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reproductive treatments Flashcards

1
Q

What are symptoms of low testosterone?

A

Loss of early morning erections, decreased libido, increased shaving, decreased energy

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2
Q

How is low testosterone diagnosed?

A

serum testosterone before 11 low on 2 occasions

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3
Q

Treatment low testosterone if not desiring fertility? Options? Risks?

A 
Testosterone replacement. Options: 
- daily gel (tostran). 
-3 weekly IM injection (sustanan.) 
-3 month IM injection (nebido). 
-less commonly Implants/oral preparation
Risks:  can increase haematocrit causing risk of hyperviscosity and stroke. PSA (prostate specific antigen) should be measured to see if prostate cancer triggered
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4
Q

How to treat secondary hypogonadism (deficiency of gonadotrophins etc)?

A

Treat with gonadotrophins for spermatogenesis. LH stimulates leydig cells to increase intratesticular testosterones to higher levels than in circulation. FSH stimulates seminiferous tubule development and spermatogenesis

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5
Q

Why not give testosterone to men wanting fertility?

A

Will decrease LH/FSH even more reducing spermatogenesis

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6
Q

How to do sperm induction process?

A

Give hCG injections that act on LH receptors. If no response after 6 months add FSH injections

-avoid giving testosterone if desiring fetility

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7
Q

What is commonest cause of infertility in women?

A

PCOS

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8
Q

Features of PCOS?

A

Polycystic morphology on US, hyperandrogenism (clinical or biochemical), irregular periods

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9
Q

Second commonest cause infertility women? Characteristics?

A

Hypothalamic amenorrhea - no energy for fertility (low BMI, excess exercise, stress, genetic suceptibility)

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10
Q

How to do ovulation induction in women?

A

Develop one ovarian follicle so as not to risk multiple pregnancies (risk to mother & child)- small increase in FSH is goal

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11
Q

How to restore ovulation in PCOS?

A
  1. lifestyle changes/weight loss/metformin. 2. letrozole - aromatase inhibitor (first lie) - reduces oestradiol so increases FSH/LH. 3. clomiphene - oestradiol receptor modulator - antagonist so reduces negative feedback from oestradiol increasing LH/FSH. 4. FSH stimulation (to increase a bit to stimulate follicle to grow)
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12
Q

How does IVF work? what should be done for male factor infertiltiy?

A
  • generally: oocyte retrieval, fertilisation in vitro (either IVF - put in dish with sperm to fertilize or intra-cytoplasmic sperm injection ICSI for male factor infertiltility) , embryo incubation, embryo transfer
    1. give FSH large dose (superovulation) to get multiple follicles developing - retrieve eggs from ovary but don’t want premature ovulation so that there is still egg in follicle.
    2. GnRH antagonist to prevent premature ovulation - start FSH and 6 days in start GnRH antagonist to block LH surge and thus premature ovulation or GnRH agonist started before FSH (desensitises GnRH receptor when given continuously).
    3. Then LH exposure via hCG (acts on LH receptor) for LH surge to induce oocyte maturation (more long lasting - become haploid from diploid).
    4. Oocyte retrieval. Embryo transfer to endometrium.
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13
Q

Barrier contraception?

A

Condoms, diaphragm, cap with spermicide

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14
Q

Female contraception? Permanent contraception?

A

OCP, progestin only, long acting reversible contraception LARC, emergency contraception

permanent: sterilisation (women), vasectomy (men)

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15
Q

Condoms positives and negatives?

A

+ Prevents pregnancy, protect against STI, easy to get, no contraindications
- can interrupt sex, reduce sensation, interfere with erections, needs skill

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16
Q

OCP mechanism of action, positives, negatives?

A

OCP gives both oestrogen and progestogen and therefore negatively feeds back to decrease LH/FSH and prevent ovulation., the progesterone thickens cervical mucus and thins endometrial lining preventing implantation.
+Easy to take, once a day, reduce endometrial/ovarian cancer, weight neutral usually, take back to back no withdrawal bleed
- No sti protection, side effects (spotting, nausea, mood, breast tenderness, hungry), blood clots, not good during breastfeeding, P450 enzymes reduce efficacy.
-non contraceptive uses: periods lighter/less painful (endometriosis, menorrhagia), regular withdrawal bleed, PCOS (helps reduce LH & hyperandrogenism)

17
Q

Progestin only pill mechanism?. Positives and negatives?

A

-Less reliably inhibit ovulation (progestin thickens cervical mucus/thins endometrial lining preventing implantation)
+good when no oestrogen, periods may stop, better for breast-feeding, periods lighter/less, take without break
-No STI protection, shorter room to take it (shorter acting), side effects (irregular bleeding, mood, headache, breasts, libido)

18
Q

Long acting reversible contraceptives LARC - mechanism, uses? what are different types and how does each work?

A
  • Need to exclude STIs before.
  • Prevent implantation but rarely cause ectopic pregnancy. Can be used as emergency contraception.
    1. IUD (copper coil) - mechanically prevents implantation and decreases sperm survival - 5-10 years but can cause heavy periods. 2. intra-uterine systems IUS - secretes progesterone to thin lining of endometrium & thicken mucus (3-5years) (mirena coil) - can help heavy bleeding. 3. progestogen only injectables or subdermal implants.
19
Q

What are things to consider for choice of contraception?

A

risk of blood clots, other conditions that may benefit from OCP, weight, medications, STI prevention, P450 liver enzyme inducing drugs - anti-epileptics, antibiotics, teratogenic drugs (lithium, warfarin) - more effective methods needed

20
Q

What are the risks of hormone replacement therapy and why?

A
  1. DVT/PE - because oral oestrogens first pass metabolism through liver so increase SHBG, triglycerides, CRP. Transdermal oestrogens safer for DVT. Avoid oral if BMI>30.
  2. hormone sensitive cancers - breast cancer - slight increase - risk related to duration of treatment, continuous worse than sequences. Ovarian cancer small increase after long term use. endometrial cancer risk (prescribe progestogens in all women with endometrium)
  3. CV disease: no increased risk if starting before 60yrs, only if started 10yrs after menoapuse. possible benefit of oestrogen supplementation in women with POI
  4. stroke: small increased risk. oral > transdermal, combined > oestrogen only
21
Q

What must we do to prevent endometrial cancer? what can post-menopausal bleeding indicate?

A

Must prescribe progestogens - assess HRT safety/efficacy at 3 months then annually. Progestogen reduces bleeds and thus prevents endometrial cancer - post menopausal bleeding may be endometrial cancer.

22
Q

what are progestogens?

A

synthetic progestins + natural hormone progesterone

23
Q

what are benefits of HRT?

A
  • relief of symptoms of low eostrogen (flushing, distrubed sleep, low libido, low mood)
  • less osteoporosis related fractures (decreased by 1/3)
24
Q

what are masculining hormones for transgender men? risks?

A
  • testoterones (injections/gel)
  • side effects: polycythaemia, lower HDL, obstructive sleep apnoea, no increase in CVD
  • progesterone to suppress period if needed (endometrial hyperplasia 15%)
25
Q

what changes happen after masculinising hormones for transgender men in 1-6 months?

A

balding, deeper voice/acne/increased and coarser facial & body hair, change in body fat distribution, clitoris enlargement, period stops, increased muscle mass/strength

26
Q

what is given to pre-pubertal young people who want to transition?

A

GnRH agonist for pubertal suppression (give continuously so desensitises GnRH receptor) & then sex steroids

27
Q

what is amount of post-treatment regret for trans people? when is gender reassignment surgery given?

A

1-2 %

1-2 years after hormonal treatment

28
Q

what is sex & gender?

A

sex biologically defined (female, male, intersex)

gender social construct - how you identify as (female, male, non-binary)

29
Q

what is cisgender & transgender

A

cisgender - same sex and gender

transgender - different sex and gender - transitioning or planning to transition

30
Q

what is gender non-conforming & gender dysphoria?

A

gender non-conforming -gender doesnt match assigned sex

-gender dysphoria - when this causes distress

31
Q

what is non-binary?

A

gender doesnt match to traditional binary gender understanding –> agender, bigender, pangender, gender fluid

32
Q

what are feminising hormones given to transgender women + side effects

A
  1. estrogen (transdermal,oral, IM): high dose eostrgoen eg. 4-5mg /day to aim for oestradiol levels 743 pmol/L
    - side effects: DVT, high BP, CV, high tricyclerides, hormones senstivie cancers, abnormal LFT
  2. reduce testosterone –> GnRH agonists (desensitisation of HPG axis) , anti-androgens (spironolactone)
33
Q

what will not change with feminising hormones and what should they consider before hormone therapy?

A

height, voice, adams apple dont change

-consider sperm banking

34
Q

what changes occur with feminising hormones and when?

A
  • 1-3 months: decrease sexual desire/function, baldness slows or reverses
  • 3-6 months: softer skin, body fat distribution, decrease testicular size, breast development/tender
  • 6-12 months: hair softer/finer
35
Q

what are options of emergency contraceptions? side effects?

A
  1. copper IUD most effective: fitted up to 5 days after unprotected sex
  2. ulipristal acetate 30mg (ellaOne): stops progesterone working normally & prevents ovulation. take within 5 days of sex (earlier better)
  3. levonorgestrel 1.5mg (levonelle) least effective esp if BMI>27. synthetic progesterone prevents ovulation, take within 3 days after sex

side effects: headache, abdominal pain, nausea. liver p450 enzyme medications make them less effective. if vomit 2-3h after taking it need to take another

36
Q

when is OCP contraindicated?

A

migraine with aura (stroke risk), smoking >15/day + age>35, stroke or CVD history, current breast cacner, liver cirrhosis, dibaetes with complications

BRS (81 decks)

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