Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Anovulation Treatment & Management

  • Author: Armando E Hernandez-Rey, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
 
Updated: Dec 30, 2015
 

Medical Care

The medical management of anovulation is complex because it entails initiating a multitiered approach to patient care.

First and foremost, the clinician should be well acquainted with the most common etiologies and able to rule them out, specifically those that can pose serious dangers to a patient's immediate health. Fortunately, anovulation usually manifests in a clinical setting geared toward the treatment of chronic diseases and conditions, which provides the precision necessary for an accurate diagnosis. Despite this, patients often have a history of multiple doctor visits because of inadequate or unsuccessful treatment by other physicians secondary to a misdiagnosis. The care of these patients must be tailored to their individual presentations and the specific disease entities responsible for anovulation. A holistic approach, consultation with other specialists, and routine follow-up should be the rule, not the exception.

Acute bleeding secondary to anovulation

Most causes of dysfunctional uterine bleeding respond to either oral or intravenous estrogen. Treatment using the parenteral route can be initiated with estrogen (Premarin) 25 mg IV q4h by accelerating the mitotic activity at the level of the endometrium. If no response is seen after 24 hours, suction dilation and curettage is warranted.

If the bleeding is not as vigorous, high-dose birth control pills (totalling 3 pills/d for 7 d), followed by continuation of oral contraceptives for a minimum of 3 months, has equal efficacy in reestablishing the endometrium.

Because of the menstrual irregularities associated with anovulation, anemia is a concern and must be treated with allogeneic blood transfusion if blood parameters fall below critical levels. Intravenous estrogen (Premarin) or high-dose combined oral contraceptives may be needed to ameliorate or terminate the acute bleeding episode. Dilation and curettage should never be the first-line treatment in this clinical setting; however, in the case of intractable bleeding, it may be the only alternative. Subtotal or total hysterectomy is rarely, if ever, necessary.

Anovulation and amenorrhea

Pregnancy test and hormonal studies measuring thyroid function, prolactin levels, and gonadotropin levels should be obtained. These hormonal assays should be followed by a progestational challenge to evaluate the endometrial lining and the presence of a hypoestrogenic state.

The first possibility is normal levels with a positive withdrawal bleed. This indicates anovulation and unopposed estrogen stimulation. Treatment is focused on providing progesterone support and cyclicity in the form of oral contraceptives or progestin alone, which is paramount in the prevention of endometrial hyperplasia.

If TSH or prolactin levels are elevated, correcting the primary problem is usually enough to attain ovulatory cycles once again.

If gonadotropin levels are low or normal, a diagnosis of hypogonadotropic hypogonadism is assumed and a space-occupying lesion versus hypothalamic suppression due to exercise or weight fluctuations (eg, anorexia nervosa, bulimia) must be ruled out. Treatment again focuses on the cause of the suppression.

If FSH and LH levels are elevated (hypergonadotropic hypogonadism), the problem is usually related to an absence of inhibitory signals that originate from the ovary under normal conditions; therefore, ovarian failure is presumed. Generally, other signs and symptoms of hypoestrogenism, such as vaginal dryness, emotional lability, and hot flushes due to vasomotor spasm, help confirm the diagnosis. If this occurs before age 30 years, a karyotype is necessary to rule out the presence of a Y chromosome or fragile X premutation. Owing to the high rate of malignant germ cell tumors in this setting, a gonadectomy must be performed immediately. Other considerations are certain autoimmune and infectious processes that can destroy ovarian tissue through infiltration of autoimmune complexes.

Next

Surgical Care

Surgical care is usually indicated to resolve the underlying cause for the anovulation, typically when medical therapy has failed.

Surgery is also indicated in rare cases, such as a macroadenoma of the pituitary with unrelenting growth eliciting severe symptoms (eg, headaches, bitemporal hemianopsia, diplopia). In the event of a benign or malignant neoplasm of ovarian or adrenal origin, exploratory laparotomy, resection, and staging are indicated.

Ovarian drilling and ovarian wedge resection are other surgical modalities used in the treatment of anovulation due to PCOS, with a spontaneous ovulation rate of more than 80% after the procedure.

While dilation and curettage is never first-line therapy for acute bleeding, practitioners are sometimes left with no other option. In even rarer cases, hysterectomy may be the only solution to the profound anemia stemming from acute blood loss.

Bariatric surgery has been advocated in the surgical treatment of severe obesity when accompanied by medical complications in which weight loss could be curative. Gastroplasty, vertical banded gastroplasty, gastric banding, and vertical stapling are commonly used but are less effective than the roux-en-Y gastric bypass. Typically patients with a BMI greater than 40 are candidates for surgery, assuming past attempts at medical treatment have failed, although patients with a BMI of 35-40 and underlying life-threatening medical problem may be considered as well.[33]

Previous
Next

Consultations

Consider consultations with the following specialists:

  • Neurosurgeons - In the presence of a macroadenoma unresponsive to medical management with bromocriptine
  • Psychiatrists/psychologists - For patients with body dysmorphic disorder and concomitant anorexia nervosa and bulimia
  • Nutritionists - For patients with anorexia nervosa and bulimia
  • Endocrinologists - When anovulation is due to adrenal disorders such as Cushing syndrome, Addison disease, overt type 2 diabetes mellitus, panhypopituitarism (ie, Sheehan syndrome), refractory thyroid disease
  • Gynecologic oncologists/general surgeons - In the case of either an adnexal mass or adrenal mass of benign or malignant origin
  • Reproductive endocrinologists and infertility specialists - When fertility is desired in order to appropriately monitor ovulation induction with either clomiphene citrate or gonadotropins or in the management of PCOS
Previous
Next

Diet

When considering a specific diet in the setting of anovulation, the principal focus must be in reference to the endocrinologic and metabolic derangements observed in PCOS. Therefore, a well-structured low-carbohydrate/low-cholesterol regimen is imperative because of the insulin resistance and cardiovascular risks commonly occurring in these patients.

The effectiveness of organized weight loss programs such as Weight Watchers, Curves, or Jenny Craig has been well documented to improve the recidivism rate in overweight patients attempting to lose weight when done in conjunction with counseling and support group initiatives.

Previous
Next

Activity

Cardiovascular exercise helps offset the inherent risks associated with PCOS.

Weight-bearing exercise should be recommended for patients with hypoestrogenic states, such as premature ovarian failure, when estrogen replacement is a contraindicated.

Previous
 
 
Contributor Information and Disclosures
Author

Armando E Hernandez-Rey, MD Consulting Staff, Reproductive Endocrinology and Infertility, Robotic and Minimally Invasive Surgery, Conceptions: Center for Fertility & Genetics of Florida; Assistant Professor of Women's Health, Florida International University College of Medicine

Armando E Hernandez-Rey, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, American Society for Reproductive Medicine, Society for Reproductive Investigation, Society of Laparoendoscopic Surgeons, AAGL, Society for Reproductive Endocrinology and Infertility

Disclosure: Received consulting fee from Inuitive Surgical for independent contractor; Received consulting fee from Vita Med MD for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Frances E Casey, MD, MPH Director of Family Planning Services, Department of Obstetrics and Gynecology, VCU Medical Center

Frances E Casey, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, Society of Family Planning, National Abortion Federation, Physicians for Reproductive Health

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Krystene I Boyle, MD, Cassandra Blot, MD, and Peter G McGovern, MD, to the development and writing of this article.

References
  1. Warren MP, Vu C. Central causes of hypogonadism--functional and organic. Endocrinol Metab Clin North Am. 2003 Sep. 32(3):593-612. [Medline].

  2. Speroff L, Glass RH, Kase NG. Anovulation and the polycystic ovary syndrome. Clinical Gynecologic Endocrinology and Infertility. Philadelphia, PA: Lippincott Williams & Wilkins; 1999. 487-513.

  3. Spence JE. Anovulation and monophasic cycles. Ann N Y Acad Sci. 1997 Jun 17. 816:173-6. [Medline].

  4. Yen SC, Jaffe RB, Barbieri RL. Chronic anovulation due to CNS-hypothalamic-pituitary dysfunction. Reproductive Endocrinology: Physiology, Pathophysiology and Clinical Management. 4th ed. London, England: Elsevier Science; 1999.

  5. Franks S, Mason H, White D, Willis D. Etiology of anovulation in polycystic ovary syndrome. Steroids. 1998 May-Jun. 63(5-6):306-7. [Medline].

  6. Rasgon N. The relationship between polycystic ovary syndrome and antiepileptic drugs: a review of the evidence. J Clin Psychopharmacol. 2004 Jun. 24(3):322-34. [Medline].

  7. Bilo L, Meo R. Polycystic ovary syndrome in women using valproate: a review. Gynecol Endocrinol. 2008 Oct. 24(10):562-70. [Medline].

  8. Haiman CA, Pike MC, Bernstein L, et al. Ethnic differences in ovulatory function in nulliparous women. Br J Cancer. 2002 Feb 1. 86(3):367-71. [Medline].

  9. Laven JS, Imani B, Eijkemans MJ, Fauser BC. New approach to polycystic ovary syndrome and other forms of anovulatory infertility. Obstet Gynecol Surv. 2002 Nov. 57(11):755-67. [Medline].

  10. Dunaif A. Hyperandrogenic anovulation (PCOS): a unique disorder of insulin action associated with an increased risk of non-insulin-dependent diabetes mellitus. Am J Med. 1995 Jan 16. 98(1A):33S-39S. [Medline].

  11. Guzick DS, Hoeger K. Clinical Updates in Women's Health Care: Polycystic Ovary Syndrome. 2009 Jan.

  12. The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004 Jan. 81(1):19-25. [Medline].

  13. Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril. 2009 Feb. 91(2):456-88. [Medline].

  14. Franks S, Robinson S, Willis DS. Nutrition, insulin and polycystic ovary syndrome. Rev Reprod. 1996 Jan. 1(1):47-53. [Medline].

  15. Pritts EA. Treatment of the infertile patient with polycystic ovarian syndrome. Obstet Gynecol Surv. 2002 Sep. 57(9):587-97. [Medline].

  16. Legro R. Polycystic ovary syndrome. Precis, Reproductive Endocrinology: An Update in Obstetrics and Gynecology. 2nd ed. American College of Obstetricians & Gynecologists; 2002. 85-89.

  17. Thatcher S. Diagnosis of polycystic ovary syndrome. Female patient. 2004. 29:33-41.

  18. Futterweit W. Polycystic ovary syndrome: clinical perspectives and management. Obstet Gynecol Surv. 1999 Jun. 54(6):403-13. [Medline].

  19. Bergfeld WF. Hirsutism in women. Effective therapy that is safe for long-term use. Postgrad Med. 2000 Jun. 107(7):93-4, 99-104. [Medline].

  20. Timpatanapong P, Rojanasakul A. Hormonal profiles and prevalence of polycystic ovary syndrome in women with acne. J Dermatol. 1997 Apr. 24(4):223-9. [Medline].

  21. Schorge JO, Schaffer JI. Amenorrhea. Williams Gynecology. McGraw Hill; 2008.

  22. Frisch RE, McArthur JW. Menstrual cycles: fatness as a determinant of minimum weight for height necessary for their maintenance or onset. Science. 1974 Sep 13. 185(4155):949-51. [Medline].

  23. Andrico S, Gambera A, Specchia C, et al. Leptin in functional hypothalamic amenorrhoea. Hum Reprod. 2002 Aug. 17(8):2043-8. [Medline].

  24. Klein DA, Walsh BT. Eating disorders. Int Rev Psychiatry. 2003 Aug. 15(3):205-16. [Medline].

  25. Yen SC, Jaffe RB, Barbieri RL. Chronic anovulation caused by peripheral endocrine disorders. Reproductive Endocrinology: Physiology, Pathophysiology and Clinical Management. 4th ed. London, England: Elsevier Science; 1999.

  26. Warren MP, Perlroth NE. The effects of intense exercise on the female reproductive system. J Endocrinol. 2001 Jul. 170(1):3-11. [Medline].

  27. Mestman JH. Endocrine diseases in pregnancy. Gabbe S, Neibyl JR, eds. Obstetrics Normal and Problem Pregnancies. New York, NY: Churchill Livingstone; 2002. 4th ed: 1117-8.

  28. Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N. Pituitary autoimmunity in patients with Sheehan's syndrome. J Clin Endocrinol Metab. 2002 Sep. 87(9):4137-41. [Medline].

  29. Velduis JD, Weiss J, Mauras N, et al. Appraising endocrine pulse signals at low circulating hormone concentrations: use of regional coefficients of variation in the experimental series to analyze pulsatile luteinizing hormone release. Pediatr Res. 1986 Jul. 20(7):632-7. [Medline].

  30. Bills DC, Meyer FB, Laws ER, et al. A retrospective analysis of pituitary apoplexy. Neurosurgery. 1993 Oct. 33(4):602-8; discussion 608-9. [Medline].

  31. Abe T, Ludecke DK. Transnasal surgery for prolactin-secreting pituitary adenomas in childhood and adolescence. Surg Neurol. 2002 Jun. 57(6):369-78; discussion 378-9. [Medline].

  32. Molitch ME. Disorders of prolactin secretion. Endocrinol Metab Clin North Am. 2001 Sep. 30(3):585-610. [Medline].

  33. Goldman L, Ausiello D. Obesity. Cecil Textbook of Medicine. 22nd ed. 2004. 1346.

  34. Roos N, Kieler H, Sahlin L, Ekman-Ordeberg G, Falconer H, Stephansson O. Risk of adverse pregnancy outcomes in women with polycystic ovary syndrome: population based cohort study. BMJ. 2011 Oct 13. 343:d6309. [Medline]. [Full Text].

  35. ACOG Committee on Practice Bulletins, American College of Obstetricians and Gynecologists. ACOG practice bulletin: management of anovulatory bleeding. Int J Gynaecol Obstet. 2001 Mar. 72(3):263-71. [Medline].

  36. Akande EO. Plasma concentration of gonadotrophins, oestrogen and progesterone in hypothyroid women. Br J Obstet Gynaecol. 1975 Jul. 82(7):552-6. [Medline].

  37. Akande EO, Hockaday TD. Plasma concentration of gonadotrophins, oestrogens and progesterone in thyrotoxic women. Br J Obstet Gynaecol. 1975 Jul. 82(7):541-51. [Medline].

  38. Azziz R, Woods KS, Reyna R, Key TJ, Knochenhauer ES, Yildiz BO. The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab. 2004 Jun. 89(6):2745-9. [Medline].

  39. Bankowski BJ, Zacur HA. Dopamine agonist therapy for hyperprolactinemia. Clin Obstet Gynecol. 2003 Jun. 46(2):349-62. [Medline].

  40. Barbieri RL. Metformin for the treatment of polycystic ovary syndrome. Obstet Gynecol. 2003 Apr. 101(4):785-93. [Medline].

  41. Baumann EE, Rosenfeld RL. Polycystic ovary syndrome in adolescence. Endocrinologist. 2002. 12:333-48.

  42. Ben-Rafael Z, Orvieto R. Polycystic ovary syndrome: a single gene mutation or an evolving set of symptoms. Curr Opin Obstet Gynecol. 2000 Jun. 12(3):169-73. [Medline].

  43. Boccuzzi G, Angeli A, Bisbocci D, Fonzo D, Giadano GP, Ceresa F. Effect of synthetic luteinizing hormone releasing hormone (LH-RH) on the release of gonadotropins in Cushing's disease. J Clin Endocrinol Metab. 1975 May. 40(5):892-5. [Medline].

  44. Bray GA, York DA. Clinical review 90: Leptin and clinical medicine: a new piece in the puzzle of obesity. J Clin Endocrinol Metab. 1997 Sep. 82(9):2771-6. [Medline].

  45. Brenner PF. Differential diagnosis of abnormal uterine bleeding. Am J Obstet Gynecol. 1996 Sep. 175(3 Pt 2):766-9. [Medline].

  46. Camargo CA. Hypothyroidism and goiter during pregnancy. Brody SA, Ueland K, eds. Endocrine Disorders of Pregnancy. Stamford, Conn: Appleton & Lange; 1989. 1989:165-76.

  47. Campo S. Ovulatory cycles, pregnancy outcome and complications after surgical treatment of polycystic ovary syndrome. Obstet Gynecol Surv. 1998 May. 53(5):297-308. [Medline].

  48. Carmina E, Lobo RA. Polycystic ovary syndrome (PCOS): arguably the most common endocrinopathy is associated with significant morbidity in women. J Clin Endocrinol Metab. 1999 Jun. 84(6):1897-9. [Medline].

  49. Clark RA, Mulligan K, Stamenovic E, et al. Frequency of anovulation and early menopause among women enrolled in selected adult AIDS clinical trials group studies. J Infect Dis. 2001 Nov 15. 184(10):1325-7. [Medline].

  50. Cotran RS, Kumar V, Collins T. Anovulation. Robbin's Pathologic Basis of Disease. 6th ed. Elsevier Science; 1999. 1056.

  51. Daniels GH. Thyroid disease and pregnancy: a clinical overview. Endocrinol Pract. 1995. 1:287-301.

  52. del Pozo E, Wyss H, Tollis G, et al. Prolactin and deficient luteal function. Obstet Gynecol. 1979 Mar. 53(3):282-6. [Medline].

  53. Edwards CR, Forsyth IA, Besser GM. Amenorrhoea, galactorrhoea, and primary hypothyroidism with high circulating levels of prolactin. Br Med J. 1971 Aug. 3(772):462-4. [Medline].

  54. Franks S, Gharani N, Waterworth D, et al. Genetics of polycystic ovary syndrome. Mol Cell Endocrinol. 1998 Oct 25. 145(1-2):123-8. [Medline].

  55. Franks S, McCarthy M. Genetics of ovarian disorders: polycystic ovary syndrome. Rev Endocr Metab Disord. 2004 Mar. 5(1):69-76. [Medline].

  56. Frisch RE, Wyshak G, Vincent L. Delayed menarche and amenorrhea in ballet dancers. N Engl J Med. 1980 Jul 3. 303(1):17-9. [Medline].

  57. Goldsmith R, Sturgis S, Lerman J, et al. The menstrual pattern in thyroid disease. J Clin Endocrinol Metab. 1952 Jul. 12(7):846-55. [Medline].

  58. Golovleva LA, Golovlev EL, Ganbarov KhG, Skriabin GK. [Role of cosubstrates in the microbiologic oxidation of xylene isomers by a culture of Pseudomonas aeruginosa]. Mikrobiologiia. 1977 Jan-Feb. 46(1):5-9. [Medline].

  59. Hamilton-Fairley D, Taylor A. Anovulation. BMJ. 2003 Sep 6. 327(7414):546-9. [Medline].

  60. Inamasu J, Hori S, Sekine K, Aikawa N. Pituitary apoplexy without ocular/visual symptoms. Am J Emerg Med. 2001 Jan. 19(1):88-90. [Medline].

  61. Knochenhauer ES, Key TJ, Kahsar-Miller M, et al. Prevalence of the polycystic ovary syndrome in unselected black and white women of the southeastern United States: a prospective study. J Clin Endocrinol Metab. 1998 Sep. 83(9):3078-82. [Medline].

  62. Malcolm CE, Cumming DC. Does anovulation exist in eumenorrheic women?. Obstet Gynecol. 2003 Aug. 102(2):317-8. [Medline].

  63. Norman RJ. Obesity, polycystic ovary syndrome and anovulation--how are they interrelated?. Curr Opin Obstet Gynecol. 2001 Jun. 13(3):323-7. [Medline].

  64. Norman RJ, Wu R, Stankiewicz MT. 4: Polycystic ovary syndrome. Med J Aust. 2004 Feb 2. 180(3):132-7. [Medline].

  65. Pfeifer SM, Dayal M. Treatment of the adolescent patient with polycystic ovary syndrome. Obstet Gynecol Clin North Am. 2003 Jun. 30(2):337-52. [Medline].

  66. Sabogal JC, Munoz L. Leptin in obstetrics and gynecology: a review. Obstet Gynecol Surv. 2001 Apr. 56(4):225-30. [Medline].

  67. Sakakura M, Takebe K, Nakagawa S. Inhibition of luteinizing hormone secretion induced by synthetic LRH by long-term treatment with glucocorticoids in human subjects. J Clin Endocrinol Metab. 1975 May. 40(5):774-9. [Medline].

  68. Schlechte J, Sherman B, Halmi N, et al. Prolactin-secreting pituitary tumors in amenorrheic women: a comprehensive study. Endocr Rev. 1980 Summer. 1(3):295-308. [Medline].

  69. Serri O, Chik CL, Ur E, Ezzat S. Diagnosis and management of hyperprolactinemia. CMAJ. 2003 Sep 16. 169(6):575-81. [Medline].

  70. Shangold MM. Athletic amenorrhea. Clin Obstet Gynecol. 1985 Sep. 28(3):664-9. [Medline].

  71. Thomas R, Reid RL. Thyroid disease and reproductive dysfunction: a review. Obstet Gynecol. 1987 Nov. 70(5):789-98. [Medline].

  72. Tolino A, Nicotra M, Romano L, et al. Subclinical hypothyroidism and hyperprolactinemia. Acta Eur Fertil. 1991 Sep-Oct. 22(5):275-7. [Medline].

  73. Tsilchorozidou T, Overton C, Conway GS. The pathophysiology of polycystic ovary syndrome. Clin Endocrinol (Oxf). 2004 Jan. 60(1):1-17. [Medline].

  74. Use of exogenous gonadotropins in anovulatory women: a technical bulletin. Fertil Steril. 2008 Nov. 90(5 Suppl):S7-12. [Medline].

  75. Veldhuis JD, Hammond JM. Endocrine function after spontaneous infarction of the human pituitary: report, review, and reappraisal. Endocr Rev. 1980 Winter. 1(1):100-7. [Medline].

  76. Warren MP, Brooks-Gunn J, Fox RP, et al. Persistent osteopenia in ballet dancers with amenorrhea and delayed menarche despite hormone therapy: a longitudinal study. Fertil Steril. 2003 Aug. 80(2):398-404. [Medline].

  77. Warren MP, Goodman LR. Exercise-induced endocrine pathologies. J Endocrinol Invest. 2003 Sep. 26(9):873-8. [Medline].

  78. Warren MP, Vu C. Central causes of hypogonadism--functional and organic. Endocrinol Metab Clin North Am. 2003 Sep. 32(3):593-612. [Medline].

  79. Wilansky DL, Greisman B. Early hypothyroidism in patients with menorrhagia. Am J Obstet Gynecol. 1989 Mar. 160(3):673-7. [Medline].

  80. Wilson JD, Foster DW, Kronenberg HM. Disorders of the ovaries and female reproductive tract. Williams Textbook of Endocrinology. 10th ed. WB Saunders Co; 2003. 751-817.

  81. Winters SJ, Berga SL. Gonadal dysfunction in patients with thyroid disorders. Endocrinologist. 1997. 7:167-73.

  82. Yen SC, Jaffe RB, Barbieri RL. Polycystic ovary syndrome: Hyperandrogenic chronic anovulation. Reproductive Endocrinology: Physiology, Pathophysiology and Clinical Management. 4th ed. London, England: Elsevier Science; 1999.

  83. Zakarija M, McKenzie JM. Pregnancy-associated changes in the thyroid-stimulating antibody of Graves' disease and the relationship to neonatal hyperthyroidism. J Clin Endocrinol Metab. 1983 Nov. 57(5):1036-40. [Medline].

  84. Zawadski JK, Dunaif A. Diagnostic criteria for polycystic ovary syndrome. Givens J, Haseltine F, Merriman G. The Polycystic Ovary Syndrome. Cambridge, MA: Blackwell Scientific; 1992. 377-384.

  85. Prior JC, Naess M, Langhammer A, Forsmo S. Ovulation prevalence in women with spontaneous normal-length menstrual cycles - a population-based cohort from HUNT3, Norway. PLoS One. 2015. 10(8):e0134473. [Medline].

  86. Schliep KC, Zarek SM, Schisterman EF, et al. Alcohol intake, reproductive hormones, and menstrual cycle function: a prospective cohort study. Am J Clin Nutr. 2015 Oct. 102(4):933-42. [Medline].

  87. Palihawadana TS, Wijesinghe PS, Seneviratne HR. Factors associated with nonresponse to ovulation induction using letrozole among women with World Health Organization group II anovulation. J Hum Reprod Sci. 2015 Apr-Jun. 8(2):75-9. [Medline].

 
Previous
Next
 
Anovulation. Polycystic ovary. Courtesy of Jairo E. Garcia, MD.
Anovulation. On the left is an unaffected patient aged 12 years. On the right is the same patient aged 13 years after developing Cushing disease.
Anovulation. Left adrenal mass discovered incidentally.
Anovulation. MRI showing a nonenhancing area in the pituitary consistent with a microadenoma in a patient with hyperprolactinemia.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.