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We talk about ovulatory dysfunction if ovulation is irregular or absent. This alteration may be suspected in the presence of irregular menstrual cycles or that are not preceded by symptoms such as breast tension, abdominal swelling or mood swings.
In addition to the premenopausal state, one of the most common causes of ovarian dysfunction is polycystic ovary syndrome. However, the problem may also be due to hyperprolactinemia, subclinical hypothyroidism and other pathologies that cause anovulatory amenorrhea (including functional alterations in the hypothalamic-pituitary-ovarian axis, early ovarian failure and ovarian cancer).
Ovulatory dysfunction translates into the difficulty of having an effective ovulation in reproductive terms. The diagnosis of this condition is confirmed by the measurement of hormonal levels and the execution of pelvic ultrasound.
Possible Causes of ovulatory dysfunction
Look for another symptom associated with ovarian dysfunction to narrow down the list of possible causes:
- Polycystic ovary syndrome
- Turner’s syndrome
- Ovarian tumor
If the symptoms of the ovulatory phase do not manifest or if irregular menstrual cycles are present, ovulation may not occur every month.
The main symptoms associated with ovulation disorders are:
- Irregularities in the menstrual cycle
- Absence of menstruation (amenorrhea)
- Elongation of the natural rhythm of the menstrual cycle (oligomenorrhoea)
- Excessive and sudden drop in weight
- Abnormal or excessive hair growth on body and face
- Galactorrhea (secretion of milk from the nipples)
- Acne and hirsutism (abnormal or excessive hair growth on body and face)
Oligo-ovulation and anovulation
Ovulation disorders are classified as menstrual disorders, and include:
- Oligo-ovulation: this is uncommon or irregular ovulation, usually identified by the presence of cycles greater than 36 days or numerically lower than 8 cycles per year.
- Anovulation: Common cause of infertility, occurs when a woman has no ovulation. Other possible anovulatory symptoms are extremely short or long menstrual periods or a complete absence of menstruation. Anovulation is the absence of menstrual flow in fertile age for a period of at least 3 months and is usually manifested as irregularities in the menstrual cycle, understood as an unpredictable variability of duration or amount of menstrual flow. Anovulation may also cause termination of menstrual periods (secondary amenorrhea) or excessive bleeding (dysfunctional uterine bleeding).
In itself, anovulation is not associated with any physical symptoms, but in women who do not ovulate, cervical mucus is tendentially not regular, whereas in those with high androgen values can be present hirsutism.
Classification of ovulation disorders
The World Health Organization (WHO) has developed the following classification of ovulation disorders based on:
- prolactin level.
- the level of gonadotropins LH and FSH.
- estrogen levels
GROUP I Hypothalamic Hyperthal Failure:
Women with amenorrhea (absence of menstruation) and no signs of estrogen production, prolactin levels within limits, low levels of FSH, no signs of anatomical lesions of the hypothalamus-pituitary region.
Hypothalamus and hypophysis (most common cause) disorders: Women with various menstrual disorders such as lutheal phase failure, anovulatory cycles, polycystic ovary syndrome, lack of menstruation, with estrogen production and normal levels FSH and prolactin.
Ovarian Failure (Ovarian Insufficiency): Women without menstruation, no signs of ovarian function, high levels of FSH, normal prolactin values.
Congenital or acquired reproductive system abnormalities: Women without menstruation that do not respond to repeated cycles of estrogen.
Women with hyperprolactinaemia and hypothalamic-pituitary-area lesions: Women with various cycle disorders, high levels of prolactin and signs of hypothalamic-pituitary-grade lesions.
Women with infertility, hyperprolactinaemia and no lesions at the hypothalamic-pituitary region: Women with various cycle disorders, high levels of prolactin, just like in the V group but without lesions at the hypothalamic-pituitary region.
Women with no menstruation, values within prolactin limits and signs of lesions in the hypothalamic-pituitary region: Women with low estrogen levels and prolactin values within the limits.
Causes of ovulation disorders
Certain disorders of ovulation can be determined by:
- Hyperprolactinemia. Hyperprolactinemia is the abnormally high level of prolactin in the blood. Prolactin is a peptidic hormone produced by the pituitary, mainly associated with breastfeeding. Hyperprolactinemia may cause spontaneous production of breast milk and alterations in the normal menstrual cycle, thus reproducing normal body fluctuations during pregnancy and lactation (the majority of breastfeeding women have no menstruation for ovulation failure). When prolactin production rises out of this period, for different causes, ovulation processes are disturbed, although menstruation maintains a normal rhythm. The classic signs of hyperprolactinaemia are amenorrhea and galactorrhea. Hyperprolactinemia is often caused by diseases affecting the pituitary gland (for example, the presence of small benign pituitary tumors, called adenoma).
- Polycystic Ovary Syndrome (PCOS) – Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders. PCOS is a complex heterosexual disorder that can cause various disorders: anovulation, resulting in menstrual or amenorrhea irregularities, ovarian cysts (from which the polycystic ovary) and excessive amounts of androgenic hormones or amplification of their effects, causing acne and hirsutism. Is often associated with insulin resistance, obesity, type 2 diabetes, and high cholesterol levels. The symptoms and severity of the syndrome vary considerably among the affected women.
- Endometriosis – Endometriosis is a pathological condition affecting the internal lining of the uterus (endometrium), which under normal conditions are monthly subjected to hormonal stimulation and bleeding during menstruation. In the presence of endometriosis, there is a proliferation of these endometrial cells outside the uterine cavity, most commonly on the peritoneum that covers the abdominal cavity and the ovary, where ‘menstrual’ blood accumulates in cysts, giving rise to reactions to organisms that have adverse effects on the anatomy and physiology of the entire reproductive system. The main (but not universal) symptom of endometriosis is pelvic pain in various manifestations.
- Thyroid abnormalities
- Stomach-related abnormalities, weight loss, Cushing syndrome, ovarian or adrenal tumors, hypothalamic tumors
1. Induction of ovulation
The induction of ovulation is a promising assisted reproduction technology for patients with pathologies such as polycystic ovary syndrome (PCOS) and oligomenorrhea (alteration of the menstrual cycle). It is also used in in vitro fertilization to bring follicles to ripening before taking oocytes. Usually, ovarian stimulation is used in combination with ovulation induction to stimulate the formation of multiple oocytes.
Complete ovarian stimulation can be injected with a low dose of human chorionic gonadotropin (HCG), a hormone typically produced by the embryo immediately after implantation in the uterus. Ovulation will occur between 24 and 36 hours after HCG injection.
2. Repression of the ovulation
Contraception suppresses ovulation events. In fact, most hormonal contraceptives concentrate on the ovulatory phase of the menstrual cycle because it is the most important time for fertility. Estradiol and progesterone, taken in various forms, including the use of combined oral contraceptives, imitate hormonal levels in the menstrual cycle and exercise a negative feedback control by turning off follicolysis and ovulation. Hormone therapy can therefore positively or negatively interfere with ovulation and can give a sense of cycle control and fertility to the woman.
There is a talk about female sterility when it is impossible to ovulate or to do it regularly. Female sterility can be caused by alterations in normal ovulation. This is a widespread problem, responsible for about 30% of cases of sterility registered each year in the female population. This disorder is recognized by hormonal disorders of varying nature, capable of interfering with the natural regularity of the menstrual cycle. For example, possible alterations in pituitary gonadotropin secretion, resulting in ovarian failure (anovulation). If the follicle is not brought to full maturity – until the egg cell is released – it will not be possible to meet the spermatozoa contained in the sperm for a consequent conception.
Since ovulation is the result of an end-to-end hormonal regulation, anovulation is also known as hormonal sterility. The causes of this endocrine disequilibrium can be multiple, so in some cases they are the ‘simple’ result of a strong emotional or physical stress. For example, some athletes suffer from amenorrhea (lack of menstruation for at least three consecutive months) due to excessive effort in sports activity. Fortunately, this is only a temporary break of ovulation, which should not be considered as a permanent cause of sterility.