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Endocrinology 2 > Reproductive treatments > Flashcards

Reproductive treatments Flashcards

1
Q

How do LH and FSH stimulate spermatogenesis?

A

LH stimulates Leydig cells to increase intratesticular testosterone FSH stimulates seminiferous tubule development and spermatogenesis

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2
Q

what is the treatment for secondary hypogonadism in men requiring fertility?

A

Give hCG injections which act on LH receptors If no response after 6 months, add LH injections

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3
Q

what treatment should you give to a man with kallmann syndrome (congenital hypogonadotrophic hypogonadism)? What pretreatment testicular size has a better outcome?

A

FSH for 2-4 months then hCG treatment >6ml

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4
Q

How does someone qualify for testosterone replacement?

A

at least 2 low measurements of serum testosterone before 11am

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5
Q

what forms of testosterone replacement are there?

A

daily gel eg. tostran 3 weekly IM injection (sustanon) 3 monthly IM injection (nedbido) implants, oral preparations (less common)

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6
Q

what precautions should be taken with tostran (daily testosterone gel)

A

be careful not to contaminate partner

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7
Q

What are the safety cautions of taking testosterone?

A

Increased haematocrit (risk of hyperviscosity and stroke) Prostate specific antigen levels

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8
Q

Why do we only want to develop one follicle during ovarian induction in PCOS?

A

if >1 follicle develops, this risks multiple pregnancy with more risk

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9
Q

How do you restore ovulation in anovulatory PCOS?

A
  1. Lifestyle/weight loss/metformin 2. Letrozole (aromatase inhibitor) reduces oestradiol to reduce negative feedback 3. Clomiphene - oestradiol receptor antagonist 4. FSH stimulation
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10
Q

How does letrazole, an aromatase inhibitor, affect the gonadohypothalamopituitary axis?

A

Inhibits conversion of testosterone to oestradiol Oestradiol normally has a negative feedback effect on the hypothalamus and anterior pituitary By reducing oestradiol we are reducing negative feedback, therefore increasing release of GnRH and LH and FSH FSH stimulates follicle growth

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11
Q

how does clomiphene (an oestradiol receptor antagonist) affect the gonado-hypothalamo-pituitary axis?

A

Works as an antagonist of the oestradiol receptors, reducing negative feedback of oestradiol (blinds the receptors to oestradiol), resulting in increased GnRH and FSH/LH, increased FSH stimulates follicle growth

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12
Q

What are the 4 stages of IVF treatment?

A
  1. FSH injection and oocyte retrieval
  2. Fertilisation in vitro
  3. Embryo incubation
  4. Embryo transfer
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13
Q

What two types of in vitro fertilisation are there?

A

Intra-cytoplasmic sperm injection (if problem with sperm)

In vitro fertilisation (standard)

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14
Q

What are the two types of treatment that are used to prevent LH surge and premature ovulation?

A
  1. GnRH antagonist given on day 6 of IVF (or day 5 of FSH treatment)
  2. GnRH agonist given 8 days before FSH treatment and maintained for duration of treatment
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15
Q

How can both a GnRH agonist and antagonist be used to block an LH surge?

A

GnRH is pulsatile

If you give a non-pulsatile GnRH agonist continuous high dose, there will be an initial flare and then LH inhibition due to desensitization of LH receptors

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16
Q

How are the eggs carefully matured?

A

By hCG exposure

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17
Q

What are the symptoms of ovarian hyper-stimulation syndrome and what is it caused by?

A
  • pleural effusion
  • ascites
  • renal failure
  • ovarian torsion

hCG injection - hCG is very long lasting and can cause this side effect

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18
Q

how does hCG work to cause egg maturation?

Why do we use it instead of LH?

A

acts on LH receptors

It is more effective and more likely to result in pregnancy

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19
Q

What are the barrier methods of contraception?

A

male/female condom/ diaphragm or cap with spermicide

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20
Q

what are the hormonal methods of contraception?

A

combined oral contraceptive pill

progestogen-only pill

long acting reversible contraception (LARC)

emergency contraception

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21
Q

what are the permanent methods of contraception?

A

Vasectomy

Female sterilisation

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22
Q

How does the oral contraceptive pill work?

A

oestrogen provides negative feedback to hypothalamopituitary axis, decreasing GnRH and LH/FSH, resulting in anovulation

progesterone thins endometrial lining and thickens cervical mucus to reduce implantation and prevent sperm entering

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23
Q

what are the benefits of the combined oral contraceptive pill?

A

One pill a day

effective

doesn’t interrupt sex

reduce endometrial and ovarian cancer

can take several packets back to back and avoid withdrawal bleeds

weight neutral in 80%

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24
Q

what are the downsides of the combined oral contraceptive pill?

A
  • No protection against STIs
  • Difficult to remember
  • P450 enzyme inducers eg. antibiotics, may reduce efficacy
  • Not great during breastfeeding
  • side effects such as spotting, nausea, sore breasts, changes in mood and libido, feeling hungry
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25
Q

what are three combined oral contraceptive pill non-contraceptive uses?

A
  1. Helps make periods lighter and less painful
  2. Withdrawal bleeds will usually be regular
  3. PCOS: help reduce LH and hyperandrogenism
26
Q

what are the benefits of the progesterone only pill or ‘mini pill’?

A
  • suitable if can’t take oestrogen
  • easy to take
  • doesn’t interrupt sex
  • can help heavy or painful periods
  • periods may stop
  • can be used when breastfeeding
27
Q

progesterone only pill negatives?

A
  • less reliably inhibits ovulation than OCP
  • No protection against STIs
  • can be difficult to remember
  • shorter acting so needs to be taken at the same time every day
  • side effects: irregular bleeding, headaches, sore breasts, changes in mood, changes in sex drive
28
Q

Give 3 examples of long acting reversible contraceptives

A
  1. Intra-uterine device (IUD) ie. copper coil
  2. Intra-uterine systems which secretes progesterone eg. mirena coil
  3. Progesterone only injectable contraceptives or subdermal implants.
29
Q

How long does the copper coil last for?

What are the downsides?

A

5-10 years

heavy periods, can come out during the first 3 months along with periods

30
Q

what are the benefits of coils?

A
  • can be used for women with or without previous children
  • Prevent implantation of conceptus - important for some religions
  • can be used as emergency contraception
31
Q

Precautions/ things to bear in mind regarding intra-uterine coils?

A

must exclude STIs and cervical screening must be up to date before insertion

rarely can cause ectopic pregnancy

32
Q

What are the three types of emergency contraception? How long can they be used after unprotected sex?

A
  1. Copper intra-uterine device <5 days after
  2. Emergency contraceptive pills:
  • ulipristal acetate 30mg (ellaOne) <5 days
  • levonorgestrel 1.5mg (Levonelle) <3 days
33
Q

how does ulipristal acetate (ellaOne) work?

A

stops progesterone working normally and prevents ovulation

34
Q

how does levonorgestrel work? who is it less effective in?

A

synthetic progesterone prevents ovulation

must be taken within 3 days of unprotected intercourse

women with BMI greater than 27kg/m2

35
Q

what are the side effects of emergency contraceptive pills?

A

headache, abdominal pain, nausea

liver P450 enzyme inducer medications make it less effective

If vomit within 2-3hr of taking it, may need to take another

36
Q

what is one of the major risks of the OCP?

A

risk of venous thromboembolism (VTE)/CVD/stroke

37
Q

in what circumstances should you avoid the OCP?

A

migraine with aura (risk of stroke)

smoking >15/day and age >35 years

stroke or CVD history

current breast cancer

liver cirrhosis

diabetes with retinopathy/nephropathy/neuropathy

38
Q

what other conditions may benefit from OCP?

A

menorrhagia

endometriosis

fibroids

39
Q

what are medications that can effect choice of contraception?

A

P450 liver enzyme inducing drugs eg. anti-epileptics, some antibiotics

teratogenic durgs eg. lithium or warfarin

40
Q

Which are the three most effective types of contraception?

A

Implant, IUS and IUD

41
Q

what does peri-menopausal mean?

A

within 12 months of last menstrual period

42
Q

what does post menopausal mean?

A

after 12 months of last menstrual period

43
Q

which is safer for venous thrombo-embolism, transdermal or oral oestrogens and why?

A

Oral oestrogens undergo first pass metabolism in the liver and increase SHBG, triglycerides, CRP

so transdermal is safer

44
Q

at what BMI should people avoid oral oestrogens?

A

>30

45
Q

what is the other risks besides VTE when having hormone replacement therapy?

A

breast cancer (hormone sensitive cancers)

only risk is in women with combined HRT (oestrogen and progesterone)

ovarian cancer - small increase in risk after long term use

cardiovascular risk if starting 10 years after menopause

small increased risk of stroke –> oral >transdermal oestrogens, combined >oestrogen only

46
Q

what must you do to prevent endometrial cancer in women when giving oestrogen?

A

also prescribe progestogens

47
Q

When should you assess hormone replacement therapy’s safety?

A
  • after 3 months
  • then annually
48
Q

post-menopausal bleeding can indicate what?

A

endometrial cancer

49
Q

name the benefits of HRT?

A

relief of sympyoms of low oestrogen:

  • flushing
  • disturbed sleep
  • decreased libido
  • low mood
  • less osteoporosis related fractures (decreased by 33%)
50
Q

cisgender means?

A

same sex and gender

51
Q

gender non-conforming

A

gender does not match assigned sex

52
Q

gender dysphoria

A

when gender not matching assigned sex leads to depression

53
Q

non-binary

A

gender does not match to traditional gender understanding

eg. agender, bigender, pangender, gender fluid

54
Q

transgender

A

transitioning or planning to transition physical appearance from one to another

55
Q

transgender males

transgender women

A

female sex at birth, but male gender

male sex at birth, but female gender

56
Q

What treatment is given to prepubertal young people who want gender reassignment surgery?

A

GnRH agonist for pubertal suppression and then sex steroids

gender reassignment surgery after 1-2 years of hormonal treatment

57
Q

which sex steroid hormones are given to transgender men?

what are the side effects?

A

testosterone injection or gel, progesterone to suppress menstrual bleeding if needed

  • polycythaemia
  • lower HDL
  • obstructive sleep apnoea
58
Q

what happens as a result of giving testosterone to transgender men, and in what period?

A
  • balding
  • deeper voice/acne/increased and coarser facial and body hair
  • change in distribution of body fat
  • enlargement of clitoris
  • menstrual cycle stops
  • increased muscle mass and strength

1-6 months

59
Q

what are the feminizing hormones for transgender women?

A
  1. oestrogen - 4-5mg per day –> aim for estradiol levels of 734pmol/L
  2. GnRH agnosists to induce desensitization of HPG axis, and anti-androgen medications eg. cyproterone acetate, spironolactone - has a negative effect on androgen receptor
60
Q

What are the effects of giving feminising hormones for transgender women?

A
  • 1-3 months decrease in sexual desire/function, baldness slows/may reverse
  • 3-6 months softer skin and change in body fat distribution, change in testicular size, breast development and tenderness
  • 6-12 months hair becomes softer and finer

Endocrinology 2 (17 decks)

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