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!!!!! BRS YR2 !!!!! > Endo - Reproductive Treatments > Flashcards

Endo - Reproductive Treatments Flashcards

1
Q

What is testosterone replacement given for?

A

not looking for fertility

but wants to improve symptoms

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2
Q

What symptoms does T replacement treat?

A

→ loss of early morning erections
→ low libido
→ decreased energy
→ reduced shaving frequency

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3
Q

Why is testosterone not given to people wanting fertility, even if they have low T?

A

→ testosterone leads to negative feedback on LH + FSH
→ reduces FSH and LH
→ reduces spermatogenesis

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4
Q

What levels of testosterone are required for T replacement to be given?

A

→ at least 2 low measurements of serum T before 11 am

→ low measurements < 9 mol/L

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5
Q

What forms of T replacement are available?

A

→ daily gel (e.g. Tostran)
→ 3 weekly intramuscular injections (e.g. Sustanon)
→ 3 monthly intramuscular injections (e.g. Nebido)
→ implants + oral prep (less common)

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6
Q

Why do you have to be careful with daily gel T replacement?

A

have to be careful and not contaminate partner

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7
Q

What factors need to be monitored when taking T replacement? Why?

A

→ increased haematocrit (ratio of RBC to blood vol) : could lead to hyperviscosity and stroke
→ PSA levels (prostate specific antigen) : overstimulation of prostate could cause cancer

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8
Q

What is primary hypogonadism?

A

→ high LH + FSH
→ but problems with gonads themselves
→ so low T produced from gonads

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9
Q

How hard is it to treat?

A

difficult to treat

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10
Q

What is secondary hypogonadism?

A

→ low LH and FSH produced

→ so low T

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11
Q

How is secondary hypogonadism treated induce spermatogenesis?

A

treat with LH + FSH

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12
Q

How do LH and FSH induce + promote spermatogenesis?

A

→ LH stimulates Leydig cells to increase intratesticular testosterone (to x100 the levels than in circulation)
→ FSH stimulates seminiferous tubule development + spermatogenesis

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13
Q

How is low T in secondary hypogonadism treated in those who want fertility?

A

→ hCG injections (acts on LH-receptors

→ if no response after 6 months, add FSH injections

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14
Q

What are the symptoms of PCOS?

A

2/3 of these qualify for PCOS:
→ hyperandrogenism (clinical or biochemical
→ PCOS morphology on ultrasound
→ irregular periods

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15
Q

What are the features of hyperandrogenism?

A

→ hirutism

→ acne

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16
Q

What are the signs or features of hypothalamic amenorrhoea?

A 
→ low body weight
→ excessive exercise
→ stress
→ genetic susceptibility
→ irregular periods
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17
Q

What is hypothalamic amenorrhoea?

A

stress on the body causes hypothalamus to stop releasing GnRH, stopping release of LH and FSH

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18
Q

What is ovulation induction?

A

→ aim to develop one ovarian follicle

→ methods aim for small increase in FSH

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19
Q

Why is only one ovarian follicle the aim for ovulation induction?

A

→ if more than 1 develops, has risks of multiple pregnancies (twins or triplets)
→ multiple pregnancies = many risks for mother + baby during preganancy

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20
Q

What are the 4 methods in which ovulation can be induced?

A

→ lifestyle / weight loss / metformin
→ letrozole
→ clomiphene
→ FSH stimulation

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21
Q

How does letrozole induce ovulation?

A

→ aromatase inhibitor
→ aromatase = converts T to Oestradiol
→ inhibiting aromatase = low oestradiol
→ low oestradiol = reduced negative feedback on pituitary and hypothalamus
→ this increases GnRH + LH + FSH
→ stimulates follicle growth + egg release

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22
Q

How does clomiphene induce ovulation?

A

→ oestradiol receptor antagonist
→ reduces the amount of oestradiol produced
→ reduces negative feedback on hypothalamus and pituitary
→ increases GnRH + LH + FSH
→ stimulates follicle growth + egg release

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23
Q

What are the different steps of IVF?

A

→ oocyte retrieval
→ fertilisation in vitro
→ embryo incubation
→ embryo transfer

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24
Q

What is oocyte retrieval?

A

→ high doses of FSH to stimulate follicle growth

→ eggs collected outside of utero

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25
Q

What is fertilisation in vitro?

A

either:
→ IVF (in vitro fertilisation) : sperm + egg mixed in a dish)
→ ICSI (intra-cytoplasmic sperm injections) : single sperm injected directly into the egg

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26
Q

What in embryo incubation?

A

waiting 3-5 days

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27
Q

What is embryo transfer?

A

the strongest embryo in implanted into the endometrium

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28
Q

When in ICSI preferred over IVF?

A

when there’s problems with male fertility or sperm

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29
Q

What are the key steps in IVF in terms of hormones?

A

→ FSH stimulation (super ovulation so that multiple follicles develop )
→ prevent premature LH surge (to prevent premature ovulation before eggs can be collected)
→ expose eggs to LH when mature

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30
Q

Why does premature ovulation need to be prevented in IVF patients?

A

→ prevents egg form being collected before it’s ready to be collected

31
Q

What medications or hormones prevent premature LH surge in IVF patients?

A

→ GnRH antagonist protocol (short protocol)

→ GnRH agonist protocol (long protocol)

32
Q

When is FSH given in accordance with GnRH antagonist?

A

→ FSH = day 2 to day 10

→ GnRH antagonist = day 6 to approx. day 10

33
Q

When is FSH given in accordance with GnRH agonist?

A

→ FSH = day 2 to day 10

→ GnRH agonist = day -7 to day 10

34
Q

Why can’t LH be used to induce oocyte maturation?

A

→ very short-acting so would have to be given in very large doses
→ still not as effective as hCG injections

35
Q

How are GnRH antagonists or GnRH agonists used to prevent an LH surge?

A

→ GnRH needs to be given in a pulsatile manner to stimulate LH
→ continuous high dose of GnRH causes desensitisation of GnRH receptors, leading to LH inhibition
→ GnRH agonists given over a long period cause this desensitisation
→ GnRH antagonists inhibit receptors and inhibit LH

36
Q

How are eggs exposed to LH?

A

→ hCG (acts on LH receptors)

→ GnRH agonists (causes an LH surge at first)

37
Q

Why are eggs exposed to LH?

A

→ to induce maturation

→ allows them to go from diploid to haploid

38
Q

Why is LH not given when trying to induce oocyte maturation?

A

→ short-acting so large doses needed

→ less effective than hCG

39
Q

What are the common methods of contraception?

A

→ Barrier: male / female condom/ diaphragm or cap with spermicide
→ Combined Oral Contraceptive Pill (OCP)
→ Progestogen-only Pill (POP)
→ Long Acting Reversible Contraception (LARC)
→ Emergency Contraceptio

40
Q

What are some permanent methods of contraception?

A

→ vasectomy

→ female sterilisation

41
Q

What are the positives of barrier contraception?

A

→ protects against STIs
→ easy to obtain (free form clinics and there’s no need to see a healthcare professional)
→ no contra-indications

42
Q

What are some negatives of barrier contraception?

A 
→ Can interrupt sex
→ Can reduce sensation
→ Can interfere with erections 
→ Some skill to use eg correct fit 
→ Two are not better than one
43
Q

What is the OCP?

A

→ oral contraceptive pil
→ contains progesterone and oestrogen
→ results in an ovulation

44
Q

How does the oral contraceptive pill stop conception?

A

→ Oestrogen + progesterone - anovulation due to negative feedback on GnRH and gonadotrophins (LH and FSH)
→ Progesterone - thickening of the cervical mucus and thinning of endometrial lining

45
Q

What are the positives of the OCP?

A

→ 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)

46
Q

What are the negatives of the OCP?

A

→ It can be difficult to remember
→ No protection against STIs
→ P450 Enzyme Inducers may reduce efficacy
→ Not the best choice during breast feeding

47
Q

What are the possible side effects of the OCP?

A 
→ Spotting (bleeding in between periods)
→ Nausea
→ Sore breasts
→ Changes in mood or libido
→ Feeling more hungry
48
Q

What non-contraceptive uses does the OCP have?

A

→ Helps make periods lighter and less painful (e.g. endometriosis or period pain or menorrhagia)
→ Withdrawal bleeds will usually be very regular
→ PCOS: help reduce LH and hyperandrogenism

49
Q

What is the POP?

A

→ progesterone only pill
→ works like OCP
→ less reliable than OCP in inhibiting ovulation

50
Q

What are the positives of POP?

A

→ often suitable if you cannot 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

51
Q

What are the negatives of POP?

A

→ Can be difficult to remember
→ No protection against STIs
→ Shorter acting – needs to be taken at the same time each day

52
Q

What are the possible side effects of POP?

A 
→ Irregular bleeding
→ Headaches
→ Sore breasts
→ Changes in mood
→ Changes in sex drive
53
Q

What are LARCs?

A

long acting reversible contraceptives

54
Q

What are some examples of LARCs?

A

→ IUD (intr-uterine device)
→ IUS (intra-uterine systems) -
→ Progestogen-only injectable contraceptives or subdermal implants

55
Q

What is an IUD?

A

→ intra-uterine device
→ copper coil, mechanically prevents implantation,
→ decreases sperm egg survival, lasts 5-10 years
→ can cause heavy periods, and 5% can come out especially during the first 3 months with periods

56
Q

What is an IUS?

A

→ intra-uterine systems
→ acts as the coil but also secretes progesterone
→ thickens cervical mucus (Can be helpful for women with heavy bleeding)
→ Lasts 3-5 years

57
Q

What are the advantages of LARCs?

A

→ Suitable for most women including those with no previous children
→ Can be used as emergency contraception
→ Rarely can cause ectopic pregnancy
→ Prevent implantation of conceptus – important for some religions

58
Q

What are some examples of emergency contraceptions?

A

→ IUD - most effective (less than 1% chance of pregnancy) - fitted up to 5 days after unprotected sex
→ Emergency contraceptive pill, ULIPRISTAL ACETATE - 30mg, taken within 5 days of unprotected sex (earlier the better)
→ Emergency contraceptive pill, LEVONORGESTREL - synthetic progesterone, 1.5mg, taken within 3 days of unprotected sex (least effective)

59
Q

What are the possible side effects of emergency contraceptives?

A

→ Headache
→ Abdominal pain
→ Nausea
→ Liver P450 enzyme inducer medications make it less effective
→ If vomit within 2-3 hours of taking it, need to take another

60
Q

What factors need to be taken into consideration when choosing contraception?

A

→ Risk of Venous Thromboembolism (VTE) / CVD / Stroke
→ Comorbidities
→ Other conditions that may benefit from a contraception e.g. menorrhagia/endometriosis/fibroids
→ Need for prevention of STIs
→ Concurrent medication

61
Q

What comorbities mean that OCP should be avoided?

A 
→ 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
62
Q

What concurrent medication should be considered when taking contraception?

A

→ 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

63
Q

What is the general disadvantage of user dependent contraceptions?

A

more chance or failure due to incorrect use

64
Q

What are the symptoms of menopause?

A 
→ Hot flushes
→ sweating
→ disturbed sleep
→ Low libido
→ vaginal dryness
→ low mood
→ Joint and muscle aches
→ Absent periods
65
Q

What is HRT?

A

hormone replacement therapy

66
Q

What are the risks of HRTs?

A

→ VTEs (venous thrombo-embolisms): Deep
Vein Thrombosis (DVT) or Pulmonary Embolism (PE)
→ Oral oestrogens - go through liver to undergo first pass metabolism (more risky) VS transdermal = straight into the bloodstream
→ Breast cancers = slight increased risk with combined HRT (oest and prog)
→ Ovarian cancer - increased risk after long term use
→ Endometrial cancers = must prescribe progestogens to minimise risk (post-menopausal bleed may indicate endometrial cancer)
→ No increased risk of CVD (cardiovascular disorder) if started before aged 60
→ Increased risk if started 10 years after menopause
→ Possible benefits of oestrogen supplementation in young women e.g. Premature Ovarian Insufficiency (POI)
→ Risk of stroke - small increase, most increase with oral combined pill (least = transdermal oestrogen only)

67
Q

What are the benefits of HRT?

A

→ Relieves symptoms caused by low oestrogen- e.g. flushing, disturbed sleep, decreased libido, low mood
→ Less osteoporosis related fractures

68
Q

What are some HRTs that can be used for transgender + gender non-binary individual?

A

→ GnRH agonist
→ high dose continuously pre- puberty
→ delays prepubertal effects to make the decision and then sex steroids
→ Gender reassignment surgery after 1-2 years of hormonal treatment

69
Q

What are the masculinising hormones for transgender men?

A

→ Testosterone (injections, gels)

→ Progesterone to suppress menstrual bleed (if needed)

70
Q

What are the changes experienced after HRT for transgender men?

A

In 1 to 6 months:
→ 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
Q

What are the feminising hormones for transgender women?

A

→ Oestrogen (transdermal, oral, intramuscular)
→ GnRH angonists/ant-androgen medications = reduce testosterone levels
→ consider sperm bank before start of HRT

72
Q

What can HRT not change for transgender women?

A

Height, voice and Adam’s apple will not change

73
Q

What are the effects of feminising hormones for transgender women?

A

→ 1 TO 3 MONTHS: Decrease in sexual desire / function (including erections) / Baldness slows or may reverse
→ 3 TO 6 MONTHS: Softer skin / Change in body fat distribution / Decrease in testicular size / Breast development / tenderness
→ 6 TO 12 MONTHS: Hair may become softer and finer

!!!!! BRS YR2 !!!!! (72 decks)

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