What are the WHO defined class of an ovulation ? Class I: Hypothalamic-pituitary failure.

Patient is amenorreic and does not bleed after progesterone challenge. There is hypogonadotrophic hypogonadism with low serum levels of gonadotrophins (FSH & LH) as well as serum oestrogen. Which syndromes or diseases may yield to such HPO axis failures?

Example   are 1) Stress related amenorrhoea

2) Anorexia nervosa.

3) Kallmann’s syndrome

4) Isolated gonadotrophin deficiency. . Pulsatile GnRH therapy is mainly used for WHO group me anovulatory patients.

What are the WHO defined class of an ovulation?  Class II: Hypothalamic-pituitary dysfunction.

The patients are anovulatory and oligo-amenorreic. They are normo-gonadotropic with normal serum levels of gonadotrophins and oestrogen. This group includes entity of polycystic ovarian disease (PCO). PCO patients constitute the largest group of anovulatory women encountered in clinical practice (60-85% of cases) of all anovulation or oligo ovulation.

What are the WHO defined class of an ovulation?  Class III: Ovarian failure.

These patients are also amenorreic with failure to bleed to progesterone challenge. However they have hypergonadotropic (raised serum FSH, LH) hypogonadism with raised serum levels of gonadotrophins and decreased serum oestrogen (E2) levels. This group includes all variants failure (primary Ovarian Failures) and resistance.

Group I and II are the anovulatory groups. Group III women with ovarian failure are not amenable to successful stimulation of ovulation and are managed with oocyte donation.

The most commonly encountered group of patients with anovulation are those belonging to WHO group II and in that also mainly those with PCOD.

Do you have time to refresh our knowledge on the commonest cause of oligo/ anovulation.

It is one of the most common endocrine disorders, although its aetiology remains unknown. The disorder manifests in a heterogeneous group of patients with symptoms such as obesity, hyper-androgenism, menstrual cycle disturbances and infertility. 

When you should level her as PCO ? 
A universally agreed definition of either PCO or PCOS is not available. According to one of the definitions, these patients have symptoms of 
A) oligo-amenorrhea, B) obesity and C) Phenotypically there are usually but not always symptoms of hyper-androgenism (acne, hirsutism) Endocrine and metabolic disturbances are usually present in the form of elevated serum concentrations of LH,(day 3 serum FSH:LH>1.5),testosterone, insulin and prolactin are commonly seen. But one should remember that insuin and Testosterone are usually not done for diagnosis and Treatment Do) On USG have enlarged ovaries with >10 cysts numbering 2 to 8 mm in diameter, scattered either around or through an echo-dense, thickened stroma .

Clomiphene is the first line-drug for ovulation induction in hypothalamic pituitary disorder (WHO group II). However, if patients who fail to respond and in those with hypothalamic-pituitary failure (WHO group I), gonadotrophin therapy under close supervision should be attempted at tertiary care center.