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Year 2 - BRS > 3.13 - Reproductive treatments > Flashcards

3.13 - Reproductive treatments Flashcards

1
Q

What are the symptoms for low testosterone? (4)

A
  • loss of early morning erections
  • lower libido
  • decreased energy
  • lower frequency of shaving
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2
Q

How do we diagnose low testosterone?

A
  • at least 2 low fasting measurements of serum T before 11am (meant to be high)
  • investigate cause of low T
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3
Q

What different types of testosterone replacement treatments are there? (4)

A
  • daily gel - care not to contaminate partner
  • 3 weekly intramuscular injection
  • 3 monthly intramuscular injection
  • less common (implants, oral preparations)
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4
Q

What do we need to monitor for safety when replacing testosterone?

A
  • increased haematocrit (risk of hyperviscosity and stroke)
  • prostate (prostate specific antigen - PSA levels)
  • gynaecomastia, acne, aggression, prolonged painful erection
  • disturbed liver function
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5
Q

What is secondary hypogonadism in males?

A

Deficiency of gonadotrophins (LH/FSH) i.e. hypogonadotrophic hypogonadism

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6
Q

How do we treat primary and secondary hypogonadism in males?

A
  • primary - hard to treat
  • secondary - treat with gonadotrophins (LH/FSH) to induce spermatogenesis
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7
Q

What would LH and FSH do to the testes?

A
  • LH stimulates Leydig cells to increase intratesticular testosterone levels to much higher than in circulation (x100)
  • FSH stimulates seminiferous tubule development and spermatogenesis
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8
Q

Why do we avoid giving testosterone to men desiring fertility and what do we give instead?

A
  • for secondary hypogonadism (low sperm and T) , giving T would lower LH and FSH further = worsen spermatogenesis
  • instead give treatment inducing spermatogenesis:
  • hCG injections (act on LH receptors)
  • if no response after 6 months, add FSH injections
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9
Q

What are the main signs of polycystic ovary syndrome (PCOS)? (3)

A
  • hyperandrogenism (clinical or biochemical) - hirsutism / acne
  • PCO morphology on ultrasound
  • irregular periods

(Rotterdam PCOS Diagnostic Criteria) - need 2/3

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10
Q

What is hypothalamic amenorrhoea?

A

When you have insufficient energy for fertility due to decrease in hypothalamus function

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11
Q

What are the causes of hypothalamic amenorrhoea?

A
  • low body weight
  • excessive exercise
  • stress
  • genetic susceptibility
  • (anorexia nervosa)

Essentially causes of hypothalamic hypogonadism

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12
Q

What is the aim of ovulation induction?

A
  • to develop one ovarian follicle
  • if >1 follicle develops, this risks multiple pregnancy (twins/triplets) - has risks for mother and baby during pregnancy
  • ovulation induction methods aim to cause small increase in FSH
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13
Q

What are the different methods to restore ovulation in PCOS? (In order)

A
  • lifestyle / weight loss by 5%
  • metformin
  • letrozole (aromatase inhibitor - stops T—>E2 = lower E2 = higher FSH&LH)
  • clomiphene (oestradiol receptor modulator/antagonist = lower E2 = higher FSH&LH)
  • FSH stimulation (injection)
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14
Q

What are the different methods to restore ovulation in hypothalamic amenorrhoea? (5)

A
  • lifestyle / weight gain / reduce exercise
  • pulsatile GnRH pump
  • FSH stimulation (injection)
  • letrozole (aromatase inhibitor)
  • clomiphene (oestradiol receptor modulator)
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15
Q

What are the steps to in vitro fertilisation (IVF)?

A
  1. give high dose FSH to stimulate production of multiple follicles (superovulation)
  2. prevent LH surge to delay ovulation (e.g. GnRH antagonist)
  3. when follicles good size, give hCG injection = LH-like exposure to mature eggs
  4. oocyte retrieval
  5. fertilisation in vitro - either put in dish with sperm and let sperm fertilise egg, or intra-cytoplasmic sperm injection (male factor infertility)
  6. embryo incubation
  7. embryo transfer –> endometrium
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16
Q

What % of pregnancies are unplanned?

A

19-30%

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17
Q

What are non-permanent methods of contraception? (5)

A
  • barrier: male/female condom / diaphragm / cap with spermicide
  • combined oral contraceptive pill (OCP)
  • progesterone-only pill (POP)
  • long acting reversible contraception (LARC)
  • emergency contraception
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18
Q

What are permanent methods of contraception? (2)

A
  • vasectomy
  • female sterilisation
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19
Q

What are the positives of condoms? (3)

A
  • protect against STIs
  • easy to obtain - free from clinics/no need to see healthcare professional
  • no contra-indications as with some hormonal methods
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20
Q

What are the negatives of condoms? (5)

A
  • can interrupt sex
  • can reduce sensation
  • can interfere with erections
  • require some skill to use e.g. correct fit
  • two are not better than one
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21
Q

How does the combined oral contraceptive pill (OCP) work - three methods?

A
  1. anovulation
  2. thickening of cervical mucus
  3. thinning of endometrial lining to reduce implantation
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22
Q

How does the OCP affect the HPG axis to cause anovulation?

A
  • pill has oestrogen and progesterone
  • this has negative feedback on hypothalamus and pituitary
  • this decreases LH and FSH leading to anovulation
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23
Q

What are the positives of the combined OCP? (6)

A
  • easy to take - one pill a day at any time
  • effective
  • does not interrupt sex
  • can take several packets back to back and avoid withdrawal bleeds
  • reduces endometrial and ovarian cancer
  • weight neutral in 80% (10% increase, 10% decrease)
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24
Q

What are the negatives of the combined OCP? (4)

A
  • can be difficult to remember to take
  • no protection against STIs
  • P450 enzyme inducers may reduce efficacy
  • not the best during breast feeding
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25
Q

What are the possible side effects of combined OCP? (5)

A
  • spotting (bleeding in between periods)
  • nausea
  • sore breasts
  • changes in mood or libido
  • feeling more hungry
  • (try different OCPs to see which suits best)
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26
Q

What is an extremely rare side effect of combined OCP?

A

Blood clots in legs or lungs (2 in 10,000)

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27
Q

What are some non-contraceptive uses of the combined OCP?

A
  • helps make periods lighter and less painful (e.g. endometriosis/fibroids, dysmenorrhoea - painful periods, menorrhagia - heavy periods)
  • regular withdrawal bleeds / no bleeds
  • PCOS - OCP reduce LH and hyperandrogenism (acne and hirsutism)
28
Q

What are the advantages of the progesterone only pill (POP) aka mini-pill? (7)

A
  • works as OCP but less reliably inhibits ovulation
  • often suitable if you cannot take oestrogen
  • easy to take - one pill a day
  • does not interrupt sex
  • can help heavy/painful periods
  • periods may stop (temporarily)
  • can be used when breastfeeding
29
Q

What are the negatives of the progesterone only pill (POP)? (3)

A
  • can be difficult to remember to take
  • no protection against STIs
  • shorter-acting - needs to be taken at the same time everyday
30
Q

What are the possible side effects of the POP? (5)

A
  • irregular bleeding
  • headaches
  • sore breasts
  • changes in mood
  • changes in sex drive
31
Q

What are the two main methods of long-acting reversible contraceptives (LARC)?

A
  1. coils
    - intra-uterine device (IUD) i.e. copper coil
    - intra-uterine systems (IUS) i.e. Mirena coil
  2. progesterone-only injectable contraceptives or subdermal implants
32
Q

What are coils suitable for and what do they do overall?

A
  • suitable for most women
  • prevent implantation of conceptus - important in some religions
  • rarely can cause ectopic pregnancy (so exclude STIs and do cervical screening)
  • can be used as emergency contraception
33
Q

What are intra-uterine devices (IUDs)?

A
  • mechanically prevent implantation
  • decrease sperm/egg survival
  • last 5-10 years
34
Q

What are side effects of IUDs? (2)

A
  • can cause heavy periods
  • 5% can come out especially during first 3 months with periods
35
Q

What are intra-uterine systems (IUS)?

e.g. Mirena coil

A
  • secrete progesterone to thin the lining of the womb and thicken cervical mucus
  • can be used to help with heavy bleeding
  • lasts 5 years
36
Q

What is the problem with progesterone-only injectable contraceptives/subdermal implants?

A

Long-lasting so may not be best option if desiring fertility soon

37
Q

When can a copper IUD be used as emergency contraception?

A
  • most effective
  • can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)
38
Q

What are the two types of emergency contraceptive pills?

A
  • ulipristal acetate 30mg (ellaOne)
  • levonorgestrel 1.5mg (Levonelle)
39
Q

How does ulipristal acetate 30mg (ellaOne) work?

A
  • stops progesterone working normally and prevents ovulation
  • must be taken within 5 days of unprotected sex (earlier better)
  • 1-2% can get pregnant if ovulation has already occurred
40
Q

How does levonorgestrel 1.5mg (Levonelle) work?

A
  • less effective especially if BMI > 27kg/m2
  • synthetic progesterone prevents ovulation (does not cause abortion)
  • must be taken within 3 days of unprotected sex
  • 1-3% failure rate
41
Q

What are the side effects of the morning after (emergency contraceptive) pills? (3)

A
  • headache
  • abdominal pain
  • nausea
42
Q

What do you do if you vomit 2/3 hours after taking the emergency contraceptive pill?

A

Need to take another

43
Q

What can make the emergency contraceptive pill less effective?

A

Liver P450 enzyme inducer medications

44
Q

What is the efficacy for different types of contraception?

A
  • most effective <1% chance: implant, IUD, IUS
  • user dependent: condoms, OCP, POP etc
  • least effective: fertility awareness, withdrawal, no contraception
45
Q

When should you avoid OCPs due to contraindications (e.g. risk of venous thromboembolism/CVD/stroke)? (4)

A
  • migraine with aura (risk of stroke)
  • smoking (>15/day) at age of >35
  • stroke or CVD history
  • current breast cancer
46
Q

What other conditions may benefit from OCP? (6)

A
  • menorrhagia
  • endometriosis
  • fibroids
  • PMS
  • acne
  • hirsutism
47
Q

What type of contraception is best when there is need for prevention of STIs?

A

Barrier methods better than hormonal

48
Q

What concurrent drugs affect the efficacy of OCP? (2)

A
  • P450 liver enzyme-inducing drugs (e.g. anti-epileptics, antibiotics)
  • teratogenic drugs (e.g. lithium, warfarin) = more effective methods of contraception needed e.g. progesterone-only implant, IU contraception
49
Q

What are the benefits of hormone replacement therapy (HRT)? (2)

A
  • relief of symptoms due to low oestrogen e.g. flushing, sweats, disturbed sleep, decreased libido, low mood
  • reduction in osteoporosis related fractures

(Transdermal E2 reduces risk of VTE and stroke, lower risk of CVD in younger/recently PM women)

50
Q

What are the risks of HRT? (4)

A
  • venous thrombo-embolism (DVT or PE)
  • hormone sensitive cancers (breast, ovarian, endometrial)
  • cardiovascular disease
  • risk of stroke

(And need for progesterone as well as oestrogen increases risk of VTE and breast cancer)

51
Q

How does HRT cause venous thrombo-embolism (DVT/PE)?

A
  • oral oestrogens undergo first pass metabolism in the liver –> increased clotting factors
  • transdermal oestrogens are safer for VTE risk than oral
  • avoid oral oestrogens in BMI > 30kg/m2
52
Q

How can HRT cause breast cancer?

A
  • slight increase in women on combined HRT (oestrogen and progesterone)
  • risk related to duration of treatment and reduces after stopping
  • continuous worse than sequential (oes then prog)
  • assess risk in each individual before prescribing
53
Q

How can HRT cause ovarian cancer?

A

Small increase in risk after long-term use

54
Q

How can we reduce the chance of endometrial cancer caused by HRT?

And what clinical sign could indicate endometrial cancer?

A
  • must describe progestogens in all women with an endometrium
    • oestrogen only - only if no uterus e.g. had hysterectomy
    • everyone else - oestrogen AND progesterone as progesterone protects endometrium
  • progestogens - synthetic progestins and the natural hormone progesterone
  • post-menopausal bleeding could indicate endometrial cancer
55
Q

Who is at increased risk of CVD after HRT?

A
  • improved risk in younger women and sooner after menopause
  • increased risk if started later i.e. 10y after menopause
  • likely benefit in younger women e.g. POI
56
Q

How can HRT increase risk of stroke?

A
  • small increased risk
  • oral have more risk than transdermal oestrogens
  • combined (E2+P) more risk than oestrogen only
57
Q

What is the definition of gender?

A

A social construct - how you see yourself as male, female or non-binary

58
Q

What is the definition of sex?

A

Biologically defined e.g. male, female or intersex

59
Q

What is the definition of cisgender?

A

Same sex and gender

60
Q

What is the definition of gender non-conforming and gender dysphoria?

A
  • gender non-conforming: gender does not match assigned sex
  • gender dysphoria: when that causes distress
61
Q

What is the definition of non-binary?

A

Gender does not match to traditional binary gender understanding e.g. agender, bigender, pangender, gender fluid

62
Q

What is the definition of transgender?

A
  • transitioning or planning to transition physical appearance from one gender to another
  • transgender man - female sex at birth, but male gender
  • transgender women are 3x more common than transgender men
63
Q

How do prepubertal young people transition?

A
  • GnRH agonist to delay puberty then sex steroids
  • waiting list for specialist clinic around 4y
  • post treatment regret is 1-2%
  • gender reassignment surgery after 1-2 years of hormonal treatment
64
Q

What do you treat transgender men with?

A
  • masculinising hormones
  • testosterone (injections, gels)
  • progesterone (to suppress menstrual bleeding if needed - endometrial hyperplasia 15%)
65
Q

What do you treat transgender women with?

A
  • feminising hormones
  • reduce testosterone - GnRH agonists (induce desensitisation of HPG axis), anti-androgen medications
  • oestrogen (transdermal, oral, intramuscular) - high dose oestrogen e.g. 4-5mg per day (side-effects: higher risk of VTE 2.6%)

Year 2 - BRS (84 decks)

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