly lower cost and risk.
In Vitro Fertilization. With IVF, eggs are aspirated from the ovarian follicles using a transvaginalapproach with the aid of an ultrasound. They are fertilized with sperm in the laboratory, resulting in the formation of embryos. Multiple embryos are transferred into the uterine cavity with a cumulative pregnancy rate of 55% after 4 IVF cycles.
Ovarian Reserve Testing (ORT)
This assessment is mostly reserved for the infertile woman aged 35 or over.
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Definition. ORT refers to assessment of the capacity of the ovary to provide eggs that arecapable of fertilization.
• It is a function of (1) number of follicles available for recruitment, and (2) the health and quality of the eggs in the ovaries.
• The most significant factor affection ORT is a woman’s chronological age with a major decrease around age 35.
Measures of ovarian reserve. These tests help predict whether a woman will respond to ovar-ian stimulation or whether it would be best to proceed directly to in-vitro fertilization (IVF).
• Day 3 FSH is the most commonly used test for ORT. FSH levels are expected to be lowdue to the feedback of estrogen from the stimulated follicles. An increase in FSH level occurs if there is follicle depletion.
• Anti-Mullerian hormone (AMH). This glycoprotein is produced exclusively by smallantral ovarian follicles and is therefore a direct measure of the follicular pool. As the number of ovarian follicles declines with age, AMH concentrations will decline.
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• Antral follicle count (AFC) is the total number of follicles measuring 2-10 mm indiameter that are observed during an early follicular phase transvaginal sonogram.
The number of AF correlates with the size of the remaining follicle pool retrieved by ovarian stimulation. AFC typically declines with age.
MENOPAUSE
A 53-year-old woman visits the gynecologist’s office complaining of hot flashes, vaginal dryness, and irritability. She states that her symptoms started 1 year ago and have progressively been getting worse. Her last gynecologic examination was 2 years ago, at which time her mammogram was normal.
Definition. Menopause is a retrospective diagnosis and is defined as 12 months of amenor-rhea. This is associated with the elevation of gonadotropins (FSH and LH). The mean age of 51 years is genetically determined and unaffected by pregnancies or use of steroid contraception.
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Smokers experience menopause up to 2 years earlier.
• Premature menopause occurs age 30–40 and is mostly idiopathic, but can also occurafter radiation therapy or surgical oophorectomy.
• Premature ovarian failure occurs age <30 and may be associated with autoimmunedisease or Y chromosome mosaicism.
Diagnosis. The laboratory diagnosis of menopause is made through serial identification ofelevated gonadotropins.
Etiology. The etiology of menopausal symptoms is lack of estrogen.
Clinical Findings. The lack of estrogen is responsible for the majority of menopausal symptomsand signs.
• Amenorrhea. The most common symptom is secondary amenorrhea. Menses typicallybecome anovulatory and decrease during a period of 3–5 years known as perimenopause.
• Hot flashes. Unpredictable profuse sweating and sensation of heat is experienced by
75% of menopausal women. This is probably mediated through the hypothalamic thermoregulatory center. Obese women are less likely to undergo hot flashes owing to peripheral conversion of androgens to estrone in their peripheral adipose tissues.
• Reproductive tract. Low estrogen leads to decreased vaginal lubrication, increased vagi-nal pH, and increased vaginal infections.
• Urinary tract. Low estrogen leads to increased urgency, frequency, nocturia, and urgeincontinence.
• Psychic. Low estrogen leads to mood alteration, emotional lability, sleep disorders,and depression.
• Cardiovascular disease. This is the most common cause of mortality (50%) in post-menopausal women, with prevalence rising rapidly after menopause.
• Osteoporosis. This a disorder of decreased bone density leading to pathologic frac-tures when density falls below the fracture threshold.
GYN Triad
Premature Ovarian Failure r/o Y Chromosome Mosaic
• Hot flashes, sweats
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• Age 25 years
• ↑ FSH level
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Osteoporosis
Anatomy. Themost commonbone type of osteoporosis is trabecular bone. The most common anatomic site is in the vertebral bodies, leading to crush fractures, kyphosis, and decreased height. Hip and wrist fractures are the next most frequent sites.
Diagnosis. The most common method of assessing bone density is with a DEXA scan (dual-energy x-ray absorptiometry). The most common method of assessing calcium loss is 24-h urine hydroxyproline or NTX (N-telopeptide, a bone breakdown product).
Risk factors. The most common risk factor is positive family history in a thin, white female.
Other risk factors are steroid use, low calcium intake, sedentary lifestyle, smoking, and alcohol.
Prevention. Maximum bone density is found in the mid-20s. Maintenance of bone density isassisted by both lifestyle and medications.
Table II-12-4. Osteoporosis
| Lifestyle | Ca2+ and vitamin D intake |
| Weight-bearing exercise | |
| Stop cigarettes and alcohol | |
| Medical | Historic gold standard for comparing therapies: estrogen replacement |
| Inhibit osteoclastics: bisphosphonates (alendronate, risedronate) |
Increase bone density: SERMs (raloxifene)
Definition of abbreviations: SERMS, selective estrogen receptor modulators.
• Lifestyle. Calcium and vitamin D intake, weight-bearing exercise, and elimination ofcigarettes and alcohol.
• Medications. Bisphosphates (e.g., alendronate, risedronate) inhibit osteoclastic activity.Selective estrogen receptor modulators (SERMs; e.g., raloxifene) increase bone density. Bisphosphonates and SERMs are the first choices for osteoporosis treatment. Calcitonin and fluoride have also been used. While estrogen is a highly effective therapy, it should not be primarily used to treat osteoporosis because of concerns detailed in the next paragraph.
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Hormone Replacement Therapy
Benefits and risks
• Estrogen therapy continues to be the most effective and FDA-approved method for relief of menopausal vasomotor symptoms (hot flashes), as well as genitourinary atrophy and dyspareunia.
• The Women’s Health Initiative (WHI) study of the National Institutes of Health (NIH) studied 27,000 postmenopausal women with a mean age of 63 years. These included women with a uterus on hormone therapy (HT), both estrogen and progestin, and hysterectomized women on estrogen therapy (ET) only.
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