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Therapeutics II > Block 5: Infertility > Flashcards

Block 5: Infertility Flashcards

1
Q

What is infertility?

A

Inability to conceive after 12 months of unprotected sexual intercourse

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2
Q

How is lifestyle linked to fertility?

A
  1. Increase in protien, fruits, veggies
  2. Men need zinc
  3. Exercise too much stop ovulation
  4. Fertility improves with BMI of 24–30 kg/m2
  5. Fertility decreased in those with BMI less than 19 kg/m2
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3
Q

What are the RF of infertility?

A
  1. Age older than 35 years
  2. Tobacco use
  3. Alcohol use
  4. Caffeine use (more than 500 mg/day)
  5. Vitamin D deficiency
  6. Excessive exercise
  7. BMI less than 19 kg/m2 or more than 25 kg/m2 for women
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4
Q

How do you assess infertility?

A
  1. TIming of intercourse
  2. Modifiable RF (smoking, alcohol, caffeine, obesity)
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5
Q

How do you identify infertility cause?

A
  1. Semen analysis
  2. Confirmation of ovulation
  3. Documentation of tubal patency
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6
Q

How do you treat hyperprolactinemia?

A

Increased prolactin can cause infertility
First line: dopamine agonist (bromocriptine, carbergoline)
Second: surgery

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7
Q

How do you treat hypothyroidism?

A

Change menstrual cycle or sperm production

First line: thyroxine

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8
Q

What are the fertility agents?

A
  1. Clomiphene citrate
  2. Aromatase inhibitors(Femara (letrozole), Arimidex (anastrozole) –used off label)
  3. Human menopausal gonadotropin (hMG)
  4. Follicle-stimulating hormone (FSH)
  5. Human chorionic gonadotropin (hCG)
  6. Gonadotropin-releasing hormone analogs
    (GnRH)
  7. Metformin/ thiazolidinediones
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9
Q

What is the tx for ovulatory dysfunction?

A

First line: Clomiphene (Clomid®)

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10
Q

Clomiphene

Brand, MOA, Counseling, ADR, CI

A

Clomid
MOA: SERM
* Competes with estradiol for estrogen receptors at the hypothalamus
* Blocks estrogen negative feedback at the hypothalamus
* Increase in GnRH -> release of more FSH and LH -> stimulates ovaries

Counseling:
* Women failing to ovulate with 100 mg/day or failing to conceive following 3 to 6 months of ovulatory response to clomiphene should be considered for alternative treatments

ADR:
* Hot flashes
* Mild pelvic discomfort
* Breast tenderness

CI:
* Uncontrolled thyroid or adrenal dysfunction
* Primary ovarian failure or ovarian cysts
* Abnormal uterine bleeding
* Hepatic disease (hepatic metabolism)
* Pregnancy (category X)

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11
Q

What is the tx of PCOS?

A
  1. Weight loss, nutrition, exercise
  2. Insulin-sensitizing agents: First line: metformin 500-850mg BID and TZD
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12
Q

What are the gonadotropins?

A

LH, FSH

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13
Q

Indications and risks for gonadotropins?

A

Indication: Women with hypogonadism and PCOS
Risks: Multiple gestation, ovarian hyperstimulation

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14
Q

What is endometriosis?

A

Chronic disorder resulting in pain and infertility, endometrial tissue found outside the uterus

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15
Q

What are the risk facotrs for endometriosus?

A
  1. Menstruation-related problems
  2. Genital tract abnormalities
  3. Never had children/delayed pregnancy
  4. Elevated estrogen levels
  5. Genetic predisposition
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16
Q

What are the s/s of endometriosus?

A

Sx:
1. Pelvic pain
1. Subfertility
1. Dyspareunia
1. Dysmenorrhea
1. Abnormal menses
1. GI/GU symptoms
1. Asymptomatic

Signs:
1. Ligament tenderness
1. Tender nodules
1. Tender pelvic or adnexal mass
1. Small lesions on ovaries (dark brown, black, or blue lesions, nodules, and cysts)

17
Q

What are the goals of therapy?

A
  1. Remove tissue deposits
  2. Prevent progession of the condition
  3. Reduce the severity of pain
  4. Prevent or correct infertility
18
Q

What are the tx of endometriosus?

A

First: COC
Second: NSAIDs, GnRH agonist, Danazol, Progestin

19
Q

Therapy that doesn’t reduce scarring or cause reversal of endometriosis?

A

COC

20
Q

NSAID agents for endometriosus?

MOA, Caution

A

Ibuprofen 400 mg q4-6h
Naproxen 250 mg q6-8h

MOA: Decreases PG production
Caution: Reactive airways disease, renal disease, GI ulcer

21
Q

GNRH agonist

MOA, Brand, ADR, Dosing

A

MOA:
* Prevents LH surge that occurs right before ovulation, which helps with timing of ovulation
* overstimulation = desensitization=downregulation=hypogonadism
* Induces “menopause” state

Brand: Leuprolide (Lupron), nafarelin (Synarel)
ADR: Hot flashes, vaginal dryness, irregular vaginal bleeding, mood changes, fatigue, and loss of bone density
Dosing: 1000 mg Ca daily while taking GnRH agonist

22
Q

What are the add-on therapy for GnRH?

A

Improves side effects and helps to reduce bone loss:
1. Norethinedrone 5 mg po daily
2. Norethindrone + Conjugated equine estrogen 5 mg po daily + 0.625 mg po daily
3. Norethindrone + Etidronate 2.5 mg po daily + 400 mg po daily x 14 days every 8 weeks

23
Q

Danazol

MOA, ADR, CI

A

MOA: Pituitary suppression of midcycle FSH/LH, Immunosuppressive
ADR: Androgenic: acne, hot flashes, increased LDL, weight gain, edema, hirsutism, myalgia (voice change is not reversible)
CI: Avoid in hyperlipidemia and liver disease, teratogenic

24
Q

Progestin agents for endometriosis?

A

Medroxyprogesterone 30-100 mg PO qd OR 150mg IM q3months
Norethindrone 15 mg qd
Megestrol 40 mg PO qd OR 3.75 mg IM q month

25
Q

Progestins

MOA, ADR

A

MOA: Decreases endometrial buildup of tissue and decrease inflammation
ADR: Delay in return to fertility, breakthrough bleeding, weight gain, edema, depression, mood swings, breast tenderness

26
Q

Aromatase inhibitors

Products, MOA, ADR

A

Anastrozole (Arimidex) and Letrozole (Femara)
MOA: Interrupt local estrogen formation within the endometriosis implants themselves
ADR: Significant bone loss with prolonged use, HA, GI complaints, joint and bone pain, edema, sweating, flushing

27
Q

1st line for infertility tx?

A

Conservative surgery: resection of lesions

Radical surgery (other option): definitive tx, induces menopause

28
Q

What are the surgical risks?

A
  1. Pelvic damage
  2. General surgical risks
29
Q

What are the monitoring parameters for endometriosis?

A
  1. Relieved within 2 months of therapy: If symptoms persist, consider different medical and/or surgical therapy
  2. For infertility, most experts recommend 6 months of watchful waiting after surgical intervention
  3. Lipids, BP measurements, BMI
30
Q

What is dysmenorrhea?

A

Crampy pelvic pain that occurs with menses

31
Q

What causes dysmenorrhea?

A

Primary: Caused by menstrual period, mediated by prostaglandins
Secondary: Caused by menstrual period, mediated by prostaglandins, later in life

32
Q

What is the tx plan for dysmenorrhea?

A

Non Pharm:
* Topical heat therapy
* Exercise
* Low-fat vegetarian diet
* Transcutaneous electric nerve stimulation
* Acupressure/acupuncture

NSAIDs: Scheduled dose starting 1 day prior to menses or prn, Trial for 2-3 menstrual cycles, Take with food or milk

OCs: Trial of 2-3 months to determine efficacy

Depot medroxyprogesterone: Renders most patients amenorrheic within 1 year, Lack of menses -> absence of PG release

Levonorgestrel-releasing IUD: Reduces menstrual flow -> decrease in PG release

If contraception is desired: OC is initial tx
If contraception is not desired: Scheduled NSAIDs are initial treatment

33
Q

What is the criteria for being diagnosed with PMDD?

A
  1. Sx during last week of luteal phase, remit with menses
  2. At least 5 of the following are present: Depressed mood, anxiety, affective lability, anger or irritability, decreased interest in activities, fatigue, difficulty concentrating, changes in appetite, sleep disturbance, feelings of being overwhelmed, physical symptoms
    (One symptom must be depressed mood, anxiety, irritability or affective lability)
  3. Symptoms interfere with work/social relationships
  4. Symptoms are not an exacerbation of an underlying psychiatric disorder
34
Q

What is the non pharm tx for PMS/PMDD?

A
  1. Chart sx for at least 2 cycles
  2. Lifestyle modifications
  3. Vitamin B6 50-100 mg daily
  4. Calcium carbonate 1200 mg daily
  5. Not recommended: herbal medicines, homeopathic remedies, dietary supplements
35
Q

What is the pharm tx for PMS/PMDD?

A

First: SSRI
Alternatives:
* Clomipramine (TCA)
* Venlafaxine (SNRI)
* OC (Ethinyl estradiol/drospirenone +/- levomefolate (Beyaz®/Yaz®), Drospirenone (progesterone))
* Leuprolide (GnRH agonist): severe PMDD but expensive

Therapeutics II (30 decks)

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