Details of WHO class I anovulation causes & treatment- how far gynecologist should treat?

Details of WHO class I anovulation causes & treat 

Hypothalamic— pituitary (HP) causes of amenorrhea and ovulatory dysfunction

Primary HP amenorrhea is rare. Hypothalamic— pituitary (HP) causes of amenorrhea are of two types :- A) primary hypothalamic diseases B) Secondary hypothalamic diseases: For instance  Kallmann syndrome (congenital HP amenorrhea associated with anosmia or hypo-osmia) is a primary hypothalamic disorder . When such syndrome, genetic counseling should always be  carried out before attempting pregnancy

HP amenorrhea due to stress, exercise and eating or weight disorders is due to sec hypothalamic

 diseases. B) Secondary hypothalamic disease :-- HP amenorrhea due to stress, exercise and eating or weight disorders is mediated through the hypothalamic centers for gonadotropin-releasing hormone (GnRH). Treatment should be aimed at correction the underlying condition. Secondary amenorrhea due to pituitary infarction or blood-loss shock (Sheehan’s syndrome) is associated with adrenocorticotropic hormone (ACTH) and thyroid-stimulating hormone (TSH) deficiency, which should be corrected before attempting pregnancy. Obesity is a common cause of anovulation in developed countries. It has been estimated that 50% of women who are more than 20% over their ideal weight will be anovulatory or have luteal insufficiency. Often a 20% reduction in body weight is all that is required to restore fertility. Because obesity is associated with PCO, PCOS and insulin resistance, these disorders must be ruled out or treated first before attempting OI.

Anovulation or oligo ovulation i.e. all types of ovulatory disorder, its causes.	Test	Finding	Treatment
Hypothalamic	FSH/LH-both are low.	<5 mlU/mL	Diet/gonadotropin
Hyperprolactinemia	Prolactin	>  35 ng/mL	Bromocrptine
Polycystic ovaries	LH:FSH	Most often : 2:1 ratio	Clomiphene as primary therapy
Adrenal hyperplasia	DHEAS	>180 μg/dL	Dexamethasone
Insulin resistance	Insulin	>20 μU/mL	Diet/insulin sensitizers
Hypothyroid	TSH	>10 μIU/mL, especially if TPO ab is +ve	Levothyroxine
Menopause	FSH	>20 mIU/mL	Estrogen to prevent bone loss. To ensure adequate sleep.
Premenopausal	FSH	>10 mIU/mL	Clomiphene, better hMG.
Luteal insufficiency	Progesterone	<18 ng/mL	Clomiphene/Better hMG

When to prescribe clomiphene? : The principke is  CC treatment with CC is effective only in patients with sufficient serum estradiol levels. After correction of underlying problems, including those related to stress, exercise and eating disorders, treatment with gonadotropins is effective in patients with low FSH levels, but it must be started at a low dose because of the possibility that ovaries unaccustomed to FSH will be hyperstimulated .ment- how far gynecologist should treat?