Ovarian hyperthermia syndrome is a form of secondary amenorrhea, which is associated with prolonged suppression of the gonadotropic function of the pituitary gland, which occurs against the background of taking COCs. Symptoms are typical for women of reproductive age who have been using combined oral contraceptives for pregnancy protection for a long time. After the end of their intake, the ovulatory cycle does not recover for a long time, menstruation is absent. When diagnosing hyperthermia syndrome, they rely on anamnesis data, laboratory examination of hormone levels and ultrasound of the pelvic organs. Treatment is often not required, hormonal stimulation is prescribed according to indications.
ICD 10
E89.4 Ovarian dysfunction that occurred after medical procedures
General information
Ovarian hyperthermia syndrome when taking COCs occurs in 0.7% of cases, no direct dependence on the duration of drug use has been established. The frequency of amenorrhea caused by oral contraceptives is not higher than in other women who do not use this method of prevention. Ovarian hyperthermia is manifested in the presence of predisposition and genetically determined insufficient secretion of gonadotropin-releasing hormones. Pathology is more common in women with various hormonal abnormalities in the anamnesis, which indicate unstable functioning of the hypothalamic-pituitary-ovarian axis.
Causes
Ovarian hyperthermia syndrome most often develops when using 2nd generation COCs containing ethinyl estradiol and levonorgestrel in large doses. Also, iatrogenic amenorrhea associated with inhibition of ovarian function occurs during treatment with progestogenic drugs (norethisterone, medroxyprogesterone), androgen derivatives, gonadotropin-releasing hormone agonists. The causes of ovarian hyperthermia syndrome are associated with the following features:
- Premorbid background. Women with hyperthermia are characterized by late menarche, prolonged formation of the menstrual cycle in adolescence, ovarian dysfunction. Sometimes patients are worried about meager periods. The use of COC imposes a normal cycle and masks the existing problems.
- Infections. Transferred ARVI, infectious diseases of the nervous system, genitals during the formation of menstruation disrupt the work of the hypothalamus and pituitary gland, reduce the susceptibility of the ovaries to hormonal effects and cause hyperthermia in adulthood.
- Medicinal products. A high risk of secondary amenorrhea and hyperthermia due to the use of COCs is noted in women who are treated with reserpine, phenothiazine derivatives, who use narcotic drugs. Their effects are realized through a decrease in the content of dopamine, serotonin and other neurotransmitters in the neurons of the brain.
- Hyperprolactinemia. Ovarian hyperthermia is a consequence of depletion of catecholamine reserves and natural blockade of gonadotropins. There is a disinhibition of prolactin production and inhibition of ovarian function, which is accompanied by a decrease in follicle-stimulating hormone in the blood.
- Endocrine pathologies. Dysfunction of the adrenal cortex leads to an increase in testosterone, dihydroepiandrosterone in the blood, and the amount of 17-ketosteroids increases in the urine. Ovarian hyperthermia is observed in hypothyroidism, autoimmune thyroiditis.
Pathogenesis
The mechanism of the contraceptive action of COCs is associated with the suppression of ovulation by reducing the production of gonadotropins and releasing hormones. Also, with prolonged use of hormones, there is a decrease in the thickness of the endometrium. Ovarian hyperthermia develops as a consequence of a violation of the rhythm and synchronicity of gonadotropin emissions. Studies show that 23% of women with amenorrhea have depletion of catecholamine reserves, blockade of lyuliberin secretion. This ceases to restrain prolactin emissions. Therefore, with the abolition of COCs, hyperprolactinemia occurs in some patients, which is clinically manifested by galactorrhea.
Classification
Ovarian hyperthermia can manifest in two forms, depending on the severity of the syndrome and the reaction to hormone therapy. As a test, women are prescribed progestogens in a cyclic mode from the 5th to the 25th day of the menstrual cycle, it is also possible to conduct tests with a combination of estrogens with progestins. The reaction indicates one of the following types of hyper – inhibition:
- Incomplete hyper-inhibition. When hormones are prescribed, a menstrual-like reaction occurs, smearing secretions from the genital tract. But according to the results of ultrasound, there is no maturation of follicles or other signs of ovulation.
- Complete hyper-inhibition. The endometrium does not respond to the appointment of progestins or cyclic estrogen therapy in combination with progestins. This type is associated with a combination of pathology of the hypothalamic-pituitary system and uterus.
Symptoms
The cancellation of the hormonal agent leads to the development of menstrual-like bleeding. If a woman does not continue taking the drug after a 7-day break, menstruation does not begin in the next cycle. She may be absent for several months. At the same time, there are no vegetative symptoms, neuropsychiatric disorders caused by a lack of estrogens. Sometimes there is vaginal dryness, which is accompanied by pain during sexual intercourse. Ovulation does not occur, so the onset of pregnancy is impossible.
Complications
Treatment should be started if the menstrual cycle does not recover independently for 3 months after the end of the course of taking contraceptives, otherwise hyperthermia takes a stable form that is resistant to the appointment of hormone therapy. A complication is persistent secondary infertility, for the treatment of which it is impossible to apply methods of assisted reproductive technologies due to the lack of maturation of their own eggs.
Diagnostics
After the end of taking combined oral contraceptives, the menstrual cycle is normally restored immediately, but sometimes amenorrhea is possible within 2-3 months. If the symptoms have not disappeared, it is necessary to consult a gynecologist, if necessary, an endocrinologist or a neurosurgeon may be prescribed. The following diagnostic methods are used:
- Gynecological examination. The mucous membrane of the vagina, the cervix is not changed. There may be dryness, lack of mucus. Cracks at the entrance to the vagina occur as a result of sexual intercourse without lubricant. With a bimanual examination, the volume of the uterus is slightly less than normal, the ovaries are painless, their size is not changed.
- Ultrasound of the pelvis. The normal size of the uterus or its small hypoplasia is noted, the thickness of the endometrium is reduced to 5-6 mm. The size of the ovaries corresponds to the norm, multiple follicles with a diameter of 8-10 mm are visualized on their surface. There are no other pathological symptoms.
- Laboratory diagnostics. There is a decrease in the level of FSH and LH in the blood. Estradiol corresponds to the lower limit of the age norm. There is often an increase in prolactin, sometimes testosterone, dihydroepiandrostenedione in the blood. Biochemical changes are not characteristic.
- CT or radiography of the skull. The size of the TS, which can be reduced, is being investigated. This condition is characteristic of true pituitary hypofunction, which is not associated with ovarian hyperthermia when taking COCs. An increase in the Turkish saddle on the background of hyperprolactinemia may be an indicator of prolactinoma.
Treatment
For the treatment of this condition, hospitalization in the department of gynecology is not required. Menstruation occurs spontaneously within 3 months without special treatment. If this does not happen, conservative therapy with hormonal agents is carried out, the purpose of which is to restore ovulatory cycles.
- Gestagens. To stimulate menstruation, they are prescribed for 10 days from the 15th day of the cycle. After discontinuation of the drug, menstrual bleeding occurs. Oral forms of didrogesterone, natural micronized progesterone or its oil solution are used (in this case, 3-5 injections are made).
- Antiestrogens. Clomiphene citrate is used in tablets from 3 to 7 or from 5 to 9 days. It is recommended to prescribe after a cycle induced by progestogens. Ultrasound control of follicle maturation is required. To restore menstruation, 3-4 courses of folliculogenesis and ovulation stimulation are required.
- Dopamine receptor agonists. With an increased concentration of prolactin, bromocriptine or cabergoline is prescribed to reduce it. The dosage is selected individually, starting from the minimum, gradually increasing every 2-3 days. After the cycle is restored, dose reduction is also carried out gradually.
Prognosis and prevention
Ovarian hyperthermia syndrome passes independently or under the influence of treatment and usually does not affect reproductive function. In most women, fertility after taking oral contraceptives is restored within a year. Prevention of hyperthermia consists in a thorough examination before choosing a method of contraception, the use of modern drugs with minimal doses of hormones.
To maintain the work of the pituitary-hypothalamus system, it is necessary to avoid stress, heavy physical exertion, observe the daily routine and eat rationally. The lack of night sleep and mental overload negatively affect the functioning of the pituitary gland, so women with a predisposition to pathology are not recommended night shifts.
