eMedicine Specialties > Obstetrics and Gynecology > Reproductive Endocrinology and Infertility
Luteal Phase Dysfunction: Treatment & Medication
Updated: Oct 8, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Hyperprolactinemia and hypothyroidism cause luteal phase deficiency (LPD) through hypothalamic-pituitary dysfunction.
- Bromocriptine and levothyroxine, respectively, are used to treat LPD in women with these conditions.
- In women without hyperprolactinemia and hypothyroidism, vaginal progesterone is advocated to supplement endogenous progesterone production. The vaginal suppository or gel is preferred over both the oral and intramuscular forms because of superior endometrial progesterone concentrations. Vaginal suppositories are less expensive but are messier than the vaginal gel. Progesterone should be continued for 8-10 weeks to cover the time of the ovarian-placental shift.
- Clomiphene citrate corrects LPD by improving folliculogenesis and the resultant luteal phase following ovulation. Successful treatment with gonadotropins and human chorionic gonadotropins (hCGs) probably results from superovulation rather than from a correction of LPD.
- Following any of these treatments, the patient should have a repeat endometrial biopsy to determine that LPD has been corrected.
Medication
The goals of pharmacotherapy in luteal phase deficiency are to restore ovarian function, reduce morbidity, and prevent complications.
Hormone replacements
Medical treatment centers on hormonal support of the patient's luteal phase.
Bromocriptine (Parlodel)
Used if hyperprolactinemia is the underlying pathology causing LPD. Tablets can be used vaginally in patients who cannot tolerate adverse GI effects.
Adult
1.25 mg (ie, half of 2.5-mg tab) PO qd; increase to 2.5 mg/d after 2 wk; repeat EB after prolactin level in reference range is achieved, to document correction of LPD
Pediatric
Not established
Toxicity may increase with ergot alkaloids; amitriptyline, butyrophenones, imipramine, methyldopa, phenothiazines, and reserpine may decrease bromocriptine effects
Documented hypersensitivity; ischemic heart disease; peripheral vascular disorders
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
Caution in renal or hepatic disease
Levothyroxine (Levoxyl, Synthroid)
If LPD is caused by hypothyroidism, correction of endocrine disease results in normal luteal phase.
Adult
1.6-1.9 mcg/kg ideal body weight PO; repeat TSH and T4 in 6-8 wk to determine if dose adjustment needed; once normalization achieved, repeat EB to confirm correction of LPD
Pediatric
Not established
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 patients who have hypothyroidism are 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; monitor thyroid status periodically
Clomiphene citrate (Clomid, Serophene)
Stimulates release of pituitary gonadotropins. Improves folliculogenesis and, therefore, the luteal phase. Works best in biopsies that are lagging 1 week behind the date of endometrial sampling.
Adult
Initial: 50 mg PO qd from days 5-9 of menstrual cycle; if repeat EB does not confirm correction of LPD, then increase in 50-mg doses (ie, 100 mg, 150 mg); no increment in dosage necessary once correction of LPD accomplished
Pediatric
Not established
Danazol may reduce response to clomiphene
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
Cabergoline (Dostinex)
Long-acting dopamine receptor agonist with high affinity for D2 receptors. Prolactin secretion by anterior pituitary predominates under hypothalamic inhibitory control exerted through dopamine.
Adult
0.5-3.0 mg PO 2 times/wk; once prolactin level is within reference range, repeat EB to confirm correction of LPD
Pediatric
Not established
May increase effects of antihypertensive medications (adjust dose accordingly); dopamine agonists may reduce effects of cabergoline
Documented hypersensitivity; uncontrolled hypertension
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
Concomitant use with hypertensives; do not use to inhibit physiologic lactation due to relatively high incidence of stroke, seizures, and hypertension; monitor prolactin levels monthly; caution in hepatic impairment
Progesterone (Crinone Vaginal Gel, Progestasert)
Progesterone supplementation may be administered PO, IM, or vaginally. Oral progesterone is metabolized rapidly in liver, and the metabolites have little effect on endometrial activity. When administered IM, fails to achieve adequate levels of endometrial progesterone compared with vaginal forms. Vaginal progesterone is DOC for LPD; this is because of the proximity of the uterus to where the medication is delivered. Vaginal gel 8%, either qd or bid, is better tolerated compared to suppository form. Gel also provides increased receptor sites in the endometrium compared with suppository. Treatment begins 2 days after ovulation as determined by ovulation predictor kit. Correction of LPD can be confirmed by repeat EB.
Adult
Vaginal gel: Apply qd/bid
Oil: 25 mg IM bid
Pediatric
Not established
Aminoglutethimide may decrease effects
Documented hypersensitivity; thrombophlebitis, carcinoma of the breast, undiagnosed vaginal bleeding
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Fluid retention may occur; caution in patients with history of depression, impaired liver function, diabetes, and epilepsy; monitor for loss of vision, proptosis, diplopia, migraine, signs of embolic disorders
Follitropins (Follistim, Gonal-F, Fertinex)
Improve folliculogenesis, which increases total progesterone. This remains an expensive method associated with increased patient discomfort because medication is administered SC.
Adult
75 IU IM; increase to desired follicular response
Pediatric
Not established
None reported
Documented hypersensitivity; ovarian failure, uncontrolled thyroid or adrenal dysfunction, tumor of the ovary, breast, uterus, hypothalamus, or pituitary; undiagnosed vaginal bleeding; ovarian cystic enlargement not due to polycystic ovarian disease
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Ovarian enlargement may be accompanied by abdominal distention; serious respiratory distress, thromboembolic events, atelectasis may occur
More on Luteal Phase Dysfunction |
| Overview: Luteal Phase Dysfunction |
| Differential Diagnoses & Workup: Luteal Phase Dysfunction |
 Treatment & Medication: Luteal Phase Dysfunction |
| Follow-up: Luteal Phase Dysfunction |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
luteal phase dysfunction, LPD, luteal phase deficiency, luteal phase defect, progesterone, infertility, recurrent pregnancy loss
