The causes, symptoms and diagnosis of anovulation

As soon as the girl's body becomes ready for maternity, her period begins. Approximately in the middle of the menstrual cycle, an egg is matured monthly and the ovary leaves, ready for fertilization. This process is called ovulation and takes only a quarter of an hour. It is in the next 24 hours after the release of the egg, its fertilization and the birth of a new life are possible. Dysfunction of the ovary, which amounts to a violation of the maturation of the follicle and the egg in it or its release at the due time, is called anovulation. Ideally, the willingness to conceive, bear and give birth to a child should be maintained in a woman of fertile age from puberty to the menopausal period. However, in reality everything is somewhat different.

Causes of the absence of ovulation

In almost healthy women several times a year can observe anovulatory cycles, when there is no escape of the egg. They are caused by hormonal disorders, because the process of ovulation is controlled by hormones. The causes of anovulation with a normal (initially) hormonal background are in its temporary fluctuations, sometimes quite significant, caused by impaired functioning of the hypothalamic-pituitary-ovarian system, associated with nervous and physical overstrain; eating disorders (anorexia, bulimia, compliance with rigid diets); taking medications; consequences of acute and recurrent chronic pathologies; a sharp change in climate; reorganization of the system of procreation and its transition to a new phase. To such periods are: puberty (development of fertility); postpartum (the period of breastfeeding); premenopausal (extinction of fertility). The absence of ovulation, caused by temporary causes, refers to the physiological and does not require treatment.

Separate conversation requires anovulation, caused by taking oral contraceptives. Their action is based on the violation of natural processes that connect the hypothalamus, pituitary gland and ovaries. In most women, fertility is restored without problems when discontinuing the use of birth control pills, but not at all. This is very individual.

Pathological (chronic) anovulation is a regular absence of ovulation. Its main cause is a hormonal imbalance, caused by a violation of the function of the ovaries. Ovulatory dysfunction is most often observed in women with polycystic ovaries. Premature dystrophy of the ovaries, excess or deficiency of estrogens, follitropin and luteotropin, a violation of their ratio may affect the mechanism of ovulation. Sclerokistoz ovary, which is considered a complication of polycystosis or dystrophy, is the formation of multiple small immature cysts with a dense shell.

But anovulation due to a lack of progesterone raises questions. After all, it is possible to speak about progesterone deficiency only in the second phase of the cycle, when ovulation has already occurred. If ovulation was not, then the low level of progesterone is completely normal. Inadequate progesterone production is usually considered in the context of menstrual cycle disorders and the process of maturation of germ cells due to impaired ovarian function. Isolated deficiency of progesterone practically does not occur, therefore therapy by a progesterone is exposed to criticism and admits far not all doctors, at least, mass.

Risk factors

Risk factors for ovulatory dysfunction - congenital pathologies of reproductive organs and their development; hyperplasia of the adrenal glands; excess prolactin or androgens; acute and chronic inflammatory processes of the pelvic organs (especially endometritis and endometriosis ); venereal infections; thyroid dysfunction; chronic obesity or dystrophy; bad habits; the effect of autoimmune processes is also not excluded.

[1], [2], [3], [4], [5], [6], [7], [8]

Pathogenesis

Pathogenetic links in the process of ovulation are the above causes that upset the hormonal balance, which results in a violation of the first phase of the ovulatory cycle at any stage - maturation or release of the egg from the dominant follicle.

Polycystic ovary syndrome is the main role in the pathogenesis of anovulation. In this case, the hypothalamic-pituitary and ovarian ovulatory mechanisms are violated. In the pathogenesis of sclerokinosis, as its complications, hyperproduction of foliotropin is also considered, which contributes to abnormal ovarian function and the formation of dense cysts instead of follicles, which makes ovulation impossible. Luteotropin deficiency is also considered.

Another hypothesis in the first place displays the hyperactivity of the adrenal cortex, the violation of the secretion of steroids and estrogen deficiency, which upsets the process of maturation of the follicles, leads to the development of androgenital syndrome, anovulation and amenorrhea.

For the period of formation of fertility, anovulation due to insufficient level of luteotropin is typical, its production grows and reaches peak values by 15-16 years. The reverse process - a decrease in the synthesis of hormones necessary for ovulation occurs with the extinction of ability to childbearing (menopause).

In hypothalamic-pituitary disorders with an excess of prolactin, anovulation is a consequence of the inhibitory effect of it several times the amount normal to the ovaries, the pituitary function of producing luteotropin (does not reach the peak required for ovulation), and hypothalamic-synthesis of gonadotropin-releasing hormone.

Neoplasms of hypothalamic localization and other neuroprocesses in the hypothalamus, starvation, a sharp decrease in body weight can cause a decrease and even completely stop the production of gonadotropin-releasing hormones and with a normal prolactin content.

The consequence of surgical intervention for pituitary adenoma, as well as - radiation therapy may be the absence of ovulation due to a sharp decrease in the level of gonadotropic hormones. This is also promoted by excessive secretion of androgens.

Anovulation can be accompanied by a lack of menstruation or uterine bleeding, however, women often have a single-phase (anovulatory) menstrual cycle that ends with menstrual bleeding. Failure affects the ovulatory phase, and the secretory and development of the yellow body does not occur at all. Virtually the entire single-phase cycle is the proliferation of endometrial cells, followed by their necrosis and rejection. During its course in the ovaries completely different in nature and duration of the stages of development and regression of the follicle.

For anovulation, hyperestrogenia is more characteristic throughout the entire cycle, without changing for progesterone effect in the second phase of the normal cycle. Although sometimes the level of estrogen is reduced, which affects the nature of changes in the endometrium - from hypo- to hyperplastic, accompanied by proliferation of glandular polyps.

Bleeding at the end of the anovulatory cycle is explained by the regression of immature follicles, which, as a rule, is accompanied by a decrease in the level of estrogens. The functional layer of the endometrium is subjected to destructive changes - vascular permeability increases, effusions, hematomas, necrosis of tissues appear. The surface layer of the endometrium is rejected, causing bleeding. If this does not occur, bleeding diapedesis occurs as a result of migration of red blood cells through the shells of blood vessels.

Every third case of female infertility, according to statistics, is caused by the lack of ovulation. In turn, the leading cause of this dysfunction, gynecologists call polycystic ovary, which is diagnosed in no more than one in ten of the fair sex of childbearing age. In this case, the external signs of polycystosis are detected by ultrasonic examination of ovaries of women of fertile age twice as often. But the clinical picture, corresponding to the syndrome of polycystic ovaries, is not found at all.

Sclerokistoz ovaries is diagnosed in three to five percent of gynecological pathologies, one third of cases is accompanied by persistent infertility.

[9], [10], [11], [12], [13], [14], [15], [16]

Symptoms of the absence of ovulation

Basically, women do not know about the absence of ovulation when their desire to become a mother is not realized. After several fruitless attempts to become pregnant, most women go to the doctor to find out what is wrong with them. Therefore, the main symptom of anovulation is the inability to become pregnant. Sometimes with anovulation, amenorrhea is observed (after strong experiences, regular exhausting sports, strict diets and starvation). However, the majority of women still have menstruation with anovulation, more precisely bleeding that a woman takes for menstruation, since the difference is not felt either in their periodicity, or in the quantitative (blood loss), or in the qualitative (the woman's well-being in this period) attitude. Anovulation with regular menstruation is not at all a rarity, but rather even a norm.

Uterine bleeding is not always regular, however, women interpret it as a change in the duration of the cycle and usually do not hurry to the doctor.

Hyperestrogenia is characterized by abundant and prolonged bleeding. Their result can be the development of anemia (anemia), accompanied by its symptoms - weakness, rapid fatigue, dizziness, shortness of breath, paleness of the skin, dryness and brittle hair and nails.

Estrogen deficiency (hypoestrogenia) is characterized by scanty monthly discharges and their short duration. There may be amenorrhea, which may indicate sclerokistoza. On ultrasound in this case, there are enlarged or wrinkled ovaries, necessarily covered with tuberous formations with contours of cysts. Haemorrhage in the male type, underdevelopment of the uterus and mammary glands, overweight. The presence of all symptoms is not necessary. There may be symptoms of general malaise - sleep disturbances, libido, headaches, weakness, fatigue, fatigue.

The first signs of anovulation are not too obvious, the most notable of them is the absence of menstruation is observed not often. However, such symptoms as irregularity, changes in the number of secretions (oligomenorrhoea) should be alerted; the absence of habitual signs of approaching menstruation (pre-local syndrome) or their noticeable decrease; no increase in basal body temperature in the proposed second phase of the cycle.

Disturbing symptoms may be hirsutism (excessive growth of androgen-dependent hair), a significant change in body weight in a short period of time, light discharge from the nipples (hyperprolactinemia), sudden mood swings.

Sometimes it is necessary to be very attentive to yourself and your body, to notice trouble with a monthly ovulatory cycle and seek medical help on time, and not in a neglected stage.

The following types of ovulation are distinguished depending on the cause that caused it: physiological and pathological anovulation. The first refers to the periods of restructuring of fertility - adolescent, postpartum and the period of its extinction.

Anovulatory cycles can occur in any woman during periods of very high loads, due to alimentary causes, acute illnesses and exacerbations of chronic. Often they simply do not notice, sometimes, if the causes that cause them are substantial and prolonged, a woman may stop her menstruation or change her periodicity and intensity. When the stressful for the body factor is eliminated, the condition of the woman usually normalizes.

With pathological anovulation, the absence of the second phase of the menstrual cycle occurs regularly. Chronic anovulation is necessarily accompanied by persistent infertility and is often found precisely during attempts to realize its maternal function. The expressed symptoms for the chronic form of absence of ovulation are not characteristic, monthly bleedings are usually regular. To suspect in itself this pathology, basically, it is possible, measuring basal temperature. Pathological anovulation is subject to compulsory treatment if the woman plans to have children.

[17], [18], [19], [20]

Complications and consequences

Regular absence of ovulation can lead to aggravation of hormonal imbalance, impaired ovarian function, even if anovulation was caused by other causes, because the whole hypothalamic-pituitary-ovarian axis is involved in the process.

As a result of chronic anovulation with hyperestrogenemia, abundant uterine bleeding develops, leading to disruption of hematopoiesis and anemia. Refusal of treatment usually leads to persistent infertility.

[21], [22], [23], [24], [25]

Diagnostics of the absence of ovulation

To establish in house conditions, whether the ovulation passes normally, it is possible in two ways: by means of measurement of basal temperature during several menstrual cycles and construction of its schedule, and also - having applied bought in a drugstore the express test for ovulation.

The temperature graph of the anovulation cycle has the form of a monotonic curve, more rarely a broken line, all the graphs do not exceed 37 ℃.

The express test registers the peak luteotropin content in the urine before ovulation, if ovulation does not occur, then the jump in this indicator is absent.

If there are suspicions about the presence of ovulatory dysfunction, it is necessary to consult a specialist and undergo a thorough diagnostic examination. All patients with anovulation recommended medico-genetic counseling, it may be necessary to consult an endocrinologist.

In addition to the usual medical interview and classical clinical tests, specific tests are used to determine the woman's general health status, giving an idea of her hormonal status.

The most accurate representation of the degree and nature of the ovulatory disorder is given by the serum levels of prolactin and gonadotropic hormones ( follicle-stimulating and luteinizing ).

The increased content of serum prolactin suggests consultation of the endocrinologist and a blood test for plasma concentrations of TSH, T4, T3 (thyroid hormones).

In case of violations of the well-functioning of the hypothalamus and pituitary gland and the normal content of prolactin, the serum level of foliotropin, luteotropin, estradiol may be normal (normogaladotropic anovulation) or decreased (hypogonadotropic anovulation).

In the case of ovarian anovulation, the follitropin content is significantly (four to five times or more) higher than the norm. The assumption of this origin of anovulation makes it necessary to prescribe a minimally invasive diagnosis - ovarian biopsy using a laparoscope, as well as immunological tests for detecting autoantibodies to ovarian tissues.

The increase in serum luteotropin concentration, in particular, the ratio of its level to the content of follitropin, reinforced by the corresponding symptomatology assumes the presence of a syndrome of polycystic ovaries.

Ovulatory dysfunction is indicated by low serum progesterone content in the second phase of the cycle (when this second phase is determined depending on the individual cycle, and not on the standard schedule on day 21), and also the absence of secretory changes resulting from diagnostic curettage (scraping endometrium).

The serum concentration of estradiol may be significantly lower (oligomenorrhea) or normal in regular anovulatory cycles.

Progesterone sample is used as an alternative to the previous analysis: the body's response to intramuscular injection of progesterone within seven to ten days can confirm sufficient saturation with estrogens (within two to five days after the course, there is a menstrual bleeding) and insufficient - the result is negative.

The androgen status of the patient is evaluated, and in case of increased content of male sex hormones, a sample with dexamethasone is administered to clarify the origin of hyperandrogenism.

A PCR analysis can also be performed for the presence of sexually transmitted infections.

Of the hardware studies in the first place, the patient is prescribed ultrasound for anovulation. When ultrasound examination on the computer monitor shows the absence of a dominant follicle. In the syndrome of polycystic ovaries, more follicles are ripening immediately than necessary, they can not be distinguished from the dominant ones, and they do not mature until the end, but they turn into cysts, which the ovary "overgrows". A similar picture is seen in the case of multifollicular ovaries. Differentiation is carried out by hormonal background analysis.

Other instrumental diagnostics may be required - ultrasound and x-ray of the mammary glands, tomography of the brain, examination of the thyroid gland.

[26], [27], [28], [29]

Differential diagnosis

Based on the results of the examination, differential diagnosis is performed. The method of data analysis and exclusion establishes the exact cause of anovulation, excludes neoplasms, in particular, the pituitary gland.

Treatment of the absence of ovulation

Ovulatory dysfunction, which arose as a result of high physical exertion, does not require hormonal treatment. With decreasing intensity of training and dosing of loads, anovulation passes independently.

Prevention

In the prevention of the development of anovulation plays a huge role played by the education of adolescent girls in a pragmatic attitude towards their health: comprehending them the need to observe rational physical activity, the optimal mode of work and rest, timely treatment to the doctor if symptoms of unpleasantness in the sexual sphere appear. Familiarize them with methods of preventing sexually transmitted infections, minimizing stress, and the need for adequate nutrition.

The diet of a woman of childbearing age should be two-thirds of herbal products - vegetables, fruits, legumes, cereals. A third should be protein products - meat, fish, dairy. Estrogen deficiency is associated with deficiency in the body of zinc and copper, so in the diet must necessarily be eggs, liver, bran seafood and whole wheat bread, leafy vegetables green (raw).

[30], [31], [32]

Forecast

Medicine today has enough resources to help women with ovulatory cycle disorders. Anovulation is not a verdict, but before treating this pathology with hormonal therapy, it is necessary to carefully examine and try more sparing methods, for example, yoga.

[33], [34]