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CCFP 3 > Infertility + Insomnia > Flashcards

Infertility + Insomnia Flashcards

1
Q

Primary + secondary amenorrhea definition

A

Primary = no menarche by 16 or no secondary sexual characteristics + no menarche by 14
Secondary = no menses in 3mo with prev normal menstruation or no menses for 9mo in pt with prev oligomenorrhea

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2
Q

Differential?

A

Pregnancy
Hypothalamic dysfunction (low FSH, LH, estrogen)
Anorexia
Exercise
Stress
Nutritional deficit
Pituitary dysfunction
Brain tumor
Sheehan’s syndrome
Ovarian dysfunction
Menopause
Turner’s
PCOS
Endocrine
Hyperprolactinemia
Thyroid dz
Cushings

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3
Q

Questions to ask in history of amenorrhea

A

History
Sexual Hx
How long been trying
Coital frequency + timing
Lubricants
Menstrual hx
LMP
Cycle
Regularity
PMH
STI hx
Obs hx
Miscarriages
Past surgeries
Meds
Teratogenic meds
Prev contraeption

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4
Q

Stats for infertility

A

75% couples pregnant in 6 months
85% in 1 year
90% in 2 years
Causes: ⅓ male, ⅓ female, ⅓ combined
10% cases idiopathic

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5
Q

Lifestyle management of infertility

A

Folic acid
Smoking cessarion
Wt control
Avoiding alcohol

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6
Q

What to educate pts on?

A

Ovulation
Optimal intercourse timing (6d prior to ovulation q2-3d)
Reduced fertility with age
Adoption
Risk of pregnancy loss, chromosomal abnormalities, ASD, schizophrenia with increasing age

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7
Q

Ix for females

A

Rubella
Varicella
STIs inc HIV + hepatitis B + C
Day 3 LH/ FSH/ prolactin/ TSH/ estradiol/ testosterone
Day 21 progesterone
Pelvic US, HSG or hysteroscopy

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8
Q

Ix for males, and what further tests would you order if a) you found normal volume azoospermia and b) you were concerned for a tumor?

A

STIs inc HIV + hepatitis B + C
Rubella
Semen analysis
If normal volume azoospermia: LH, FSH, prolactin, estradiol
US if concerned for obstruction or tumors

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9
Q

Female causes

A

PCOS
Hyperprolactinemia (prolactinoma)
Thyroid disease
Cushings
PID
Adhesions
Prev ectopic
Uterine abnormality
Fibroids
Endometriosis

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10
Q

Male causes

A

Varicocele
STI
Mumps
TB
Klinefelters
Torsion
RT
Hernia repair
Drugs: cannabis

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11
Q

Rx to induce ovulation

A

Clomiphene citrate
Gonadotrophin
Metformin (PCOS)
Bromocriptine (for hyperprolactinemia)

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12
Q

Rx for males

A

Selective estrogen receptor modulators
Aromatase inhibitors
hCG
Testosterone

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13
Q

Surgical management for female

A

Tuboplasty
Lysis of adhesions

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14
Q

When to refer a couple

A

<35: after 1 yr trying
35-40: after 6mo
>40: immediately

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15
Q

Sx of PCOS

A

Hirsutism
oligomenorrhea
infertility
insulin resistance
acne
obesity
poly cystic ovaries
acanthosis nigracans
metabolic syndrome

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16
Q

PCOS is considered a risk factor for the potential development of…

A

Diabetes (through insulin resistance)
Endometrial Hyperplasia/Carcinoma (through unopposed estrogen excess)

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17
Q

Rotterdam criteria for PCOS

A

Oligomenorrhea/Anovulation
Clinical/Biochemical Signs of Hyperandrogenism
Polycystic Ovaries on Ultrasound

18
Q

Ix for PCOS

A

FSH, LH, free testosterone, DHEAS, SHBG, fasting glucose

19
Q

Management of PCOS

A

weight loss, OCP, POP, metformin, IUD, spironolactone
screening: monitor lipids, BP, a1c

20
Q

Pregnancy optimisation PCOS

A

metformin, clomiphene, exogenous gonadotrophins, letrozole (aromatase inhibitor)

21
Q

Secondary causes of amenorrhea

A

Pregnancy
Anorexia Nervosa
Menopause
Peri-Menopause
Stress
Weight Changes
Exercise
Hyperprolactinemia
Hypothyroidism
Hyperthyroidism
Diabetes
Premature Ovarian Failure
Anabolic Steroids
Cushing’s Syndrome
Addison’s Disease
Hypopituitarism
Congenital Adrenal Hyperplasia
Acromegaly
Turner Syndrome
Endometrial Scarring or Injury

22
Q

Treatment for insomnia

A

brief behavioural therapy for insomnia over 2 sessions

23
Q

Infant, toddler and teen causes of insomnia

A

Infants: usually behavioural, GERD
Toddlers: associated w/ fears, tx w/ behavioural intervention
Adolescents: delayed sleep phase syndrome

24
Q

Management of insomnia in peds

A

Sleep hygiene: no naps during day, dinner 2hrs before bed, screen time d/c 1hr before bed, bedtime routine, regular wake up times, sleeping in own bed, dark sleep environment, quiet, no caffeine
Melatonin 1-5mg

25
Q

DDx for insomnia

A

Sleep apnea
Depression/ anxiety
HF, COPD, asthma, GERD, thyroid, Parkinsons, dementia, pain, nocturia, menopause
Meds: SSRIs, SNRIs, stimulants, ACEi, BB, diuretics, statins, bronchodilators, levodopa, opioids, caffeine, alcohol, nicotine, steroids
Periodic limb movement
Restless leg syndrome
Sleepwalking
Sleeptalking

26
Q

Sleep hygiene for adults

A

No caffeine or alcohol within 6hrs of bedtime
No nicotine close to bedtime
Avoid heavy exercise 3hrs before bedtime
No excess liquids or heavy meals prior to bed
No naps
No screen time 1 hr before bed
Limiting bedroom activities to sleep and sex
Regular schedule

27
Q

CBT approach

A

Identify dysfunctional sleep cognition
Challenge validity
Replace with appropriate cognition

28
Q

When would it be appropriate to prescribe meds, and how to go about it

A

Educate pt on risks
Prescribe only when insomnia has severe impact on function
Negotiate reduction and cessation plan
When presenting for renewal, reassess, education, discuss tapering or alternative therapies
Long term intermittent (<3 times weekly)

29
Q

Which insomnia meds are better for elderly pts?

A

Doxepin, short acting GABA agonist (Sublinox), melatonin

30
Q

Which insomnia meds are better for pregnant pts?

A

nortriptyline or trazodone

31
Q

Rx (pharm + non-pharm) for nocturnal leg cramps

A

Non-pharmacological treatment
Daily stretching
Stationary bicycle before sleeping
Keep bed covers loose
Avoid alcohol, caffeine, dehydration

Pharmacological treatment
Vitamin B complex TID
Vitamin E 800 units qHS
May consider iron and magnesium (although no evidence)
Diphenhydramine
Diltiazem or Verapamil
Gabapentin

32
Q

Rx of restless legs (inc if associated w/ comorbid depression or pain and if pt has ESRD)

A

Trial of oral iron therapy if ferritin<75mcg/L

Comorbid depression, obesity/metabolic syndrome - Dopamine agonist (Pramipexole, rotigotine)
Comorbid pain, anxiety, insomnia - Gabapentin
If ESRD, consider Vitamin C or E (alone or in combination)

33
Q

When does nipple DC become worrisome?

A

unilateral, uniductal, spontaneous, bloody, breast mass, >40yo

34
Q

DDx for nipple DC

A

Hyperprolactinemia:
Meds: antipsychotics, antidepressants, antiemetics, antihypertensive, estrogen, verapamil, opioids, cocaine
Pathologic - pituitary adenoma, chronic renal failure, cirrhosis, hypothyroid, Cushing disease, acromegaly
Physiological - lactation, pregnancy, stress, stimulation, macroprolactin
Lactation (Pregnancy, postpartum 6mo after delivery or 6mo after cessation of breastfeeding)

Papilloma, duct ectasia
Malignancy (DCIS)

35
Q

What does azoospermia, oligozoospermia, asthenozoospermia and teratozoospermia mean?

A

Azoospermia: 0 sperm
Oligozoospermia: <15m sperm
Asthenozoospermia: <32-40% motile
Teratozoospermia: <4% normal form

36
Q

Restless legs RF

A

uremia, neuropathy, low iron, fam hx, pregnancy, PD, MS

37
Q

Rx for restless legs

A

iron, magnesium, stretch calves, avoid caffeine, massage, heat, exercise, pramipezole, gabapentin,

38
Q

Periodic limb movement disorder - dx + rx

A

dx w/ sleep study, regular exercise, massage, dopamine agonists (ropinirole)

39
Q

Nocturnal leg cramps rx

A

regular exercise, stretching, vitamin B complex, Mg, diphenyhydramine, CCB (diltiazem), gabapentin

40
Q

Name some sleep disorders

A

nacrolepsy, restless leg syndrome, sleep terrors, sleep walking, insomnia disorder

41
Q

Insomnia meds

A

benzos, dayvigo, lunesta

CCFP 3 (67 decks)

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