Table II-12-3. “HA-IR-AN” Syndrome (Polycystic Ovarian Syndrome)
| HA | HyperAndrogynism |
| IR | Insulin Resistance |
| AN | Acanthosis Nigricans |
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USMLE Step 2 l Gynecology
Hyper-
Androgenism
Insulin
Resistance
Acanthosis
Nigricans
Figure II-12-8. Polycystic Ovarian Syndrome
Diagnosis. The diagnosis is suspected in the presence of irregular menstrual bleeding, obesity,hirsutism, and infertility. It is confirmed with an LH to FSH ratio, which is in the range of 3:1. The normal LH to FSH ratio in ovulatory patients is 1.5:1.
Management. Treatment is directed toward the primary problem and the patient’s desires.
• Irregular bleeding. OCPs will normalize her bleeding. The progestin component willprevent endometrial hyperplasia.
• Hirsutism. Excess male-pattern hair growth can be suppressed 2 ways. OCPs willlower testosterone production by suppressing LH stimulation of the ovarian follicle theca cells. OCPs will also increase SHBG, thus decreasing free testosterone levels.
Spironolactone suppresses hair follicle 5-α reductase enzyme conversion of andro-stenedione and testosterone to the more potent dihydrotestosterone.
• Infertility. If she desires pregnancy, ovulation induction can be achieved throughclomiphene citrate (Clomid) or human menopausal gonadotropin (HMG; Pergonal). Metformin, a hypoglycemic agent that increases insulin sensitivity, can enhance the likelihood of ovulation both with and without clomiphene.
INFERTILITY
A 30-year-old woman comes to the gynecologist’s office complaining of infertility for 1 year. She and her husband have been trying to achieve pregnancy for >1 year and have been unsuccessful. There is no previous history of pelvic inflammatory disease and she used oral contraception medication for 6 years. The pelvic examination is normal, and a Pap smear is done.
Definition. Infertility is defined as inability to achieve pregnancy after 12 months of unprotectedand frequent intercourse. Both male and female factors have to be evaluated in the patient with infertility. Fifteen percent of American couples suffer infertility.
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Fecundability. This is the likelihood of conception occurring with one cycle of appropriatelytimed midcycle intercourse. With the female partner age of 20 years, the fecundity rate is 20%. By age 35 years, the rate drops to 10%.
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Chapter 12 l Hormonal Disorders
Initial Noninvasive Tests
Semen analysis
• Normal values. Expected findings are volume>2 ml;pH7.2–7.8;sperm density
>20 million/ml; sperm motility >50%; and sperm morphology >50% normal. If values are abnormal, repeat the semen analysis in 4–6 weeks because semen quality varies with time.
• Timing. The first step in the infertility evaluation is a semen analysis, which should beobtained after 2–3 days of abstinence and examined within 2 h.
• Minimally abnormal. If sperm density is mild to moderately lower than normal,intrauterine insemination may be used. Washed sperm are directly injected into the uterine cavity. Idiopathic oligozoospermia is the most common male infertility factor.
• Severely abnormal. If semen analysis shows severe abnormalities, intracytoplas-mic sperm injection may be used in conjunction with in vitro fertilization and embryo transfer.
• No viable sperm. With azoospermia or failed ICSI, artificial insemination by donor
(AID) may be used.
Anovulation
Of all causes of infertility, treatment of anovulation results in the greatest success.
• History. Typically history is irregular, unpredictable menstrual bleeding, most oftenassociated with minimal or no uterine cramping.
• Objective data. A basal body temperature (BBT) chart will not show the typicalmidcycle temperature elevation. A serum progesterone level will be low. An endome-trial biopsy shows proliferative histology.
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• Correctible causes. Hypothyroidism or hyperprolactinemia
• Ovulation induction. The agent of choice is clomiphene citrate administered orallyfor 5 days beginning on day 5 of the menstrual cycle. The biochemical structure of clomiphene is very similar to estrogen, and clomiphene fits into the estrogen recep-tors at the level of the pituitary. The pituitary does not interpret clomiphene as estro-gen and perceives a low estrogen state, thus producing high levels of gonadotropins.
HMG is administered parenterally and is used to induce ovulation if clomiphene fails.Careful monitoring of ovarian size is important because ovarian hyperstimulation is the most common major side effect of ovulation induction. When a patient is given clomiphene, her own pituitary is being stimulated to secrete her own gonadotropins, whereas when a patient is administered HMG, the patient is being stimulated by exog-enous gonadotropins.
Follow-Up Invasive Tests
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