Hyperprolactinemia and Other Ovulation Disorders
Hyperprolactinemia and other ovulation disorders overview
- Ovulation disorders, which are the absence or disruption of normal ovulation with each menstrual cycle, are the cause of approximately 25 percent of infertility cases in couples.
- These disorders are caused by problems either in the ovaries and/or problems with the hypothalamus and pathways regulating reproductive hormones necessary for ovulation (the release of an egg for possible fertilization).
- The primary symptoms of ovulation disorders are irregular menstruation, no menstruation and infertility.
- We detect ovulation disorders through discussions with a woman about her periods and health history, through blood tests (such as the test for anti-Müllerian hormone or AMH level) and by using ultrasound to evaluate the ovaries.
- Treatment for ovulation disorders generally involves lifestyle changes and medication, with assisted reproductive technologies if treatment fails.
What are ovulation disorders?
Ovulation disorders are the disruption or absence of ovulation. According to the World Health Organization, ovulation disorders are the cause of about 25 percent of the cases of infertility in couples. This is because a mature egg is necessary for conception, and ovulation disorders interfere with the normal ovulation of the egg.
Following are the primary types of ovulation disorders:
- Hypothalamic dysfunction.
- Luteal phase defect.
- Primary ovarian insufficiency.
- Hormonal imbalances (including PCOS and anovulation).
What causes ovulation disorders?
For ovulation to occur, the ovaries have to be in good condition and essential reproductive hormones need to be present in the proper amounts and the correct balance with each other. Problems in either of these areas can cause ovulation disorders. Some lifestyle factors, medications and health conditions can also cause or contribute to ovulation disorders.
A woman’s endocrine system prepares her body for pregnancy through the release of certain hormones regulated by the hypothalamus and pituitary glands. The primary hormones in this regard are:
- Gonadotropin-releasing hormone (GnRH), which also plays a role in egg maturation.
- Follicle stimulating hormone (FSH), involved in causing the egg to mature in the ovary.
- Luteinizing hormone (LH), which causes the ovary to release the mature egg.
- Prolactin, which signals the body to produce breast milk.
- Estrogen, which promotes a healthy menstrual cycle.
- Progesterone, which helps with a healthy uterine lining as well as protecting the fetus.
Regular ovulation occurs once during a woman’s menstrual cycle. A deficient amount of the hormones above, or an imbalance of the mix of those hormones, can cause infrequent ovulation or no ovulation, known as anovulation.
Ovulation disorder symptoms
The primary symptoms of these disorders are irregular periods, absence of a period and problems conceiving (infertility). The woman’s periods may be infrequent, unusually frequent or occur at irregular times in her cycle.
The length of a menstrual cycle is the number of days between the first day of a woman’s period and the first day of her next period. The average length of a menstrual cycle is 28 days, although it is considered normal to have periods 21-35 days apart. Having periods outside of these ranges or inconsistently may be a sign of an ovulation disorder.
Some of the ovulation disorders listed further below may present with additional specific symptoms.
Ovulation tests for ovulation disorders
Women with the symptoms above should consult with their primary care physician, gynecologist or a fertility specialist to set up an ovulation test to see if they have a disorder. Women having trouble getting pregnant should consult with a fertility specialist.
The physician will talk with the woman about her menstrual cycles as well as her overall health and other issues that may be at play. Those could be high levels of stress, being overweight and taking certain medications. A thorough pelvic exam may be a part of this ovulation test.
Blood testing will also likely be performed to evaluate hormones including FSH, LH, AMH, prolactin, estradiol, testosterone and GnRH. An ultrasound scan may be performed to evaluate the condition of the ovaries. The physician may also want to conduct a CT scan or MRI of the hypothalamus and/or pituitary gland.
Below is a list of common ovulation disorders and descriptions of associated symptoms and causes.
Hyperprolactinemia is an over production of the hormone prolactin, which is responsible for milk production in women and can disrupt ovulation. An abundance of prolactin can lessen estrogen production, causing infertility directly, and affect levels of testosterone.
This ovulation disorder is most often related to a problem with the pituitary gland. Hyperprolactinemia can be caused by pregnancy, a tumor that produces prolactin (prolactinoma) and by certain medications, mostly those taken for psychiatric treatments but also medications for high blood pressure, nausea and pain (opiate drugs).
Symptoms for women are problems with menstruation (no period or irregular periods), vaginal dryness and producing breast milk when they are not pregnant.
A blood test can usually detect elevated levels of prolactin, and if hyperprolactinemia is suspected, additional blood work can be performed. If a tumor is the suspected cause, an MRI of the brain and pituitary gland is in order.
Treatments depend on the cause of the hyperprolactinemia. Medications can reduce prolactin levels. If a tumor is the cause, radiation and surgery are options for treatment.
Hypothalamic dysfunction is a malfunctioning of the hypothalamus, a region in the brain that controls the pituitary gland and regulates various functions in the body. Hypothalamic amenorrhea is an absence of menstruation caused by hypothalamic dysfunction.
The most common symptoms of hypothalamic dysfunction are irregular or absent periods. Hypothalamic dysfunction can be due to surgery, tumors, radiation, brain injury and genetic conditions. It can also be caused by recent and severe weight loss or gain, excess physical and emotional stress, nutritional deficiencies, and a high or very low body weight.
The latter issues can be addressed by lifestyle changes such as weight loss and stress reduction techniques. Most causes of hypothalamic dysfunction are treatable, from simple lifestyle changes to medications that can regulate or replace hormones to surgery to remove a tumor in the brain.
Luteal phase defect
This ovulation disorder occurs during the luteal phase of the menstrual cycle when ovulation takes place. Luteal phase defect is when the endometrium, the lining of the uterus, doesn’t thicken enough to maintain attachment of an embryo to become pregnant or to properly maintain that pregnancy. This may be due to insufficient progesterone being produced by the ovaries or because the endometrium isn’t responding to the progesterone.
Symptoms include spotting of blood between periods, more frequent periods, miscarriage and infertility. Luteal phase defect can be difficult to diagnose, but blood tests can evaluate levels of LH, FSH and progesterone. Pelvic ultrasound can determine the thickness of the endometrium, which can indicate luteal phase defect.
Women who are trying to become pregnant or wish to in the future can take medications with guidance from a physician to help stimulate their ovaries’ follicles and to trigger ovulation. These include clomiphene citrate (Clomid) and human chorionic gonadotropin. After ovulation, progesterone can be given to promote growth of the endometrium.
Primary ovarian insufficiency
Also called premature ovarian failure, primary ovarian insufficiency (POI) is when a woman’s ovaries stop working before she begins menopause, normally before age 40. The exact cause of primary ovarian insufficiency, a defect of the ovaries, isn’t known in about 90 percent of cases.
The cause is thought to be related to the ovary follicles, which is where eggs grow and mature before ovulation. Whether primary ovarian insufficiency is related to problems in the follicles or an earlier than normal drop in the number of follicles is unknown.
Causes of the problem may be related to genetic disorders, autoimmune disease, radiation or chemotherapy, and toxins such as cigarette smoke and pesticides. Women between the ages of 35 and 40 are at higher risk of premature ovarian insufficiency. POI may cause other medical problems for women besides ovulation disorders.
Women often seek medical attention for premature ovarian insufficiency when they have trouble getting pregnant. Other symptoms for this condition include hot flashes, vaginal dryness, irritability and decreased sex drive.
POI is usually diagnosed by reviewing the woman’s medical history, pelvic exam, blood tests and ultrasound. There is no proven treatment to restore normal ovarian function for women with POI. Treatments address the symptoms. These include hormone replacement therapy, calcium supplements, maintaining a healthy weight and regular exercise. If a woman with POI wishes to become pregnant, in vitro fertilization (IVF) using donor eggs is a good option.
Other types of ovulation disorders
Hormonal imbalance is itself a form of ovulation disorder, as the improper balance of hormones is necessary for ovulation. The two most important aspects of hormonal imbalances affecting ovulation are PCOS and thyroid dysfunction, which generally involves irregularities in the thyroid hormones.
PCOS affects 6-12 percent of reproductive age women. PCOS is a condition where a woman’s mature eggs are prevented from release and turn into cysts.
Anovulation, or the absence of ovulation, makes it impossible for a woman to conceive, as she releases no eggs that could be fertilized by sperm. This is frequently caused by a hormonal imbalance.
A less common cause of ovulation disorders is autoimmune oophoritis. This is inflammation of the ovaries that destroys them.