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Phase 1b - Endocrinology > Reproductive Treatments > Flashcards

Reproductive Treatments Flashcards

1
Q

What is the treatment of a testosterone deficiency in a male not desiring fertility?

A

Testosterone replacement:
* Daily Gel. Care not to contaminate partner.
* 3 weekly intramuscular injection
* 3 monthly intramuscular injection
* Less Common (Implants, oral preparations)

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2
Q

When is testosterone replacement recommended?

A

To treat men with low testosterone (Hypogonadism)
* Investigate the cause of low testosterone

Treat Symptoms:
* Loss of early morning erections
* Libido
* Decreased energy
* Shaving

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3
Q

How can one confirm male hypogonadism?

A

Confirm at least 2 low fasting measurements of serum testosterone in morning

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4
Q

What are the associated risks with testosterone replacement therapy?

A
  • Increased haematocrit (risk of hypervicsosity and stroke) due to stimulation of erythropoietin (EPO) receptors
  • Measure prostate specific antigen (PSA) levels
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5
Q

What is the treatment of a testosterone deficiency in a male desiring fertility?

A
  • Gonadotrophins (i.e. LH and FSH) needed to induce spermatogenesis
    • hCG injections (which act on LH-receptors)
    • If no response after 6 months, then add FSH injections

Secondary Hypogonadism: deficiency of gonadotrophins (LH/FSH)

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6
Q

What is the use of a LH treatment in a male desiring fertility?

A

LH stimulates Leydig cells to increases intratesticular testosterone levels much higher than in circulation (x100)

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7
Q

Which receptors do HCG injections stimulate?

A
  • LH receptors on Leydig cells
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8
Q

What is the use of an FSH treatment in a male desiring fertility?

A

FSH stimulates seminiferous tubule development & spermatogenesis

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9
Q

How is ovulation restored in patients living with Polycystic Ovary Syndrome (PCOS) (5)?

A
  • Lifestyle / Weight Loss 5%
  • Metformin
  • Letrozole (Aromatase inhibitor)
  • Clomiphene (Oestradiol receptor modulator)
  • FSH stimulation
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10
Q

How is ovulation restored in patients living with hypothalamic amenorrhoea (5)?

A
  • Lifestyle / Weight gain / reduce exercise
  • Pulsatile GnRH pump
  • FSH stimulation
  • Letrozole (Aromatase inhibitor)
  • Clomiphene (Oestradiol receptor modulator)
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11
Q

Why should one avoid giving testosterone treatment to men desiring fertility?

A

Giving testosterone treatment could further reduce LH / FSH via negative feedbackand worsen spermatogenesis

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12
Q

What are the steps of invitro fertilisation (IVF) (6)?

A
  1. FSH stimulation (superovulation)
    • Egg retrieval
  2. Prevent premature ovulation, by preventing a premature LH surge
    • Use GnRH antagonist
  3. Exposure of cell to LH, leading to maturation of egg
  4. Fertilisation in vitro
  5. Egg maturation
  6. Implantation
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13
Q

What is the aim of ovulation induction?

A

Aim to develop one ovarian follicle, to increase FSH by a small amount

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14
Q

Upon egg retrieval which hormone is exposed to the eggs for maturation?

A
  • LH
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15
Q

Which hormone is used to trigger egg maturation?

A

hCG

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16
Q

If there is a male factor of infertility how does IVF take place?

A
  • Intra-cytoplasmic injection of sperm (ICSI)
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17
Q

What are the common forms of contraception (Male 2 / Female 6)?

A
  • Male:
    • Barrier:
      • Condom
    • Permanent:
      • Vasectomy
  • Female:
    • Barrier:
      • Diaphragm or cap with spermicide
    • Medication:
      • Combined oral contraceptive pill (OCP)
      • Progesterone-only (Pill)
    • Long acting reversible contraception (LARC)
    • Emergency contraception
    • Permanent: Hysterectomy / Salpinectomy
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18
Q

What are the advantages of condoms (3)?

A
  • Protection against STIs
  • Easy to obtain - free from clinics / No need to see a healthcare professional
  • No contra-indications
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19
Q

What are the disadvantages of condoms (4)?

A
  • Can interrupt sex
  • Can reduce sensation
  • Can interfere with erections
  • Some skill to use
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20
Q

What hormones are within the oral contraceptive pill?

A
  • Oestrogen and progesterone
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21
Q

How do combined oral contraceptive pills work?

A
  • Anovulation
    • Progesterone causes the thickening of the cervical mucous, prevent sperm penetration, and thinning of the endometrial lining to reduce implantation
    • Oestrogen exerts negative feedback on GnRH hypothalamic neurones and gonadotrophs within the pituitary gland, this reduced LH and FSH secretion leading to anovulation
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22
Q

What are the contraceptive benefits of using OCPs (6)?

A
  • Easy to take - one pill a day (any time of the day)
  • Effective
  • Can take several packets back-to-back and avoid withdrawl bleeds
  • Doesn’t interrupt sex
  • Reduce endometrial and ovarian cancer
  • Weight neutral in 80%
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23
Q

What are the disadvantages of using OCPs (5)?

A
  • It can be difficult to remember
  • No protection against STIs
  • P450 enzyme inducers may reduce efficacy
  • Not the best choice during breast feeding
  • Possible side effects
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24
Q

What are the possible side effects of using OCPs (6)?

A
  • Spotting (bleeding between periods)
  • Nausea
  • Sore breasts
  • Changes in mood or libido
  • Feeling more hungry
  • Extremely rare: Blood clots in the legs or lungs
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25
Q

In what comorbidities should OCP be avoided because of risk of venous thromboembolism (VTE) / CVD / Stroke (6)?

A
  • Migraine with aura (Risk of stroke)
  • Smoking (> 15 / day) + age > 35 years
  • Stroke or CVD history
  • Current breast cancer
  • Liver cirrhosis
  • Diabetes with retinopathy / nephropathy / neuropathy
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26
Q

What are the non-contraceptive benefits of using OCPs (3)?

A
  • Help reduce LH and hyperandrogenism
    • PCOS
  • Helps makes periods lighter and less painful
    • Endometriosis / Fibroids
    • Menorrhagia / Dysmenorrhoea
  • Regular Withdrawal Bleeds / or no Bleeds
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27
Q

Which enzymes reduce the efficacy of oral contraceptive piill?

A

P450

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28
Q

What are the advantages of progesterone only pill (POP) (7)?

A
  • Works as OCP but less reliably inhibits ovulation
  • Often suitable if one cannot take oestrogen
  • Easy to take - one pill a day
  • It doesn’t interrupt sex
  • Can help heavy & painful periods
  • Periods may stop temporarily
  • Can be used during breastfeeding
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29
Q

What are the disadvantages of progesterone only pill (POP) (4)?

A
  • Can be difficult to remember
  • No protection against STIs
  • Short acting - needs to be taken at the same time every day
  • Possible side effects
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30
Q

What are the possible side effects of progesterone only pill (POP) (5)?

A
  • Irregular bleeding
  • Headaches
  • Changes in mood
  • Changes in libido
  • Sore breasts
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31
Q

Which contraceptive pill can be used by breastfeeding women?

A
  • Progesterone only pill
32
Q

What are the 3 forms of long-acting reversible contraceptives (LARCs) for women?

A
  • Intra-uterine device (IUD) (copper coil)
  • Intra-uterine system (IUS) which secretes progesterone (Mirena coil)
  • Progesterone-only injectable contraceptives or subdermal implants
33
Q

What are the benefits with using a coil (IUD / IUS)?

A
  • Coils are suitable for most women including Nulliparous (no previous children)
  • Exclude STIs and cervical screening up to date before insertion
  • Prevent implantation of conceptus - important for some religions
  • Rarely can cause ectopic pregnancy
  • Can be used as emergency contraception
34
Q

What are IUDs?

A

Copper coils that mechanically prevent implantation and decrease sperm egg survival (lasts 5-10 years)

35
Q

What are the advantages of IUD (3)?

A
  • Mechanically prevent implantation
  • Decreases sperm / egg survival
  • Lasts 5-10 years
36
Q

What are the disadvantages of IUD (2)?

A
  • Can cause heavy periods
  • 5% can come out especially during first 3 months with period
37
Q

What is the main risk with using an IUD?

A
  • Can cause heavy periods and 5% come out during the first 3 months
38
Q

What is an IUS?

A
  • An intra-uterine system which secretes progesterone (Mirena coil), thinning the lining of the womb and thickens cervical mucous
39
Q

What are the advantages of IUS (3)?

A
  • Thinning lining of the womb
  • Thicken cervical mucus
  • Lasts 3-5 years
40
Q

What are the three forms of emergency contraception?

A
  • IUD
  • Pill - Ulipristal acetate
  • Levonorgestrel
41
Q

What is the most effective emergency contraception?

A
  • Copper intrauterine device (IUD)
42
Q

Which emergency contraception is least effective?

A
  • Levonorgestrel, least effective especially if the BMI > 27
43
Q

How can copper coils be used as emergency contraception?

A

Can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)

44
Q

What is within an emergency contraceptive pill?

A
  • Ulipristal acetate 30mg
45
Q

What are the side effects with using the morning after pill (4)?

A
  • Headache
  • Abdominal pain
  • Nausea
  • Can vomit within 2-3 hours of taking it - may need to take another
46
Q

How does the emergency contraceptive pill work?

A

Delays ovulation

47
Q

Which types of medications makes taking the emergency contraceptive pill ineffective (2)?

A
  • Liver p450 enzyme inducer
  • Tetrogenic (lithium or warfarin) drugs
48
Q

Until how many days after unprotected intercourse, does the morning after pill become ineffective?

A

5 days

49
Q

What is levonorgestrel?

A
  • Synthetic progesterone prevents ovulation
    • Taken within 3 days of unprotected intercourse for emergency contraception
50
Q

What is levonelle, emergency contraceptive pill?

A
  • Synthetic progesterone prevents ovulation, must be taken within 3 days of unprotected intercourse
51
Q

What are the benefits of HRT (5)?

A
  • Relief of symptoms of low oestrogen
    • ​Flushing
    • Disturbed sleep
    • Decreased libido
    • Low mood
  • Less osteoporosis (decreased by one third)
52
Q

What are the risks with hormone replacement therapy (3)?

A
  • Venous thrombo-embolism (VTE) - ​Deep vein thrombosis / Pulmonary embolism
    1. Oral oestrogens undergo first pass metabolism in liver
    2. Oral can increase SHBG, triglycerides and CRP
  • Hormone sensitive cancers
    • ​Breast cancer
    • Ovarian cancer
    • Endometrial cancer
  • CVD
  • Risk of Stroke
53
Q

Which is the most preferable form of HRT?

A
  • Transdermal oestrogens

Transdermal estrogens are safer for VTE risk than oral
Avoid oral oestrogens in BMI > 30 kg/m2

54
Q

Above what BMI range are oral oestrogen not recommended?

A
  • > 30kg/m2
55
Q

In what age group is the risk of cardiovascular disease greater with the use of HRT?

A
  • Above the age of 60
    • Increased risk if HRT is started 10 years after menopause
56
Q

Which is the highest risk associated with oestrogen only HRT?

A
  • Endometrial cancer
57
Q

What supplement reduces the risk of endometrial cancer in HRT?

A
  • Prescribe progestogens in all women with an endometrium
58
Q

Which type of HRT increases the risk of breast cancer?

A
  • Continuous combined HRT (oestrogen and progesterone)
    • Risk is related to duration of treatment
59
Q

Which is the highest risk associated with combined oral HRT?

A
  • Breast cancer
60
Q

What is gender?

A

Social Construct, how you see yourself as male, female, or non-binary

61
Q

What is non-binary?

A
  • Gender does not match to traditional binary gender understanding. Includes agender, bigender, pangender, and gender fluid
62
Q

What is cisgender?

A
  • Same sex and gender
63
Q

What is gender non-confirming?

A
  • Gender does not match assigned sex
64
Q

What is gender dysphoria?

A
  • When gender causes depression
65
Q

What is the management for prepubertal young people undergoing gender transformation?

A
  • GnRH agonist for pubertal suppression and then sex steroids
  • Gender reassignment surgery
66
Q

What hormones are given to transgender men?

A
  • Testosterone (injections, gels)
  • Progesterone to suppress menstrual bleeding if needed (endometrial hyperplasia 15%)
67
Q

Within 1 to 6 months what are the effects of hormonal therapy in transgender men (8)?

A
  • Balding (depending on your age and family pattern)
  • Deeper voice
  • Acne
  • Increased and coarser facial and body hair
  • Change in the distribution of your body fat
  • Enlargement of the clitoris
  • Menstrual cycle stops
  • Increased muscle mass and strength
68
Q

What are the side effects with testosterone supplements in transgender men (3)?

A
  • Polycythaemia
  • Lower HDL
  • Obstructive Sleep Apnoea (OSA)
  • No increase in CVD
69
Q

What should be prescribed to transgender males to suppress menstrual bleeding?

A
  • Progesterone
70
Q

What hormones are given for transgender women?

A
  • To Reduce Testosterone:
    • GnRH agonists (induce desensitisation of HPG axis)
    • Anti-Androgen medications
  • Oestrogen (transdermal, oral, intramuscular)
    • High dose oestrogen eg 4-5mg per day (side-effects: higher risk of VTE 2.6%)
71
Q

How is testosterone reduced in transgender women?

A
  • GnRH agonists (induce desensitisation of HPG axis)
  • Anti-androgen medications (crypterone acetate, spirnolactone)
72
Q

What happens to transgender women during the first 3 months (2)?

A
  • Decrease in sexual desire / function (erections)
  • Baldness slows
73
Q

What happens in 3-6 months for transgender women (4)?

A
  • Soft skin
  • Change in body fat distribution
  • Decrease in testicular size
  • Breast development / tenderness
74
Q

What will not change in transgender women undergoing hormonal therapy (3)?

A
  • Height
  • Voice
  • Adam’s apple
75
Q

How long does it take for hair to become softer and finer in transgender women?

A
  • 6 to 12 months

Phase 1b - Endocrinology (19 decks)

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