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Y4 Obs and Gynae > Gynaecology: Fertility and the Menopause > Flashcards

Gynaecology: Fertility and the Menopause Flashcards

1
Q

At what point is a couple diagnosed as sub-fertile?

A

Unprotected sex 2-3 times a week for 12 months but still no pregnancy.

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2
Q

Distinguish between absolute and relative sub-fertility?

A

A person with relative sub-fertility has 1+ factors impeding there ability to get pregnant but that doesn’t mean they won’t get there themselves.

Someone with absolute sub-fertility has 0 chance of getting pregnant without assistance.

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3
Q

Distinguish between primary and secondary sub-fertility?

A
  • Primary = never been pregnant
  • Secondary = have been pregnant but have either miscarried or are struggling to conceive again (N.B: if a child came from a previous relationship it still counts as secondary infertility)
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4
Q

What are the 5 things needed for optimum fertility?

A
  • Supply of eggs
  • Regular cycle
  • Healthy sperm
  • Patent Fallopian Tubes
  • Receptive Endometrium
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5
Q

Why might someone have a low supply of eggs?

A
  • Lifelong smokers appear to run out of eggs sooner
  • Genetic conditions e.g. Turner’s syndrome lead to reduced egg count at birth
  • Physical conditions, e.g. having had an ovary removed, naturally reduce egg count.
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6
Q

Why might someone have issues with cycle regularity (causing infertility)?

A

Mostly PCOS, but also see high BMI induced anovulation, ovarian failure (chemotherapy), hyper-prolactinaemia

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7
Q

Why might someone have issues with Fallopian Tube patency?

A

Mostly inflammatory or scaring conditions e.g:

  • PID (–> tubal occlusion)
  • Adhesions
  • Endometriosis
  • Hydrosalpinx
  • Previous ectopic pregnancies
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8
Q

Why might a man have issues with sperm health?

A

Physical:

  • Vasectomy
  • Varicocele
  • Testicular Torsion
  • Orchitis

Genetic:

  • Klinefelter’s
  • Congenital Bilateral Absent Vas Deferens

Lifestyle choices:

  • Overweight
  • Alcohol
  • Smoking
  • Anabolic Steroids
  • Emotional stress and depression
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9
Q

Why might someone have issues with a receptive endometrium?

A
  • Fibroids
  • Septum
  • Polyps
  • Asherman’s
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10
Q

What are the standard investigations for a patient with fertility issues?

A

MOOT(U) (like an MOT):

  • Male factors
  • Ovulation
  • Ovarian reserve
  • Tubal patency
  • Uterine cavity
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11
Q

How are Male factors investigated in a fertility setting?

A

Semen analysis twice in the span of 3 months:

  • mainly look at count, volume, pH, vitality, motility, and morphology
  • if grossly abnormal send for further testing (e.g. karyotyping), FSH and LH
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12
Q

How are ovulation factors investigated in a fertility setting?

A
  • Regularity of cycle
  • Urinary LH
  • Mid luteal phase progesterone (7 days before end of cycle)

These factors combined give a good impression of ovulation vs e.g. menopause

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13
Q

Why is progesterone always measured 7 days before the next period is expected?

A

Ovulation always occurs 14 days before end of cycle, progesterone rises midway through this (so 7 days before end of cycle); reliable point where all women will have raised progesterone (unless there’s an issue)

Essentially doing it this way prevents you getting false negatives related to natural variations in women’s cycles.

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14
Q

How are ovarian reserve factors investigated in a fertility setting?

A
  • FSH (on day 2-5 of cycle)

- Antral follicle count

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15
Q

What is considered an ideal result on a d 2-5 FSH test?

A

Less than 10. 50+ suggests menopause.

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16
Q

How are uterine factors causing infertility invesitgated?

A

Pelvic USS

17
Q

How are tubal factors causing infertility investigated?

A

Ideally: Laparoscopy w/ dye, shows passage through tube well but expensive and surgical risk.

Alternatives:

  • Hysertosalpingo Contrast Sonography
  • Hysterosalpingogram

Both use dye but one is x-ray the other is USS

18
Q

What should be done in primary care to aid fertility?

A
  • Reassure couple
  • Educate (on concepts of fertility, high chance of conception, what they can do to boost their odds)
  • Lifestyle advice (smoking, drinking, exercise, WEIGHT LOSS)
  • Optimise management of any pre-existing conditions
  • Ensure meds are safe for use in pregnancy
  • Tests for STIs
19
Q

What are the secondary care options for couples with fertility issues?

A
  • Ovulation induction (give clomifene citrate)

- Treat any underlying conditions (e.g. hydrosalpinx)

20
Q

What can be done in tertiary care (specialist centres) to help couples with fertility issues?

A

Refer to fertility clinic for…

  • Inter Uterine Insertion (IUI), offered to same sex couples using surrogates or couples who can’t have penetrative sex.
  • IVF, for most couples
  • Intracytoplasmic sperm insertion, best option for male factor issues
21
Q

What is the NICE recommendation in regards to IVF, and what actually happens?

A

NICE says if not pregnant after two years of RUPS, should get 3 cycles of IVF. In reality most people get one and then have to go private.

Relevant as the success rate is approx. 35%

22
Q

How is infertility diagnosed?

A

Process of exclusion, looking for clear causes, possible causes and unexplained causes.

23
Q

What history points would you look for in a woman presenting with infertility?

A
  • AGE
  • Previous fertility (primary vs secondary)
  • Menstrual cycle, do they ovulate
  • Any tubal or pelvic surgery
  • Any history of PID
  • Menorrhagia/ Dysmenorrhoea/ Pelvic pain (could all indicate potential causes)
24
Q

What history points would you look for in a man presenting with infertility?

A
  • General health
  • Alcohol or smoking
  • Previous surgery (especially for hernias or undescended testicles)
  • Previous infections (STIs)
  • Sexual dysfunction (erectile vs ejaculatory)
25
Q

What is the menopause?

A

End of a woman’s reproductive life, defined as no periods in the last 12 months. Average age in the UK is 51.

Can occur:

  • Naturally
  • From radiotherapy or chemotherapy
  • Surgically if both ovaries are removed (hysterectomy doesn’t immediately cause menopause).
26
Q

What is the perimenopause and what causes it?

A

Time before a woman has her last period when she experiences the symptoms of menopause.

Occurs because as ovaries fail to release oestrogen, levels of FSH and LH spike (negative feedback)

27
Q

At what age is menopause considered pre-mature?

A

40.

28
Q

How is menopause diagnosed?

A

In women aged 45+, not necessary.

In women below that can be done through blood tests:
- Serum FSH > than 40, at least twice, 4-6 weeks apart.

29
Q

What are the symptoms of menopause?

A
  • Hot flushes
  • Night sweats
  • Vaginal dryness
  • Low mood and/or feeling anxious
  • Joint pain
  • Muscle pain
  • Loss of interest in sex
  • Spaced/irregular/erratic bleeding throughout final period
30
Q

What are the options for therapeutic management of the menopause?

A

Number of options, depends on woman’s preference and impact of menopause on QoL:

  • Nothing: many women don’t require treatment.
  • Natural treatment: Exercise (running, swimming, yoga), Smoking cessation, Reduced alcohol and coffee intake, Mediterranean diet can reduce symptoms.
  • Hormonal treatment: HRT (combined or progesterone only)
  • Non-hormonal treatment
31
Q

What are the pros of HRT?

A
  • Benefits outweigh drawbacks for most symptomatic women under the age of 60 OR less than 10 years removed from menopause
  • Single best way of managing Hot flushes and Low mood
  • Improves sexual desire, reduced vaginal dryness, pain with sex
  • Protective against osteoporosis
  • Reduces some urinary symptoms
32
Q

What are the cons of HRT?

A
  • SEs: Headaches, Breast tenderness, Bloating, Muscle cramps, Irregular bleeding
  • (However these tend to be self-limiting, women should wait a few weeks before coming off HRT)
  • Risks: Mixed evidence, potential increased risk of IHD, Stroke, VTE.
  • (Risks seem to be mostly associated with oral HRT or women over the age of 60, so ideally give in patch form to women under 60)
33
Q

Which women are given HRT with oestrogen alone?

A

Women with no uteruses.

34
Q

What is the link between HRT and breast cancer?

A
  • Oestrogen alone = Little or no increase in risk
  • Combo HRT = Increased risk, but risk returns to normal after 5 years of stopping treatment so can be mediated by taking women off.
  • Risk of breast cancer on HRT is highly linked to risk factors such as weight and drinking, can be controlled.
35
Q

What are the types of Hormonal HRT?

A

Sequential (combined) HRT- Given to women within 12 months of last period

Continuous Combined HRT OR Tibolone- Not had a period in at least 12 months

Vaginal Oestrogen- Pessaries and creams can help with vaginal and urinary symptoms

36
Q

Typically, what does a starting regimen of HRT look like?

A

Transdermal oestrogen patch or gel +/- Micronised progesterone or Mirena (if don’t have uterus)

OR

Transdermal combined HRT

37
Q

What are the two main considerations when choosing a HRT regimen for a patient?

A

Have they had a hysterectomy?

  • Women w/o Uterus get just oestrogen as no need to protect the endometrium
  • Women w/ Uterus also get progesterone (Mirena coil or Mirconised prog) also.

+ have to consider route of administration, namely oral or transdermal.

38
Q

What are the main Non-Hormonal treatment options for HRT?

A

Lifestyle approach.

Non-Hormonal treatment options:
- Bio-identical hormones derived from soy and other plants.
- Herbal remedies e.g. St John’s wort are predominantly effective for the management of hot flushes and night sweats.
(neither are licenced in the UK and so cannot be prescribed, advice patients thinking about them to do their own reading)

CBT can be effective at tackling the mood element of the menopause.

39
Q

What medications can be used in patients for whom HRT is contra-indicated?

A 
For hot flushes:
- Clonidine
- SSRIs (namely Fluoxetine)
- Gabapentin
(can also be good for mood symptoms)

For low libido, lack of energy and concentration; Testosterone can be useful.

Y4 Obs and Gynae (13 decks)

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