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Clin Med III exam III > Menopause, Infertility and PCOS > Flashcards

Menopause, Infertility and PCOS Flashcards

1
Q

What is menopause

A

permanent cessation of menstruation, 12 months of amenorrhea without any pathological cause

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2
Q

What can cause premature menopause before the age of 40

A
  • primary ovarian insufficiency

- premature ovarian failure

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3
Q

What are the stages of menopause

A

preimenopause–> menopause—> post menopause

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4
Q

What is the pathophys behind menopause

A
  • decline in the quantity and quality of follicles and oocytes
  • granulosa cells stop making estrogen and inhibin–>loss of the negative feedback loop–> FSH and LG production increased with no response from the ovary
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5
Q

Signs and symptoms of menopause

A
  • vasomotor sx’s
  • sleep disturbances
  • mood changes
  • cognitive changes
  • breast pain/tenderness
  • joint aches and pains
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6
Q

PE findings of menopause

A
  • fusion/ resorption of labia minora
  • vagina–> atrophic, pale, lack of rugae, diminished elasticity, shorter/ narrower
  • cervix–>atrophic, decreases in size, flush with top of vaginal vault, can become stenotic
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7
Q

What are long term effects of menopause

A
  • dementia
  • cardiovascular disease
  • osteoperosis
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8
Q

Lifestyle modifications to treat menopause

A
  • lower room temp
  • use fans
  • dress in layers
  • avoid triggers
  • smoking cessation
  • exercise
  • weight loss
  • lubricants
  • vaginal dilators or intercourse
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9
Q

When is hormone replacement therapy indicated

A

women whose sx’s cannot be controlled by lifestyle modifications

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10
Q

Hormone replacement therapy is not indicated for what two things

A
  • long term use

- prevention of disease

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11
Q

Contraindications of hormone replacement therapy

A
  • CAD
  • VTE
  • CVA
  • TIA
  • liver/gallbladder disease
  • breast/endometrial cancer
  • unexplained vaginal bleeding
  • hypertriglyceridemia
  • known thrombophilias
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12
Q

Administration forms of estrogen for HRT

A
  • oral
  • transdermal
  • topical gels and lotions
  • intravaginal creams and tablets
  • vaginal rings
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13
Q

Why do you start on a low dose and then titrate with HRT

A

the lower doses have fewer effects on coagulation and inflammatory markers —> possible lower risk of stroke and VTE

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14
Q

Which type of estrogen is best for lipid profiles

A

oral 17-beta estradiol

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15
Q

Which medication for HRT has a lower risk for VTE and stroke

A

transdermal 17-beta estradiol

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16
Q

First line for HRT

A

oral micronized progesterone

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17
Q

All women with a uterus need ___ to prevent ___ (HRT)

A

need progestin to prevent endometrial hyperplasia

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18
Q

What are the side effects of progestin

A
  • mood changes

- bloating

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19
Q

Benefits of topical vaginal estrogen replacement

A
  • can be used indefinitely

- low risk for adverse effects

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20
Q

Topical vaginal estrogen only treats, ___ not ___

A

only treats vaginal atrophy, not hot flashes

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21
Q

What are SERMs used for

A

treatment of menopausal vasomotor sx’s and osteoperosis prevention

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22
Q

Do you need to give progestin with SERMs? Why or why not?

A

No because SERMs prevent estrogen induced endometrial hyperplasia

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23
Q

Which women are candidates for SERMs

A

women with moderate-to severe hot flashes who have breast tenderness w/ standard EPT
-women that cannot tolerate progestin therapy because of side effects

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24
Q

SERMs increase what risk

A

VTE risk

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25
Q

When are OCPs used for menopause

A
  • used in perimenopausal women who also desire contraception

- women who need control o fheavy bleeding

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26
Q

OCPs should be avoided in which women

A
  • obese d/t VTE risk

- hx of smoking, HTN or migraines

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27
Q

What are some non hormonal options for menopause treatment

A
  • clonidine
  • SSRIs (paroxeinte, fluoxetine)
  • venlafaxine
  • gabapentin
  • bellergal
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28
Q

What is infertility based on

A

fecundability

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29
Q

What is fecundability

A

the probability of being pregnant in a single menstrual cycle

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30
Q

What is primary infertility

A

inability to conceive in a couple who has never been pregnant

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31
Q

What is secondary infertility

A

inability to conceive in a couple with a hx of prior pregnancy

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32
Q

What type of work up is done for infertility

A
  • history and physical
  • evaluation of lifestyle
  • female evaluation
  • male evaluation
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33
Q

Labs to evaluate a female for infertility

A
  • TSH
  • prolactin
  • STI testing
  • prenatal screening
  • genetic testing
34
Q

Ovarian evaluation for infertility

A

-first need to confirm evaluation

Ovarian reserve testing

  • FSH and estradiol day 3 labs
  • clomiphene citrate challanges test
  • anti mullerian hormone
  • antral follicle count
35
Q

Uterine evaluation for infertility

A
  • hysterosalpingogram
  • hysterosalpingo contrast sonography
  • hysteroscopy
  • sonohystogram
  • pelvic US
  • laparoscopy
36
Q

What things are done for a male evaluation for infertility

A
  • scrotal US
  • semen analysis
  • STI testing
  • genetic testing
  • endocrine labs in indicated
37
Q

What is the most frequent cause of male infertility

A

oligiospermia

38
Q

What is oligiospermia

A

low concentration of sperm in ejaculate

39
Q

What is azoospermia

A

complete absence of sperm

40
Q

What is asthenospermia

A

abnormal sperm motility

41
Q

What is teratospermia

A

abnormal sperm morphology

42
Q

All infertility therapies center around what

A

manipulation of the physiologic HPO axis

43
Q

What are the two ways that the HPO axis can be manipulated

A
  • ovulation induction

- controlled ovarian stimulation

44
Q

What are the 3 classes of drugs used for ovulation induction

A
  • SERMs (clomiphene citrate, tamoxifen)
  • Aromatase inhibitors (letrozole)
  • dopamine agonist (bromocriptine, cabergoline)
45
Q

How does clomiphene cirtrae work

A

competes with estrogen in the body to bind with estrogen receptors–> inhibits and depletes the available receptors–> block the negative feedback of endogenous estrogen on hypothalamus—> higher plasma levels of FSH and LH–> stimulation of ovarian follicular growth

46
Q

What is the first line treatment for ovulation induction

A

clomiphene citrate

47
Q

What population is clomiphene citrate most successful in

A

women with oligio or anovulation who are normogonadotrophic

48
Q

When is clomiphere citrate given

A

in the early follicular phase

49
Q

If your patient is taking clomiphene citrate what should you monitor

A
  • urinary LH
  • retrospectively with basal body temperature charting
  • tranvaginal US
50
Q

Why are transvaginal US done on women that are taking clompihene citrate

A

to assess follicular response and timed administration of hCG to trigger ovulation

51
Q

When do pregnancy rates decrease with clomiphene citrate

A

after 6 cycles

52
Q

Side effects of clomiphene citrate

A
  • vasomotor sx’s
  • mood swings
  • visual sx’s (blurred or double vision)
53
Q

What are adverse effects of clomiphene citrate

A
  • miscarriage
  • birth defects
  • ovarian cancer if used for >12 months
  • increased risk of multiples
54
Q

Tamoxifen might increase the risk of what

A

miscarriage

55
Q

How do aromatase inhibitors work

A

block the enzyme that converts androgens to estrogens–> decreases estrogen levels–> decreases negative feedback and increases release of FSH

56
Q

Aromatase inhibitors may be more effective than Clomid in women with what

A

PCOS

57
Q

Side effects of aromatase inhibitors

A
  • hot flashes

- GI upset

58
Q

Aromatase inhibitors have what effect on the uterus

A

anti estrogen effects

59
Q

When are dopamine agonists used in infertility

A

restoration of ovulation in women with hyperprolactinemia

60
Q

Out of the two options for dopamine agonists which is better. Why?

A

cabergoline because it is more elective and has fewer side effects

61
Q

How do dopamine agonists work

A

acts like dopamine which suppresses prolactin synthesis and release–> normilization of prolactin returns HPO axis to normal

62
Q

When should you expect a drop in prolatin when using dopamine agonists

A

2-3 weeks

63
Q

What should accompany normalization of prolactin levels when using dopamine agonists

A

normal menstrula cycles

64
Q

Side effects of dopamine agonists

A
  • dizziness
  • nausea
  • hypotension
65
Q

What can be done to improve side effects of dopamine agonists

A

administer vaginally

66
Q

How is intrauterine insemination done

A

semen is spun down in lab, washed and injected into uterine cavity via catheter threaded through the cervix

67
Q

Steps to IVF

A
  • medication given to control ovulation stimulation
  • ovarian follicle development is done
  • HCG or lupron is given to trigger maturation
  • Oocyte is retrieved
  • oocyte and sperm is placed in IVF culture medium
  • fertilization and embryo transfer
68
Q

What is intracytoplasmic sperm injection

A

procedure where a sinlge sperm is directly injected into each mature egg

69
Q

When is ICSI used? Why?

A

“severe male factor”

because the probability the sperm will penetrate the oocyte on its own is low

70
Q

What is assisted hatching

A

a procedure in which a hole is made in the zona pellucida just prior to embryo transfer to facilitate hatching of the embryo

71
Q

Assisted hatching is used in….

A
  • older women

- couples who have had unsuccessful prior IVF attempts

72
Q

When is preimplantation genetic screening done? What does it screen for

A

used in couple that are both chromosomally normal with recurrent pregnancy loss

screens embryos for aneuploidy

73
Q

When is preimplantation genetic diagnosis done? What does it screen for?

A

used when one or both parents carry a specific known genetic mutation or defect

screens for that specific defect

74
Q

Women with PCOS have an increased risk of what types of things

A
  • CV disease
  • obesity
  • glucose intolerance/T2DM
  • metabolic syndrome
  • dyslipidemia
  • fatty liver disease
  • obstructive sleep apnea
75
Q

What are common signs and syndromes of PCOS

A
  • irregular menstrual cycles
  • obesity
  • acanthosis nigrans
  • hyperandrogenism
  • elevated serum testosterone
  • “string of pearls” on ovaries
  • mood changes
76
Q

What criteria is used to diagnose PCOS

A

rotterdam criteria

77
Q

What is the rotterdam criteria

A

2/3 of the following

  • ovulatory dysfunction
  • chemical and/or biochemical signs of hyperandrogenism
  • polycystic ovaries on ultrasound
78
Q

What are the goals of PCOS treatment

A
  • improve hyperandrogenic symptoms
  • manae underlying metabolic abnormalities and reduce risk factors
  • prevention of endometrial hyperplasia and endometrial carcinoma
79
Q

First line intervention for PCOS

A

weight loss via diet and exercise

80
Q

Treatment for PCOS is women not pursuing pregnancy

A
  • OCPs
  • metformin (alternative)
  • spironolactone
  • GnRH agonist
81
Q

Treatment for PCOS in women pursuing pregnancy

A
  • clomid
  • letrozole
  • metformin

Clin Med III exam III (10 decks)

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