Shannon’s Well Woman Assignment: Week 5

Chapter 7

1. What are the 4 main phases that cause a woman’s anovulation/irregular cycle? Why does each affect ?

The four main phases that cause a woman’s anovulation/irregular cycle are adolescence, coming off the Pill, pregnancy and breastfeeding, and premenopause. During adolescence, anovulation/irregular cycles are caused by the fuctuating levels. Cycles gradually become more regular and ovulation occurs more predictably over the course of several years as the hormonal feedback system matures and estrogen levels normalize. When a woman stops taking the Pill, it may take several cycles for the levels of estrogen to rise high enough to trigger ovulation. In addition, women who used the Pill as a “treatment” for preexisting anovulation/irregular cycles will fnd that these problems reappear after going off the Pill. The Pill does not solve the underlying problem; it only masks the symptoms. During pregnancy and breastfeeding, the hormones promoting the maturation and ovulation of an egg (specifcally FSH and LH during both times, and estrogen during breastfeeding) are suppressessed, which causes anovulation and either a complete cessation of (as in pregnancy and usually the frst months of exclusive breastfeeding) or irregular/anovulatory cycles (if the woman is not exclusively breastfeeding). A breastfeeding woman could go a year or more without ovulating and experience the same Basic Infertile Pattern (BIP), whether it be dry, sticky, or a combination of both, day after day. Fertile quality cervical fuid won’t appear because of low estrogen levels, which are indirectly caused by prolactin. Premenopause, which is the period of time (usually about 13 years before a woman’s last period) leading up to the full cessation of ovulation and menstruation (menopause), is characterized by a gradually but signifcant decrease in fertility. Due to a shortening luteal phase, the cycles become longer and ovulation occurs less and less frequently.

2. What is estrogen withdrawal bleeding? What about estrogen breakthrough bleeding?

Estrogen withdrawal bleeding refers to spotting that occurs immediately following the Peak Day due to the drop in estrogen. It also refers to the bleeding that occurs during the week that a woman is not taking the contraceptive pill. Estrogen breakthrough bleeding is light or brown spotting leading up to the Peak Day that is the result of excess estrogen without the presence of to sustain it. It can also refer to the potentially heavy bleeding that occurs in anovulatory cycles in which the lining which has been building due to the effects of estrogen can’t sustain itself, and is sloughed off. 3. Discuss each of the following as it relates to the menstrual cycle (You may make a chart if it is easier): illness, stress, travel, exercise, ovarian cysts, weight fuctuations.

Illness: Illness can only affect the menstrual cycle if it occurs during the follicular (or frst) phase, or in other words, before ovulation. Ovulation can be delayed or prevented altogether for that cycle. Should illness take place during the luteal (or second) phase of the cycle, it should not affect menstruation. This is because the luteal phase usually has a very consistent life span of 12 to 16 days and varies little for the individual woman.

Stress: Whether physiological or psychological, stress is one of the most common causes of occasional long cycles. Stress delays rather than accelerates ovulation in most cases. Because the timing of ovulation determines how long the cycle will be, a woman who experiences stress before she ovulates will most likely not ovulate at all or will ovulate later than she normally does, thus leading to a later menstruation.

Travel: Because travel is viewed by the body as a form of stress, ovulation is often delayed, which leads to extremely long cycles. Alternatively, ovulation and menstruation may cease altogether until a time when the woman is more settled and comfortable in her own home environment again.

Exercise: Depending on the intensity of exercises one engages in, it has the potential to delay or even prevent ovulation completely. The women most affected are competitive athletes with a very low ratio of body fat to total body weight, such as ballet dancers, swimmers, gymnasts, and runners. These fndings are not one hundred percent conclusive as other factors such as physical and emotional stress, diet, and changes in thyroid metabolism (things all of these women commonly struggle with) also play a part in affecting the cycle.

Ovarian cysts: One of the most common causes of temporary anovulation and irregular cycles is the presence of ovarian cysts. They can prevent ovulation if they occur during the preovulatory phase of the cycle, and can cause irregular cycles (a shorter or longer luteal phase) if they are present during the postovulatory phase. In most cases, they are not serious and go away on their own.

Weight fuctuations: Both extremes of being too thin or being overweight can affect the menstrual cycle by preventing ovulation from occuring. In order for the average woman to maintain normal ovulatory cycles, she should maintain a body mass index (BMI) between 20 and 24, which means that she has approximately 22% body fat. Those who are too thin, such as those with anorexia, or those who lose 10-15% of their body weight (or about one third of their body fat) don’t have enough body fat needed to produce the hormones necessary to ovulate. On the other extreme, those who are overweight have too much body fat. This is a problem because too much body fat can lead to excess estrogen production, which disrupts the hormonal feedback system that signals the egg follicles to mature.

4. This question deals with medical issues relating to the menstrual cycle and ovulation. For each, explain how they affect ovulation: hypothyroidism, PCOS, POI, , excessive prolactin.

Hypothyroidism: Because thyroid health is directly connected to a woman’s cycle, any change in thyroid function will lead to a change in the cycle. With regards to hypothyroidism, the thyroid is functioning in a diminished capacity. This means that it is not producing enough of the hormones (T4 and T3) necessary to maintain the correct functioning of the body, and specifcally the ovaries. Ovulation is often delayed or prevented completely when the thyroid is underperforming.

PCOS: One of the most common causes of anovulation and irregular cycles, PCOS affects up to 10% of all women. This serious hormonal disorder impacts not only the ovaries but also almost every other organ in the body. In this condition, the body produces an imbalanced amount of hormones that control the maturation of follicles. Many immature follicles are present on the ovary (creating a “string of pearls” appearance on the outer surface of the ovary when seen on an ultrasound), but the correct hormone levels necessary to trigger ovulation are often lacking. Sometimes ovulation does occur, but in many cases, women with PCOS have very irregular cycles, ones that last longer than 35 days, or do not ovulate at all.

POI: Primary Ovarian Insuffciency, which may also be referred to as Premature Ovarian Failure (POF) or Premature Menopause, is an endocrine disorder in which women don’t produce enough estrogen, and thus stop ovulating normally. This may occur years or even decades before menopause would normally occur.

Endometriosis: A fairly common condition, endometriosis is characterized by the growth of endometrial tissue in areas other than the , such as the fallopian tubes, ovaries, or even bladder. Something important to remember is that the degree of pain the condition causes is not related to its severity. A woman may be asymptomatic, or she may have lower abdominal pain that worsens during menstruation, pain during intercourse, and usually long menstrual periods. Endometriosis can cause irregular cycles and . Additional symptoms include short menstrual cycles (less than 27 days) with periods lasting longer than eight days, very few days of wet cervical fuid or even dry days throughout the cycle, and a normal luteal phase (12 to 16 days) with abnormally low temperatures hovering near the coverline, potentially signalling that progesterone levels are lower than normal.

Chapter 8 1. What are the most common types of ovarian cysts? How are they treated?

The most common types of ovarian cysts are functional cysts, which develop as a result of the normal function of the menstrual cycle. Instead of following a typical path, they continue to grow beyond normal. They may cause anovulatory, irregular, or confusing cycles. Currently, there is no consensus among physicians regarding how to defne or treat functional cysts. Surgery can be used to treat all cysts, but should only be used as a last resort due to its potential to cause adhesions and affect future fertility.

There are three types of functional cysts: follicular, luteinized unruptured follicle (LUF), and cyst. They all have hormonal causes and may occur only once or often. A follicular cyst forms when the follicle surrounding the egg continues to grow as ovulation approaches, but doesn’t rupture to release the egg, as it normally would. Instead, the follicle enlarges into a cyst that encases the egg inside, preventing ovulation. Follicular cysts will usually resolve on their own, typically by Day 5 of the next time of bleeding. A progesterone injection can be used if the woman experiences chronic . Other treatment options, which are less favorable include birth control pills and ovarian surgery. A luteinized unruptured follicle cyst forms when the mature egg remains encased in the follicle (which has undergone all the necessary sequences of a normal ovulation, including the formation of a corpus luteum that produces progesterone) instead of bursting out of it during ovulation. As with follicular cysts, luteinized unruptured follicle cysts usually resolve on their own in a similar manner. They too can be treated with a shot of progesterone if they cause the woman pain. This shot works quickly and usually relieves the woman of her discomfort within an hour of receiving the medication. Birth control pills are often prescribed, but do not solve the underlying problem. Surgery is another unfavorable option. With a corpus luteum cyst, the egg is released during normal ovulation and a corpus luteum develops as expected. However, instead of degenerating within the normal 12 to 16 days, the opening where the egg was released is sealed off and flled with excess fuid or blood, causing it to grow into a cyst. Interestingly, drugs used to boost one’s fertility increase one’s chances of developing one of these cysts. Corpus luteum cysts are not usually treated since they are innocuous and almost always resolve on their own within a few weeks to a few months.

2. What causes endometriosis? What are the symptoms? How is it treated?

While there are many theories as to the cause of endometriosis, the most common one is called “retrograde menstruation” in which some endometrial cells fow backward through the fallopian tubes and out into the pelvic cavity where they begin to implant. Because this theory alone does not explain how this process is possible, other hypotheses are currently being investigated. These include the idea that the lymphatic system of blood is allowing the tissue to travel to locations farther away from its original site in the uterus. Others think that the endometrial cells can be inadvertently transplanted to other locations during pelvic surgeries. The symptoms include the following, with the frst three being the most common, classic symptoms:

● Intense menstrual cramps ● Pain during intercourse, especially with deep penetration ● Infertility ● Chronic pelvic pain, including lower back pain ● Heavy or irregular bleeding ● Premenstrual spotting ● Intestinal pain ● Painful urination or bowel movements during menstrual periods ● Diarrhea, constipation, bloating, nausea, dizziness, or headaches during menstrual periods ● Fatigue ● Low-grade fever ● Low resistance to infection

Additional symptoms include short menstrual cycles (less than 27 days) with periods lasting longer than eight days, very few days of wet cervical fuid or even dry days throughout the cycle, and a normal luteal phase (12 to 16 days) with abnormally low temperatures hovering near the coverline, potentially signalling that progesterone levels are lower than normal.

Endometriosis is treated on an individual basis, with each woman and her family situation in mind. It is typically treated through the use of the following options:

● Nonsteroidal antiinfammatory drugs- Used to reduce the pain associated with the condition, they work in part by stopping the release of prostaglandins, one of the main chemicals responsible for causing painful periods. They do not shrink or prevent additional growth. Ibuprofen (Advil and Motrin) or naproxen (Aleve) are examples. ● Hormonal birth control- Used to reduce the amount of bleeding that may be the cause of the pain, this medication unfortunately is only a temporary fx as it does not cure the actual condition. It has side effects and risks and cannot be used by those wishing to become pregnant. ● Gonadotropin releasing hormone agonists- These drugs cause a temporary menopause and are exceptionally good at reducing severe pain. Again, these cannot be used for women who wish to become pregnant. They have numerous side effects, such as insomnia, hot fashes, vaginal dryness, and decreased libido. Hormonal therapy only works in mild cases of endometriosis and is typically taken for more than 6 months in order to be effective. As with other medication, it does not solve the problem. ● Surgery- To treat endometriosis, two types of surgery are commonly done (should be kept as a last resort). Laparoscopy is a minimally invasive surgery and can often be used to drain fuid and remove small patches of tissue. However, not all cases can be treated in this way. Occasionally, more extensive surgery may be needed when already present scar tissue is thick or involves delicate structures.

3. For PCOS, what are the overt and clinical symptoms?

The overt symptoms of PCOS, which may appear in varying degrees and ways in different women, include the following:

● Long (over 35 days) or irregular cycles that rarely result in ovulation ● A pattern of limited cervical fuid for long stretches of time ● Frequent patches of fertile-quality cervical fuid which may or may not ultimately lead to ovulation ● Excessive body or facial hair (hirsutism) ● Male pattern baldness ● Acne ● Obesity (about 50% of women with PCOS) ● Infertility

The clinical symptoms include the following:

● Enlarged, white ovaries that have what appear to be a string of pearls on the surface (These are numerous immature follicles that never reach ovulation.) ● Elevated androgen and LH levels ● A reversal of the LH:FSH ratio (LH is produced in higher quantities than FSH is.) ● Often abnormal ovulation when it does occur (i.e. the abnormal development of the egg as well as the corpus luteum)

4. What are the health risks of PCOS?

PCOS comes with a host of health risks, including the following:

● Insulin resistance (in at least 50%) ● Metabolic syndrome ● High blood pressure (hypertension) ● Type 2 diabetes ● Heart disease ● Endometrial cancer ● Breast cancer ● Ovarian cancer

Depending on one’s genotype, you may be predisposed to some of these things and not others.

5. What causes PCOS and how is it diagnosed?

While the causes of PCOS are not fully known or understood, it is thought to be caused by multiple factors.

● It appears to be passed down genetically. ● Excess insulin is often produced, which can in turn produce excess androgens, such as testosterone. Testosterone in turn leads to polycystic ovaries by preventing the eggs from maturing to the point of being able to ovulate. ● Obesity and low-grade infammation may intensify the underlying syndrome.

6. What are the various treatments of PCOS? Discuss their effectiveness and drawbacks, if any.

PCOS should be treated according to the individual’s genotype and phenotype, as well as to whether or not she is trying to conceive. One treatment option focuses on nutrition and natural methods. This method is healthier for the woman and does not have any side effects. With an emphasis on maintaining healthy insulin levels, getting suffcient exercise, and eating a diet rich in healthy fats, proteins, and moderate amounts of lower glycemic carbohydrates that don’t cause the blood sugar to spike, this treatment option has helped many women balance their hormones and relieve their symptoms of PCOS.

There are also medical options used to treat PCOS.

● The birth control pill is often prescribed to try to regulate a woman’s cycle. It does help to “regulate” the cycle, but unfortunately does nothing to treat the condition, which will reappear as soon as she goes off the medication. ● Another treatment involves the ingestion of a naturally occurring substance, called d-Chiro-inositol, that helps the woman with PCOS utilize insulin better. It is effective in improving ovulatory function, decreasing serum androgen concentrations, and improving blood pressure. ● Women can also be treated with progesterone. Referred to as cyclic progesterone therapy, women are given progesterone during every cycle to counter the unopposed estrogen that women with PCOS have. ● Metformin, a drug normally given to diabetics to treat high blood sugar, can also be used to treat PCOS because these women can have a type of insulin resistance. It can help balance hormones and encourage ovulation. ● Ovarian drilling is another treatment option for PCOS. By drilling into the ovary with a laser or needle up to 10 times, the level of male androgens can be decreased drastically. It works especially well for those who fail to ovulate with Clomid (an ovulation drug) or Metformin. However, it may cause adhesions or ovarian failure if there are complications during the procedure. ● Ovarian wedge resection involves slicing a wedge out of the enlarged, cystic ovary in order to reduce excess androgen production. While associated with a high success rate, this procedure often resulted in adhesions. It was abandoned many years ago as a common treatment option. Today, the procedure has been improved upon and can be performed with very little to no scarring by highly trained physicians. When performed well, it has the potential to increase the chances of conceiving and signifcantly lessening the numerous symptoms and risks of PCOS.