Leuprolide UWorld

[Enzymes]

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Question ID 208 from UWorld, for those interested.

I realize that a pulsatile pulse for GnrH agonists can help with infertility via promoting ovulation, but why is dysfunctional uterine bleeding incorrect? Wouldn't anovulatory cycles (due to lack of LH and FSH stimulation) be corrected by pulsatile leuprolide? Thanks for any help.

 

[J ROD]

Question ID 208 from UWorld, for those interested.

I realize that a pulsatile pulse for GnrH agonists can help with infertility via promoting ovulation, but why is dysfunctional uterine bleeding incorrect? Wouldn't anovulatory cycles (due to lack of LH and FSH stimulation) be corrected by pulsatile leuprolide? Thanks for any help.

It would need to be continuous. Usually as a depot that slowly releases the medication.

Similarly, leuprolide acetate (Eligard, Lupron, Viadur) is used off-label to induce a hypogonadotropic state and amenorrhea. Danazol or leuprolide acetate may be prescribed prior to endometrial resection or ablation or hysterectomy, as they promote endometrial atrophy.

 

[thehundredthone]

Question ID 208 from UWorld, for those interested.

I realize that a pulsatile pulse for GnrH agonists can help with infertility via promoting ovulation, but why is dysfunctional uterine bleeding incorrect? Wouldn't anovulatory cycles (due to lack of LH and FSH stimulation) be corrected by pulsatile leuprolide? Thanks for any help.

Effectively making the patient ovulate is not the most practical solution for DUB where the problem is the bleeding and not the anovulation. In fact, in anovulatory cycles, estrogen production is intact and that is the cause of DUB. That's why we ablate the HPOA completely by giving continuous GnRH so that there is no FSH and thus no more estrogen production, essentially chemical menopause.

 

[Enzymes]

But what if the bleeding was due to anovulation? Then you would want to treat the anovulation, right? I thought anovulation was treated with fertility drugs, like clomiphene. The problem in anovulation is that you are not ovulating (obviously), so you cannot produce progesterone. Estrogen is fine, but isn't really the problem. It is the buildup of estrogen hitting the uterine wall, without progesterone relief. So to treat anovulatory cycles, you would obviously want to promote ovulation (am I correct)?

I was thinking that dysfunctional uterine bleeding can have many etiologies, so that pulsatile GnRH is probably not a good choice. It is not necessarily anovulation.

 

[Lavan]

Clomiphene is used to help induce ovulation only for patients trying to get pregnant (say with PCOS). It's not a bleeding treatment, and isn't used as a long term treatment for anovulation per se.

 

[J ROD]

Clomiphene is used to help induce ovulation only for patients trying to get pregnant (say with PCOS). It's not a bleeding treatment, and isn't used as a long term treatment for anovulation per se.

I have not read the question but clomiphene is not a GnRH analog. It is an antagonist at estrogen receptors in hypothalamus. Not the same thing.

 

[thehundredthone]

But what if the bleeding was due to anovulation? Then you would want to treat the anovulation, right? I thought anovulation was treated with fertility drugs, like clomiphene. The problem in anovulation is that you are not ovulating (obviously), so you cannot produce progesterone. Estrogen is fine, but isn't really the problem. It is the buildup of estrogen hitting the uterine wall, without progesterone relief. So to treat anovulatory cycles, you would obviously want to promote ovulation (am I correct)?

I was thinking that dysfunctional uterine bleeding can have many etiologies, so that pulsatile GnRH is probably not a good choice. It is not necessarily anovulation.

Actually, when there's no progesterone relief, is when we use progesterone. Besides, if the bleeding is due to anovulation, why hit the pituitary instead of the ovaries? You would want to pinpoint the cause of anovulation along HPOA and then target therapy. Again though, the symptom to be addressed is the bleeding, not the ovulation. We don't need to mess around with that unless the patient is looking to conceive. When the bleeding can be controlled simply by adding the progesterone that is lacking, there's no need to use a drug that would alter the HPOA.

Yes, the approach to DUB is dependent on the cause, as are most therapies in medicine.