eMedicine Specialties > Obstetrics and Gynecology > Reproductive Endocrinology and Infertility
Anovulation: Treatment & Medication
Updated: Jan 5, 2010
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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. Luckily, 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.
- 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.
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.32
Consultations
- 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
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.
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.
Medication
Medical therapy of anovulation should be directed at reversal of the primary underlying cause and tailored to the individual patient.
Ovulation stimulators
Used for ovulation induction.
Clomiphene citrate (Serophene, Clomid, Milophene)
Stimulates release of pituitary gonadotropins. Acts as an antiestrogen to decrease negative estrogen feedback on hypothalamus. In addition, may have effects on pituitary gland and ovaries and can induce ovulation in women with hypothalamic amenorrhea. Improves folliculogenesis and, therefore, ovarian function during luteal phase.
Adult
50-100 mg PO qd for 5 d; not to exceed 6 mo
Pediatric
Not established
Danazol may reduce response
Documented hypersensitivity; liver disease; abnormal uterine bleeding; uncontrolled thyroid or adrenal dysfunction
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Visual symptoms and abdominal pain may occur
Thyroid products
Used to correct hypothyroidism.
Levothyroxine (Synthroid, Levoxyl, Levothroid)
If luteal phase dysfunction is caused by hypothyroidism, correction of endocrine disease results in normal luteal phase.
Adult
12.5-50 mcg PO qd; increase by 25-50 mcg/d q2-4wk to maximum 100-200 mcg/d
Pediatric
Neonate to 6 months: 25-50 mcg PO qd
6-12 months: 50-75 mcg PO qd
1-5 years: 75-100 mcg PO qd
6-12 years: 100-150 mcg PO qd
>12 years: 150 mcg PO qd
Cholestyramine may decrease liothyronine absorption; estrogens may decrease response to thyroid hormone therapy in patients with nonfunctioning thyroid glands; effect of anticoagulants increased when administered with liothyronine; activity of some beta-blockers may decrease when hypothyroid patient is converted to a euthyroid state
Documented hypersensitivity; uncorrected adrenal insufficiency
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in angina pectoris or cardiovascular disease; periodically monitor thyroid status
Oral contraceptives
Used for hormone replacement.
Ethinyl estradiol and norethindrone (Ortho-Novum, Ovcon 35, Ovcon 50)
In young females, low-dose PO contraception generally is an excellent method of hormone replacement. Any low-dose combination pill with 35 mcg of ethinyl estradiol or less or any progestin is appropriate. Also useful because, on occasion, these women may spontaneously ovulate and become pregnant.
Adult
Schedule 1 (Sunday starter): Begin dose on first Sunday after onset of menstruation or on Sunday if menstrual period starts on Sunday
21-tab package: 1 tab PO qd for 21 d followed by 7 d off medication; new course begins on 8th d after taking last tab
28-tab package: 1 tab PO qd without interruption
Schedule 2 (day 1 starter): Start dose on day 1 of menstrual cycle
21-tab package: 1 tab PO qd for 21 d followed by 7 d off medication; begin new course on day 8 after taking last tab; continue dosing cycle if 1 period is missed; pregnancy test required if 2 periods are missed
Pediatric
Not established
Phenobarbital, phenytoin, paramethadione, carbamazepine, troglitazone, rifampicin, and griseofulvin induce enzymes that decrease levels of contraceptive steroids; PO anticoagulants may increase thromboembolic potential; antibiotics may alter GI flora and cause a reduction in absorption of PO contraceptives, which may reduce efficacy
Documented hypersensitivity; endometrial and hepatic cancer; thromboembolic disorders; undiagnosed vaginal bleeding; smokers >35 y; cardiovascular disease
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in patients diagnosed with hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease
Ethinyl estradiol/norgestimate (Ortho-Prefest, Ortho TriCyclen, Ortho-Cyclen)
In young females, low-dose PO contraception generally is an excellent method of hormone replacement. Any low-dose combination pill with 35 mcg of ethinyl estradiol or less or any progestin is appropriate. Also useful because, on occasion, these women may spontaneously ovulate and become pregnant.
Adult
Schedule 1 (Sunday starter):
Begin dose on first Sunday after onset of menstruation; start Sunday if menstrual period starts on Sunday
21-tab package: 1 tab PO qd for 21 d followed by 7 d off medication; new course begins on day 8 after taking last tab 28-tab package: 1 tab PO qd without interruption
Schedule 2 (day 1 starter): Start dose on day 1 of menstrual cycle
21-tab package: 1 tab PO qd for 21 d followed by 7 d off medication; begin new course on day 8 after taking last tab; continue dosing cycle if 1 period is missed; pregnancy test required if 2 periods are missed
Pediatric
Not established
Phenobarbital, phenytoin, paramethadione, carbamazepine, troglitazone, rifampicin, and griseofulvin induce enzymes that decrease levels of contraceptive steroids; PO anticoagulants may increase thromboembolic potential; antibiotics may alter GI flora and cause a reduction in absorption of PO contraceptives, which may reduce efficacy
Documented hypersensitivity; endometrial and hepatic cancer; thromboembolic disorders; undiagnosed vaginal bleeding; smokers >35 y; cardiovascular disease
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in patients diagnosed with hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease
Bisphosphonate derivatives
Analogs of pyrophosphate and act by binding to hydroxyapatite in bone matrix, thereby inhibiting dissolution of crystals. Prevent osteoclast attachment to the bone matrix and osteoclast recruitment and viability.
Alendronate (Fosamax)
Inhibits bone resorption via actions on osteoclasts or osteoclast precursors. Used to treat osteoporosis in both men and women. May reduce bone resorption and incidence of fracture at spine, hip, and wrist by approximately 50%. Should be taken with a large glass of water at least 30 min before eating and drinking to maximize absorption. Because of possible esophageal irritation, patients must remain upright after taking the medication. Since it is renally excreted, not recommended in patients with moderate-to-severe renal insufficiency (ie, CrCl <30 mL/min or serum Cr > 3 mg/dL); use in perirenal transplantation is limited.
Adult
Prophylaxis: 5 mg PO qd; alternatively, 35 mg PO qwk
Treatment: 10 mg PO qd; alternatively, 70 mg PO qwk
Pediatric
Not established
None reported
Documented hypersensitivity; hypocalcemia; abnormalities of the esophagus; inability to stand upright for 30 min
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Must be taken at least 30 min before first food, beverage, or medication of the day and should be taken with large amounts of water; caution in renal impairment
Oral antidiabetic agents
May increase glucose uptake in peripheral tissues.
Metformin (Glucophage)
Reduces hepatic glucose output, decreases intestinal absorption of glucose, and increases glucose uptake in the peripheral tissues (muscle and adipocytes). Major drug used in obese patients who have type 2 diabetes mellitus.
Adult
Initial: 500 mg PO bid
Maintenance: 850 mg PO tid
Pediatric
Not established
Diuretics, thyroid products, PO contraceptives, phenytoin, calcium channel–blocking drugs; phenothiazines may decrease effects; cimetidine may increase levels
Documented hypersensitivity; acute myocardial infarction; septicemia; renal disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal insufficiency; discontinue therapy before performing any surgical procedures; impaired liver function
Antiandrogens
May inhibit androgen feedback on pituitary gland.
Finasteride (Proscar, Propecia)
Blocks conversion of testosterone to its more active metabolite, dihydrotestosterone. More effective when used in combination with OCPs.
Adult
1 mg PO qd
Pediatric
Not established
None reported
Documented hypersensitivity; lactation; childhood
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Minimum of 6 mo treatment necessary to determine response; caution in liver function abnormalities; monitor patients with severely diminished urinary flow for obstructive uropathy (may not be candidates for this therapy)
Spironolactone (Aldactone)
Aldosterone antagonist that inhibits ovarian and adrenal production of androgens. Competes with dihydrotestosterone binding at hormone receptor sites on hair follicle cells. Also reduces 17alpha-hydroxylase activity, lowering plasma levels of testosterone and androstenedione.
Adult
200 mg/d PO qd or divided bid
Pediatric
Not established
May decrease effect of anticoagulants; potassium and potassium-sparing diuretics may increase toxicity
Documented hypersensitivity; anuria; renal failure; hyperkalemia
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal and hepatic impairment; electrolytes and blood pressure should be monitored for first few weeks of therapy to be certain hypotension and hyperkalemia do not occur
Glucocorticoids
May be used to correct adrenal insufficiency.
Fludrocortisone (Florinef)
Partial replacement therapy for primary and secondary adrenocortical insufficiency.
Adult
0.1 mg PO qd
Pediatric
0.05-0.1 mg PO qd
Antagonizes effects of anticholinergics; rifampin, hydantoins, and barbiturates decrease effects; decreases salicylate levels
Documented hypersensitivity; systemic fungal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Taper dose gradually when therapy is discontinued; caution in Addison disease, potassium loss, and sodium retention
Antifungal agents
Inhibit a variety of cytochrome P-450 enzymes, including 11beta-hydroxylase and 17-alpha-hydroxylase, which in turn, inhibit steroid synthesis.
Ketoconazole (Nizoral)
Inhibits steroid synthesis at the level of 17-alpha-hydroxylase/17,20-lyase, a key enzyme in sex steroid production. Also inhibits testosterone binding to its binding globulin. In some cases, especially in children with markedly advanced bone age, a rapid decrease in sex hormone levels may trigger true central puberty. In this event, add GnRH analogs to the treatment regimen.
Adult
200-400 mg PO bid/tid
Pediatric
Not established
Isoniazid may decrease bioavailability; coadministration decreases effects of either rifampin or ketoconazole; may increase effect of anticoagulants; may increase toxicity of corticosteroids and cyclosporine (cyclosporine dosage can be adjusted); may decrease theophylline levels; decreases metabolism of repaglinide, thus increasing serum levels and effects
Documented hypersensitivity; fungal meningitis
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Hepatotoxicity may occur; may reversibly decrease corticosteroid serum levels (adverse effects avoided with dose of 200-400 mg/d); administer antacid, anticholinergics, or H2 blockers at least 2 h after taking ketoconazole
Dopamine agonists
Directly stimulate postsynaptic dopamine receptors. The dopaminergic neurons in the tuberoinfundibular process modulate the secretion of prolactin from the anterior pituitary by secreting a prolactin inhibitory factor (believed to be dopamine).
Pergolide was withdrawn from the US market March 29, 2007, because of heart valve damage resulting in cardiac valve regurgitation. It is important not to abruptly stop pergolide. Health care professionals should assess patients' need for dopamine agonist (DA) therapy and consider alternative treatment. If continued treatment with a DA is needed, another DA should be substituted for pergolide. For more information, see FDA MedWatch Product Safety Alert and Medscape Alerts: Pergolide Withdrawn From US Market.
Pergolide (Permax)
Pergolide withdrawn from US market. Inhibits secretion of prolactin (PRL); causes a transient rise in serum concentrations of GH and decreases serum concentrations of LH.
Adult
Administered at initial dose of 25 g/d, and then at 50 g/d with gradual dose escalation, depending on extent of serum PRL normalization
Pediatric
Not established
Antagonists such as the neuroleptics phenothiazine, butyrophenones, thioxanthenes, and metoclopramide may diminish effectiveness of pergolide, a dopamine agonist; because pergolide mesylate is more than 90% bound to plasma proteins, exercise caution if coadministered with other drugs known to affect protein binding
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause valvular heart disease (yearly echocardiograms recommended for patients on chronic therapy); inhibits secretion of prolactin; causes transient rise in serum concentrations of growth hormone and decrease in serum concentrations of luteinizing hormone; adverse effects include nausea, hypotension, hallucinations, and somnolence; use caution in patients who have been treated for cardiac dysrhythmias; may cause or exacerbate preexisting states of confusion and hallucinations or dyskinesia
Progestins
May be used for endometrial stabilization and organization of basal layer in chronic anovulation.
Medroxyprogesterone acetate (Provera, Cycrin, Depo-Provera)
Derivative of progesterone. Androgenic and anabolic effects have been noted, but apparently is devoid of significant estrogenic activity. Parenterally administered dosage form inhibits gonadotropin production, which in turn, prevents follicular maturation and ovulation. Available data indicate that this does not occur when the usually recommended PO dose is administered qd. When orally administered in the recommended doses to women adequately exposed to exogenous or endogenous estrogen, transforms the proliferative endometrium into a secretory one.
Adult
10 mg PO qd for first 10 d of menstrual cycle
Pediatric
Not recommended
Aminoglutethimide may decrease effects by increasing hepatic metabolism of medroxyprogesterone
Documented hypersensitivity; cerebral apoplexy; undiagnosed vaginal bleeding; thrombophlebitis; liver dysfunction
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in asthma, depression, renal or cardiac dysfunction, or thromboembolic disorders
Estrogens
May be used to build endometrial lining in acute and chronic anovulation.
Estrogens, conjugated/equine (Premarin)
May be used for restoration of regular menstrual cycles, which may prevent endometrial hyperplasia associated with anovulation. Improvements of hyperandrogenic effects occur in 60-100% of women but usually require a minimum of 6-12 mo of use. A pregnancy test should be performed before initiating therapy. If the woman has had no menstrual period for 3 mo, withdrawal bleeding should be induced by administration of 5-10 mg of medroxyprogesterone acetate (Provera) qd for 10 d; therapy is then begun with OCPs.
Adult
0.05 mg PO qd/tid
Pediatric
Not established
May reduce hypoprothrombinemic effects of anticoagulants; estrogen levels may be reduced with coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes; an increase in corticosteroid levels may occur when administered concurrently with ethinyl estradiol; use of ethinyl estradiol with hydantoins may cause spotting, breakthrough bleeding, and reduce contraceptive efficacy; increase in fluid retention caused by estrogen intake may reduce seizure control; antibiotics may alter GI flora and cause a reduction in absorption of PO contraceptives, which may reduce efficacy
Documented hypersensitivity; thrombophlebitis; undiagnosed vaginal bleeding
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Exercise caution in patients diagnosed with hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease
Nonsteroidal anti-inflammatory drugs
Reduce blood loss by 30-50% in cases of anovulatory bleeding.
Ibuprofen (Advil, Motrin, Excedrin IB)
Used for reduction in uterine bleeding and dysmenorrhea associated with anovulatory cycles. Blocks formation of prostacyclin, an antagonist of thromboxane, a substance that accelerates platelet aggregation and initiates coagulation. Because NSAIDs inhibit blood prostacyclin formation, they might effectively decrease uterine blood flow.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Aromatase inhibitors
These agents inhibit aromatase activity, which causes serum estrogen levels to reduce.
Letrozole (Femara)
Reduces circulating estrogen inhibiting the estrogen negative feedback of the HPA. Results in increased secretion of FSH and thus ovarian follicle development.
Adult
2.5 mg PO daily on menstrual cycle days 3-7
Pediatric
Not established
None reported
Documented hypersensitivity; liver disease; pregnancy
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with history of thromboembolic disorders or risk of complications from edema; common adverse effects include headache, nausea, dyspnea, cough, pharyngitis, back or bone pain
Anastrozole (Arimidex)
Aromatase inhibitor that significantly lowers serum estradiol concentrations by inhibiting the conversion of adrenally generated androstenedione to estrone. Used as first-line treatment of breast cancer in postmenopausal women with hormone receptor positive or hormone receptor unknown locally advanced or metastatic disease. Also used to treat advanced breast cancer in postmenopausal women with disease progression following tamoxifen therapy.
Adult
1 mg PO qd on menstrual cycle days 3-7
Pediatric
Not indicated
None reported
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with history of thromboembolic disorders or risk of complications from edema; common adverse effects include headache, nausea, dyspnea, cough, pharyngitis, back or bone pain
Gonadotropins
These agents stimulate ovarian follicular growth.
Follitropin alfa (Gonal-F)
Exogenous FSH stimulates proliferation of granulosa cells and follicular growth. Release of follicles is stimulated by human chorionic gonadotropin. Safety and efficacy of gonadotropin therapy depends on careful monitoring and should only be managed by a specialist.
Adult
37.5-75 IU/d IM/SC qd for 7-12 days, increasing after 7 days if no follicle has developed >10 mm; if response to follitropin appropriate, may administer 5,000-10,000 IU hCG IM/SC 1 day following the last follitropin dose to trigger ovum release
Pediatric
Not established
None reported
Documented hypersensitivity; hypersensitivity to streptomycin or neomycin (Follistim); pregnancy; primary gonadal failure; uncontrolled thyroid disease; uncontrolled adrenal dysfunction; breast, ovarian or uterine cancer; abnormal uterine bleeding
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Ovarian hyperstimulation syndrome; multigestational pregnancy; serial transvaginal ultrasounds, and serum E2 measurements must be done
More on Anovulation |
| Overview: Anovulation |
| Differential Diagnoses & Workup: Anovulation |
 Treatment & Medication: Anovulation |
| Follow-up: Anovulation |
| Multimedia: Anovulation |
| References |
| Further Reading |
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Keywords
dysfunctional uterine bleeding, DUB, amenorrhea, chronic anovulation, hypogonadotropic hypogonadism, hypergonadotropic hypogonadism, luteinizing hormone, LH, gonadotropin-releasing hormone, GnRH, polycystic ovary syndrome, PCOS, follicle-stimulating hormone, FSH, hypothalamic-pituitary-ovarian axis, HPO axis
