Editing Anovulation (section)

==Treatments==
Treatment should be based on diagnosis of anovulation. Treatment varies based on the 4 most common causes of anovulation: polycystic ovarian syndrome (PCOS), hypogonadotropic hypogonadism (HA), primary ovarian insufficiency (POI), and hyperprolactinemia.<ref name=":6">{{Cite journal|date=2012-12-01|title=Management of anovulatory infertility|url=https://www.sciencedirect.com/science/article/abs/pii/S1521693412000909|journal=Best Practice & Research Clinical Obstetrics & Gynaecology|language=en|volume=26|issue=6|pages=757–768|doi=10.1016/j.bpobgyn.2012.05.004|issn=1521-6934|last1=Li|first1=Raymond Hang Wun|last2=Ng|first2=Ernest Hung Yu|pmid=22703626|hdl=10722/167096|hdl-access=free}}</ref>  Importantly, semen analysis should be carried out of the XY partner to exclude severe XY factors before managing anovulatory subfertility.<ref name=":6" /> Overall, in healthy individuals with anovulation, ovulatory disorders may be favorably influenced by a [[healthy diet]] such as a higher consumption of [[monounsaturated fat]]s rather than [[trans fat]]s, vegetable rather than animal protein sources, high fat dairy, multivitamins, and iron from plants and supplements.<ref name="ChavarroRich-Edwards2007" />{{Secondary source needed|date=September 2021}}

===Treatment for polycystic ovarian syndrome (PCOS)===
{{Further|Infertility in polycystic ovary syndrome}}
Treatment for management of anovulation due to PCOS is multifaceted, including weight reduction, ovulation induction agents, insulin-sensitizing agents, gonadotrophins and ovarian drilling. In PCOS patients with overweight or obesity, weight loss is first line treatment. Studies show a reduction in weight as little of 5% by caloric restriction and increased physical activity can re-establish spontaneously ovulation and improve response to ovulation induction therapy if initiated.<ref>{{Cite journal|date=2008-03-01|title=Consensus on infertility treatment related to polycystic ovary syndrome|journal=Human Reproduction|volume=23|issue=3|pages=462–477|doi=10.1093/humrep/dem426|pmid=18308833|issn=0268-1161|author1=Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group|doi-access=}}</ref><ref>{{Cite journal|last1=Moran|first1=Lisa J.|last2=Pasquali|first2=Renato|last3=Teede|first3=Helena J.|last4=Hoeger|first4=Kathleen M.|last5=Norman|first5=Robert J.|date=2009|title=Treatment of obesity in polycystic ovary syndrome: a position statement of the Androgen Excess and Polycystic Ovary Syndrome Society|journal=Fertility and Sterility|volume=92|issue=6|pages=1966–1982|doi=10.1016/j.fertnstert.2008.09.018|pmid=19062007|issn=0015-0282|doi-access=free}}</ref> [[Weight loss]] also generally results in improved menstrual regularity and pregnancy rates in women with PCOS.<ref name="Hamilton-Fairley2003">{{cite journal|last1=Hamilton-Fairley|first1=D.|title=Anovulation|journal=BMJ|volume=327|issue=7414|year=2003|pages=546–549|issn=0959-8138|doi=10.1136/bmj.327.7414.546|pmid=12958117|pmc=192851}}</ref>

It is well recognized that insulin resistance can be part of the sequelae of PCOS and if present, contribute to anovulation. Metformin, a biguanide, is a common insulin sensitizer often given to treat women with PCOS.<ref name=":6" /> No other insulin sensitizers have evidence of effective and safe use of fertility treatment.<ref name=":6" /> Previously, [[metformin]] was recommended as treatment for [[anovulation in polycystic ovary syndrome]], but in the largest trial to date, comparing clomiphene with metformin, clomiphene was more effective than metformin alone.<ref name=":2" /> Following this study, the ESHRE/ASRM-sponsored A consensus workshop does not recommend metformin for ovulation stimulation.<ref name="pmid18243179">{{cite journal|author=Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group|date=March 2008|title=Consensus on infertility treatment related to polycystic ovary syndrome|journal=Fertil. Steril.|volume=89|issue=3|pages=505–522|doi=10.1016/j.fertnstert.2007.09.041|pmid=18243179}}</ref> Subsequent randomized studies have confirmed the lack of evidence for adding metformin to clomiphene.<ref>{{cite journal|author=Johnson NP|author2=Stewart AW|author3=Falkiner J|last4=Farquhar|first4=C. M.|last5=Milsom|first5=S.|last6=Singh|first6=V.- P.|last7=Okonkwo|first7=Q. L.|last8=Buckingham|first8=K. L.|last9=React-Nz (Reproduction And Collaborative Trials In New Zealand)|first9=a Multi-Centre Fertility Trials Group|display-authors=3|name-list-style=vanc|date=April 2010|title=PCOSMIC: a multi-centre randomized trial in women with PolyCystic Ovary Syndrome evaluating Metformin for Infertility with Clomiphene|journal=Hum Reprod|volume=25|issue=7|pages=1675–1683|doi=10.1093/humrep/deq100|pmid=20435692|doi-access=}}</ref>

==== Ovulation induction ====
{{Main|Ovulation induction}}
The main [[ovulation induction]] medications include:
*[[Antiestrogen]], causing an inhibition of the [[negative feedback]] of estrogen on the [[pituitary gland]], resulting in an increase in secretion of [[follicle-stimulating hormone]]. Medications in use for this effect are mainly [[clomifene citrate]] and [[tamoxifen]] (both being [[selective estrogen-receptor modulator]]s), as well as [[letrozole]] (an [[aromatase inhibitor]]).<ref name=":6" />
*[[Follicle-stimulating hormone]] (FSH), directly stimulating the ovaries. In women with anovulation, it may be an alternative after 7–12 attempted cycles of pituitary feedback regimens (as evidenced by clomifene citrate), since the latter ones are less expensive and more easy to control.<ref name="WeissBraam2014">{{cite journal|last1=Weiss|first1=N. S.|last2=Braam|first2=S.|last3=Konig|first3=T. E.|last4=Hendriks|first4=M. L.|last5=Hamilton|first5=C. J.|last6=Smeenk|first6=J. M. J.|last7=Koks|first7=C. A. M.|last8=Kaaijk|first8=E. M.|last9=Hompes|first9=P. G. A.|last10=Lambalk|first10=C. B.|last11=van der Veen|first11=F.|last12=Mol|first12=B. W. J.|last13=van Wely|first13=M.|title=How long should we continue clomiphene citrate in anovulatory women?|journal=Human Reproduction|volume=29|issue=11|year=2014|pages=2482–2486|issn=0268-1161|doi=10.1093/humrep/deu215|pmid=25164024|doi-access=free}}</ref>

=== Treatment for hypogonadotropic hypogonadism (HA) ===
In women with hypogonadotropic hypogonadism suspicious for functional hypothalamic amenorrhea, treatment should be centered around weight gain, reducing intensity and frequency of exercise, and stress reduction with psychotherapy or counseling.<ref name=":6" /> Athletes and women with anorexia can have reduced GnRH pulsing due to hypothalamic dysfunction due to increased energy requirements without their needs being met calorically and severely reduced caloric intake, respectively.<ref>{{Cite journal|last1=Sharma|first1=Rakesh|last2=Biedenharn|first2=Kelly R|last3=Fedor|first3=Jennifer M|last4=Agarwal|first4=Ashok|date=2013|title=Lifestyle factors and reproductive health: taking control of your fertility|journal=Reproductive Biology and Endocrinology|language=en|volume=11|issue=1|pages=66|doi=10.1186/1477-7827-11-66|issn=1477-7827|pmc=3717046|pmid=23870423 |doi-access=free }}</ref> If anovulation persists following lifestyle modifications, ovulation can be induced with pulsatile gonadotrophin-releasing hormone (GnRH) or gonadotrophin (FSH & LH) administration.<ref name=":6" />

=== Treatment for primary ovarian insufficiency (POI) ===
For women with POI that desire pregnancy, ovulation induction strategies should be avoided and assisted reproduction, such as in vitro fertilization (IVF) with donor oocytes, should be offered.<ref name=":6" />

=== Treatment for hyperprolactinemia ===
For anovulatory women with hyperprolactinemia without symptoms, they can forgo treatment and continue with close follow up and medical observation.<ref name=":6" /> If symptoms of hyperprolactinemia are present, dopamine agonists, such as bromocriptine, are first line treatment which act by inhibiting production of [[prolactin]] by the pituitary and can shrink a prolactin-secretin lesion (i.e. prolactinoma) if present.<ref name="palomba2004">{{cite journal|author=Palomba S|author2=Orio F|author3=Nardo LG|last4=Falbo|first4=A|last5=Russo|first5=T|last6=Corea|first6=D|last7=Doldo|first7=P|last8=Lombardi|first8=G|last9=Tolino|first9=A|display-authors=3|name-list-style=vanc|date=October 2004|title=Metformin administration versus laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: a prospective parallel randomized double-blind placebo-controlled trial|journal=J. Clin. Endocrinol. Metab.|volume=89|issue=10|pages=4801–4809|doi=10.1210/jc.2004-0689|pmid=15472166|doi-access=free}}</ref> In rare cases, endoscopic transnasal transsphenoidal surgery and radiotherapy, may be required to resect and shrink a prolactinoma if greater than 10&nbsp;mm in size. Importantly, individuals should be able to conceive following normalization of serum prolactin levels and shrinking or removal of the tumor.<ref name=":6" />

===Other treatments===
[[Corticosteroids]] (usually found in anti-inflammatory drugs) can be used to treat anovulation if it is caused by an overproduction of [[male hormones]] by the [[adrenal glands]]. Corticosteroids are usually used to reduce the production of [[testosterone]].