Anovulación y amenorrea secundaria: enfoque fácil y práctico / Anovulation and secondary amenorrhea: easy and practical approach / Anovulação e amenorreia secundária: abordagem fácil e prática

Resumen: La anovulación ocurre en el 30 % de la Infertilidad y la amenorrea secundarla en el 4% de mujeres en edad reproductiva. Ambas alteraciones se pueden tornar crónicas conllevando riesgos de hiperestrogenismo e hipoestrogenismo crónicos. Tanto la anovulación como la amenorrea secundaria tienen las mismas causas endocrinas, excepto que la amenorrea tiene una adicional de causa uterina. No obstante existen muchas clasificaciones etiológicas, unas combinan la amenorrea secundaria con la primaria, otras se enfocan más a la anovulación y algunas agrupan las etiologías en compartimentos, sin lograr hacerlo en forma integral. El objetivo es revisar las clasificaciones etiológicas de anovulación y amenorrea secundaria, junto con la actualización de cada una de esas causas, a fin de seleccionar la clasificación que las agrupe integralmente para enfocar el manejo en forma fácil y práctica. Para ello, se revisó la literatura médica reciente en libros de texto, PubMed, Ovid, Clinical guidelines y Cochrane library, con palabras claves. Se concluye que la clasificación etiológica integral en cinco compartimentos es una guía fácil de seguir, para lograr el diagnóstico de cada una de esas causas, actualmente, cuando existen medicamentos y procedimientos quirúrgicos seguros para manejarlas como anovulación o como amenorrea secundaria.

Abstract: Anovulation occurs in 30% of infertility and secondary amenorrhea In 4% of women In reproductive age. Both alterations can become chronic, carrying risks of chronic hyperestrogenism and hypoestrogenism. Both anovulation and secondary amenorrhea have the same endocrine causes, except that amenorrhea has an additional uterine cause. However, there are many etiological classifications, some combine secondary and primary amenorrhea, others focus more on anovulation and some group the etiologies into compartments, without achieving a comprehensive approach. The objective is to review the etiological classifications of anovulation and secondary amenorrhea, together with the update of each one of these causes, in order to select the classification that can integrally groups them so that to their management can be focused on an easy and practical way. For this purpose, recent medical literature in textbooks, PubMed, Ovid, Clinical guidelines and Cochrane library was reviewed with key words. It is concluded that the comprehensive etiological classification in five compartments is an easy guide to follow to achieve the diagnosis of each of these causes, currently, when there are drugs and safe surgical procedures to manage them as anovulation or secondary amenorrhea.

Resumo: A anovulação ocorre em 30 % da Infertilidade e a amenorreia secundária em 4 % de mulheres em idade reprodutiva. Ambas as alterações podem se tornar crônicas, implicando riscos de hiperestrogenismo e hipoestrogenismo crônicos. Tanto a anovulação quanto a amenorreia secundária têm as mesmas causas endócrinas, exceto que esta última tem ainda causa uterina. Contudo, existem muitas classificações etiológicas, umas combinam a amenorreia secundária com a primária, outras se focam mais na anovulação, e algumas agrupam as etiologias em compartimentos sem poder fazer isso de forma integral. O objetivo é revisar as classificações etiológicas de anovulação e amenorreia secundária, junto com a atualização de cada uma dessas causas, a fim de selecionar a classificação que as agrupe integralmente para focar o manejo de forma fácil e prática. Para isso, foi revisada a literatura médica recente em textos consultados em PubMed, Ovid, Clinical guidelines e Cochrane library, a partir de palavras-chave. Conclui-se que a classificação etiológica integral em cinco compartimentos é um guia fácil de seguir para obter o diagnóstico de cada uma dessas causas, atualmente, quando existem medicamentos e procedimentos cirúrgicos seguros para manejá-las como anovulação ou como amenorreia secundária.

Anovulación y disfunción ovulatoria e infertilidad / Anovulation, ovulatory disfunction and infertility

La anovulación crónica es una de las alteraciones más frecuentes que ven los ginecólogos en la consulta. Ciclos menstruales irregulares, sangrados uterinos anormales, amenorrea e infertilidad son los síntomas clínicos más frecuentemente observados. El objetivo principal en la evaluación de estas pacientes es identificar la causa que está provocando la anovulación crónica. Para propósitos de esta revisión, las causas potenciales se han agrupado en: a) amenorreas hipotalámicas, b) Anovulación crónica funcional, c) Síndrome de ovario poliquístico, d) hiperprolactinemia, e) Disfunción tiroídea, f) Falla ovárica prematura. El tratamiento está enfocado en corregir la condición que pueda estar causando el problema, optimizar la calidad de vida de la paciente y su salud, y reestablecer ciclos normales o inducir la ovulación si es que fuera necesario. Respecto a este último punto, los diferentes medicamentos y protocolos más comúnmente usados para inducción de la ovulación se analizan endetalle.

Chronic anovulation is one of the most frequent disorders seen by gynaecologists. Irregular cycles, abnormal uterine bleeding, amenorrhea and infertility are the most common clinical symptoms. The main target during the evaluation of these patients is to identify the disorders that cause chronic anovulation. For the purpose of this review, the potential causes have been grouped as follows: a) Hypothalamic amenorrhea, b) Hypothalamic functional anovulation, c) Polycystic ovary syndrome (PCO), d)Hyperprolactinemia, e) Thyroid dysfunction and f) Premature ovarian failure. The treatment of this conditionaims to correct any underlying disorder, to optimize the patient´s health and, to re-establish normal cycles or to induce regular ovulation, if required. With respect to the latter, the different drugs and protocols most commonly used for ovulation induction are reviewed in detail.

Síndrome de ovario poliquístico e infertilidad / Infertility and polycystic ovary syndrome

El Síndrome de Ovario Poliquístico (SOP) es una disfunción endocrino metabólica altamente prevalente en mujeres en edad reproductiva. De etiología incierta, se manifiesta de formas muy variadas, entre las que destacan irregularidad menstrual, oligo o anovulación, hiperandrogenismo clínico, imagen ecográfica de ovario poliquístico, obesidad, insulinorresistencia e infertilidad. Por su variedad de presentación es que su definición ha requerido varios consensos y es aún hoy motivo de controversia. La infertilidad asociada al SOP obedece a diferentes mecanismos, entre los que destacan la disfunción ovulatoria, la alteración del desarrollo endometrial, la insulinorresistencia, su impacto en la esteroidogénesis ovárica y suprerrenal y, la alta frecuencia de aborto espontáneo de primer trimestre. El enfoque diagnóstico y terapéutico del SOP debe contemplar todos estos aspectos en forma integral para restablecer adecuadamente el ambiente endocrino-metábolico previo a un embarazo y tener en cuenta las potenciales repercusiones en el mediano y largo plazo para estas pacientes como dislipidemia, diabetes mellitus tipo 2, enfermedad cardiovascular y, cáncer de endometrio y mama.

Polycystic ovary syndrome (PCOS) is a metablic endocrine disorder highly common in women of reproductive age. Of unknown etilogy, its symptoms are varied; including menstrual disorders, oligo or anovulation, clinical hyperandrogenism, visualization of polycystic ovaries on ultrasound, obesity, insulin resistance and infertility. Due to the wide range of clinical symptoms, attempts have been made to reach consensus, however controversy remains. Infertility associated to PCOS responds to different mecanisms such as ovulatory disorders, alterations in endometrial development, insulin resistance, impact on ovarian and suprarenal steroidogenesis and a high frequency of first trimester spontaneous abortions. The diagnostic and therapetic approach to PCOS must consider all these factors as a whole in order to provide an adecuate endocrine-metabolic environment prior to pregnancy and to anticipate any possible medium or long-term impact in these patients, including dyslipidemia, Type II Diabetes mellitus, cardiovascular disease and endometrial and breast cancer.

The Effects of Body Mass Index on Baseline Hormonal Status and Glucose Metabolism in Women with Chronic Anovulation / 대한불임학회지

OBJECTIVE: To assess the difference of baseline hormonal status and pathophysiology, and confirm the risk factors for long term complication according to Body Mass Index in women with polycystic ovary syndrome. MATERIALS AND METHODS: Serum level of LH, FSH, Estradiol, Prolactin, Testosterone, DHEA-S, fasting insulin were measured and 100 gm oral glucose tolerance test and endometrial biopsy were performed in total 75 chronic anovulation patients and 20 normal cycling infertility patients. 95 evaluated patients were divided into 3 groups including patients with chronic anovulation having BMI below 25, BMI beyond 25.1, normal cycling infertility patients, Group 1 (n=39), Group 2 (n=36), Group 3 (n=20), respectively. Statistical analysis was performed respect to relationship between BMI and measured hormone level, sum of glucose level during 100 gm OGTT, insulin resistance using t-test, ANOVA test, Post Hoc test, Mann-Whitney test. p<0.05 was considered as statistically significant. RESULTS: Serum LH level and LH/FSH ratio was significantly higher in Group 1, compared than Group 2 or 3 (p<0.05), BMI and LH, LH/FSH ratio was negatively correlated (r=-0.351, r=-0.318). There was no significant difference according to BMI in FSH, testosterone, estradiol, prolactin, DHEA-S level. Fasting insulin and sum of glucose level during 100 gm OGTT were significantly higher in Group 2 compared than Group 1 or Group 3 (p<0.05), there was no significant difference between Group 1 and Group 3. Insulin resistance was more frequently identified in Group 2 compared than Group 1 (p=0.001). CONCLUSIONS: BMI and LH, LH/FSH ratio were negatively correlated, so clinical significance of LH, LH/FSH ratio in diagnosis of PCOS may be attenuated by increasing body weight. Overweight patients with chronic anovulation may be the risk group for developing insulin resistance, hyperinsulinemia, glucose intolerance, later type 2 DM. Hyperinsulinemia may operate mainly in overweight chronic anovulation patients in development of hyperandrogenism.