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Year 2 Endo > Reproductive treatments > Flashcards

Reproductive treatments Flashcards

(74 cards)

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1
Q

How do we treat primary hypogonadism?

A

Difficult to treat

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2
Q

How do we treat secondary hypogonadism?

A

Treat with Gonadotrophins (ie LH and FSH) to induce Spermatogenesis

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3
Q

How does LH help with sperm induction?

A

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

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4
Q

How does FSH help with sperm induction?

A

FSH stimulates seminiferous tubule development and spermatogenesis

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5
Q

Give some symptoms of hypogonadism due to opioid abuse?

A

Low morning Testosterone

Fatigue and reduced shaving frequency

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6
Q

Why do we avoid giving T to those desiring fertility?

A 
Secondary hypogonadism (low sperm and testosterone levels) desiring fertility, giving testosterone treatment will 
   lower LH / FSH further and further reduce spermatogenesis
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7
Q

How can you treat hypogonadism in those desiring fertility?

A

Give hCG injections (which act on LH-receptors)

If no response after 6 months, then add FSH injections

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8
Q

Why would someone with Kallmann’s have a worse prognosis with treatment?

A

Congenital Hypogonadotrophic Hypogonadism (CHH) eg Kallmann syndrome have not had mini-puberty.

FSH during mini-puberty important for growing the pool of immature spermatogonia and germ cells

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9
Q

How do we overcome problems with treating those with congenital hypogonadism?

A

2-4 months pretreatment with FSH before hCG treatment

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10
Q

Which testicular size is better for the affect on treatment?

A

Pretreatment Testicular size (Seminiferous tubules)

ie testicular volume >6ml have better prognosis

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11
Q

What are the symptoms of low testosterone?

A

loss of early morning erections, libido, decreased energy, shaving

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12
Q

How do you diagnose low T?

A

At least 2 low measurements of serum testosterone before 11am.
Investigate the cause of low testosterone.

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13
Q

How do we replace T?

A 
Daily Gel eg Tostran. Care not to contaminate partner.
3 weekly intramuscular injection (eg Sustanon)
3 monthly intramuscular injection (eg Nebido)
Less Common (Implants, oral preparations)
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14
Q

What must you bear in mind safety wise whilst replacing T (biochemical risk)?

A

Increased Haematocrit (risk of hyperviscosity and stroke)

Prostate (Prostate Specific Antigen (PSA) levels)

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15
Q

What is the aim of ovarian induction (product)?

A

Aim to develop one ovarian follicle

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16
Q

What is the most common cause of anovualtion?

A

PCOS

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17
Q

Why do we only want to stimulate one follicle?

A

Multiple pregnancies

Increased risk

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18
Q

How is ovulation induction done? (its aim)

A

Ovulation induction methods aim to

increase FSH by a small amount

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19
Q

How can we restore ovulation? (from PCOS)

A
  1. Lifestyle / Weight Loss / Metformin
    1. Letrozole (Aromatase inhibitor)
    2. Clomiphene (Oestradiol receptor antagonist)
    3. FSH stimulation
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20
Q

Why do we use aromatase inhibitors?

A

Low oestrodial level which normally causes negative feedback on hypothalamus and pituitary gland

Increase FSH

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21
Q

How do oestrodiol receptor antagonist work?

A

Decreased negative feedback

Increases FSH

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22
Q

How does IVF work?

A

Oocyte retrieval

Fertilisation in vitro
(IVF or ICSI)

Embryo incubation

Embryo transfer

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23
Q

What is ICSI?

A

Intra-cytoplasmic sperm injection

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24
Q

How do we collect eggs?

A

FSH stimulation (super ovulation)

Egg retrieval directly from ovary

Want to stop premature ovulation

Do this by giving drug that prevents LH surge

Make eggs mature by giving LH

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25
How do we prevent LH surge?
GnRH Antagonist protocol (SHORT protocol) GnRH agonist (LONG protocol)
26
How can both a GnRH agonist or a GnRH antagonist be used to block an LH surge?
GnRH is pulsatile so low dose can prevent surge Non-pulsatile GnRH high dose is a blocker causes desensitisation
27
What happens when eggs mature (milestone)?
Becomes haploid | Achieves its capability of being fertilised by sperm
28
How do we mature eggs?
give hCG to trigger egg maturation
29
What is ovarian hyper-stimulation syndrome?
Main side effect of IVF Pleural effusion Ascites Renal failure Ovarian Torsion
30
Summarise a cycle of IVF prep to get oocyte
High dose FSH to induce follicle growth GnRH to prevent LH surge Trigger injection to mature eggs (hCG or GnRHa) Oocyte retrieval from ovary Embryo transfer to endometrium
31
What are the pros of barrier contraception (condoms)?
Easy to obtain – free from clinics No need to see a healthcare professional Protect against STI’s No contra-indications as with some hormonal methods
32
What are the cons of barrier contraception (condoms)?
``` Can interrupt sex Can reduce sensation Can interfere with erections Some skill to use properly eg ensure no air, not too large or small. Two are not better than one ```
33
How does the OCP work?
1. Negative feedback on hypothalamus and pituitary 2. Thickening of Cervical Mucus 3. Thinning of Endometrial Lining to reduce implantation
34
What are the pros of the OCP?
Easy to take – one pill a day (any time of day) Effective Doesn’t interrupt sex Can take several packets back to back and avoid withdrawal bleeds Reduce endometrial and ovarian cancer Weight Neutral in 80% (10% gain, 10% lose)
35
What are the cons of the OCP?
It can be difficult to remember No protection against STIs P450 Enzyme Inducers may reduce efficacy Not the best choice during breast feeding
36
What are the possible side effects of the OCP?
``` Spotting (bleeding in between periods) Nausea Sore breasts Changes in mood or libido Feeling more hungry (try different OCPs to see which suits best) ```
37
What are the very rare side effects?
Blood clots in the legs or lungs (2 in 10,000)
38
What are the non-contraceptive uses of the pill?
Helps make periods lighter and less painful (eg endometriosis or period pain or menorrhagia) Withdrawal bleeds will usually be very regular PCOS: help reduce LH and hyperandrogenism
39
What are the pros of the mini pill?
Works as OCP but less reliably inhibits ovulation Often suitable if can't take oestrogen ``` Easy to take – one pill a day, every day with no break It doesn’t interrupt sex Can help heavy or painful periods Periods may stop (temporarily) Can be used when breastfeeding ```
40
What are the cons of the mini pill?
Can be difficult to remember No protection against STIs Shorter acting – needs to be taken at the same time each day
41
What are possible side effects of the mini pill?
``` Irregular bleeding Headaches Sore breasts Changes in mood Changes in sex drive ```
42
What is LARCs?
Long acting reversible contraceptives
43
What are the three LARCs?
IUD (intra-uterine device) IUS (intra-uterine systems) Progesterone-Only injectable contraceptives or subdermal implants
44
What are the features of IUD?
Copper Coil- mechanically prevent implantation, decrease sperm egg survival. Lasts 5-10yrs. Can cause heavy periods, and 5% can come out especially during first 3months with periods
45
What are the features of IUS?
which secretes progesterone (eg Mirena Coil) to thin lining of the womb and thicken cervical mucus (can be used to help with heavy bleeding). Last 3-5yrs
46
What are the features of coils?
are suitable for most women including Nulliparous (no previous children). Exclude STI’s 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
47
How can an IUD be used as emergency contraception?
Copper intrauterine device (IUD) most effective | can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)
48
What are the emergency contraception pills?
Emergency contraceptive pill, ulipristal acetate 30 mg (ellaOne) Ulipristal acetate stops progesterone working normally and prevents ovulation. Must be taken within 5 days of unprotected intercourse (earlier better). Emergency contraceptive pill, levonorgestrel 1.5 mg (Levonelle) least effective (esp if BMI >27 kg/m2) Synthetic Progesterone prevents ovulation (don’t cause abortion). Must be taken within 3 days of unprotected intercourse.
49
What are the possible side effects of the morning after pill?
headache, abdominal pain, nausea. Liver P450 Enzyme inducer medications make it less effective. If vomit within 2-3hrs of taking it, may need to take another.
50
What are the consideration you should make to choose contraception?
Risk of Venous Thromboembolism (VTE) / CVD / Stroke Comorbidities Other conditions that may benefit from OCP eg Menorrhagia / Endometriosis / Fibroids Need for prevention of Sexually Transmitted Infections Concurrent medication
51
When should you avoid the OCP?
``` Migraine with aura (risk of stroke) Smoking (>15/day) + age >35yrs Stroke or CVD history Current Breast cancer Liver Cirrhosis Diabetes with retinopathy/nephropathy/neuropathy ```
52
What concurrent medication should you be aware of with the contraception?
``` P450 liver enzyme-inducing drugs (eg anti-epileptics, some antibiotics) Teratogenic drugs (eg lithium or warfarin), more effective methods of contraception needed (eg progestogen-only implant, or intrauterine contraception).  ```
53
What is peri-menopausal?
Within 12 months of last menstrual period (LMP)
54
What are the risks of HRT?
Venous Thrombo-embolism Hormone sensitive cancers Cardiovascular risk (none)
55
Why are venous thrombosis embolism risks of HRT?
eg Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) Oral oestrogens undergo first pass metabolism in liver Oral >> Increase SHBG, Triglycerides, CRP Transdermal estrogens are safer for VTE risk than oral Avoid oral oestrogens in BMI > 30 kg/m2
56
How can HRT increase cancer risk?
Breast Cancer Slight increase only in women on Combined HRT (ie oestrogen AND progesterone) Risk related to duration of treatment and reduces after stopping Continuous worse than Sequential Assess Background risk in the individual woman before prescribing Ovarian cancer- Small increase in risk after long-term use. Endometrial Cancer- Must prescribe Progestogens in all women with an endometrium !
57
How do you assess HRT safety (time periods)?
At 3 months Then annually
58
What are the main features of CVD and HRT?
No increased risk if started before age 60 yrs Increased risk if started 10 years after menopause Possible benefits of oestrogen supplementation in young women e.g. Premature Ovarian Insufficiency (POI)
59
What are the main features of stroke and HRT?
Small increased risk Oral > transdermal oestrogens Combined > oestrogen only
60
What are the benefits of HRT?
Relief of symptoms of low oestrogen eg Flushing, disturbed sleep, decreased libido, low mood, Less osteoporosis related fractures decreased by one third
61
What is the difference between gender or sex?
Gender is social construct, how you see yourself as male, female, or non-binary. Sex is biologically defined eg male, female, or Intersex.
62
What is cisgender?
Same Sex and Gender
63
What does gender non-conforming mean?
Gender does not match assigned sex
64
What is gender dysphoria?
Identity issues cause depression
65
What is non-binary?
Gender does not match to traditional binary gender understanding, includes agender, bigender, pangender, gender fluid
66
What is transgender?
Transitioning or planning to transition physical appearance from one to another
67
How can people transition?
Prepubertal young people - GnRH agonist for pubertal suppression and then sex steroids. Post-treatment regret 1-2% Gender Reassignment surgery after 1-2 yrs of hormonal treatment
68
What hormones do you give for transgender men?
Testosterone (injections, gels)
69
What are the side effects of giving T?
Polycythaemia, lower HDL, Obstructive Sleep Apnoea (OSA). No increase in CVD
70
What happens after giving T to transgender men?
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
71
What are the feminising hormones with transgender women?
Estrogen (transdermal, oral, intramuscular) | High dose oestrogen eg 4-5mg per day to aim for estradiol levels of 734 pmol/L.
72
What are the side effects of giving oestrogen?
VTE dose-related at 2.6%, high BP, Cardio-Vascular Disease, high Triglycerides, hormone sensitive cancers eg breast cancer, abnormal Liver Function tests 3%
73
How is T reduced in transgender women?
``` GnRH agonists (induce desensitization of HPG axis) Ant-Androgen medications (eg Cyproterone acetate, Spirnolactone) ```
74
What happens as transgender women feminise?
1 TO 3 MONTHS: Decrease in sexual desire / function (including erections) / Baldness slows / may reverse 3 TO 6 MONTHS: Softer skin and Change in body fat distribution / Decrease in testicular size / Breast development and tenderness 6 TO 12 MONTHS: Hair may become softer and finer

Year 2 Endo (15 decks)

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