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Year 2 RE > Endocrine Aspects of Male Hypogonadism > Flashcards

Endocrine Aspects of Male Hypogonadism Flashcards

1
Q

What type of hormone is testosterone?

A
  • steroid hormone
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2
Q

What are the 2 locations where testosterone is produced?

A
  • leydig cells clls

- zona reticularis (most inner layer of adrenal gland) produce 5%

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3
Q

What 2 proteins is testosterone bind with?

1 - albumin and lipoprotein
2 - albumin and glycoprotein
3 - glycoprotein and sex hormone binding globulin
4 - albumin and or sex hormone binding globulin

A

4 - albumin and or sex hormone binding globulin

  • 55% bound to albumin
  • 45% bound to sex hormone binding globulin
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4
Q

Label the parts of the testes using the labels below:

vas deferens
tail of epididymis 
tunica albuginea
body of epididymis
head of epididymis
seminiferous tubules
A 
1 = head of epididymis
2 = seminiferous tubules 
3 = tunica albuginea
4 = vas deferens
5 = body of epididymis
6 = tail of epididymis
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5
Q

Label the parts of the seminiferous tubules using the labels below:

sertoli cells
leydig cells
spermatogonium
myoid cells
basal lamina
A 
1 = spermatogonium
2 = sertoli cells
3 = leydig cells
4 = myoid cells
5 = basal lamina
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6
Q

What are the 2 key functions of the sertoli cells?

A

1 - stimulate spermatogenesis

2 - secrete inhibin B, anti-Mullerian hormone and aromatase

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7
Q

What are all androgens synthesised from?

A
  • cholesterol
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8
Q

Before cholesterol can be converted into pregnenolone (steroid hormone that plays a key role in the production of other steroid hormones, including progesterone and testosterone) there is one key enzyme and hormone that that are involved. What are these?

1 - FSH and CP450
2 - FSH and lactate dehydrogenase
3 - LH and CP450
4 - LH and lactate dehydrogenase

A

3 - LH and CP450

  • leutenising hormone (LH) activates enzyme cytochromes P450
  • enzyme cytochromes P450 converts cholesterol to pregnenolone
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9
Q

Cholesterol can be converted into pregnenolone (steroid hormone that plays a key role in the production of other steroid hormones, including progesterone and testosterone) by leutenising hormone (LH) and cytochrome P450 causing it to convert cholesterol into pregnenolone. What 2 androgen can pregnenolone then become?

1 - estrogen and dehydroepiandrosterone (DHEA)
2 - progesterone and estrogen
3 - progesterone and testosterone
4 - dehydroepiandrosterone (DHEA) and progesterone

A

4 - dehydroepiandrosterone (DHEA) and progesterone

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10
Q

Before cholesterol can be converted into pregnenolone (steroid hormone that plays a key role in the production of other steroid hormones, including progesterone and testosterone) leutenising hormone (LH) acts on cytochrome P450 causing it to convert cholesterol into pregnenolone. Pregnenolone can then become dehydroepiandrosterone (DHEA) and progesterone. What hormone can both of these then be converted into?

1 - estrogen
2 - testosterone
3 - aromatase
4 - growth hormone

A

2 - testosterone

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11
Q

Order the pathway below for the hypothalamic-pituitary-testis axis:

FSH binds with sertoli cells stimulating spermatogenesis
gonadotrophin releasing hormone released from hypothalamus
leutenising hormone (LH) secreted by anterior pituitary gland
follicular stimulating hormone (FSH) secreted by anterior pituitary gland
testosterone provides negative feedback to pituitary gland and hypothalamus
LH binds with leydig cells and they secrete testosterone

A 
1 = gonadotrophin releasing hormone released from hypothalamus
2 = leutenising hormone (LH) secreted by anterior pituitary gland
2 = follicular stimulating hormone (FSH) secreted by anterior pituitary gland
3 = LH binds with leydig cells and they secrete testosterone 
4 = FSH binds with sertoli cells stimulating spermatogenesis
5 = testosterone provides negative feedback to pituitary gland and hypothalamus
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12
Q

What 2 affects does testosterone have on the skin?

1 - supports collagen function and growth of facial and body hair
2 - supports collagen and removes acne
3 - growth of facial and body hair and removes acne
4 - growth of facial and body hair and pigmentation

A

1 - supports collagen function and growth of facial and body hair

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13
Q

What 3 affects does testosterone have on the male sex organs?

1 - sperm capacitation, prostate growth, erections
2 - sperm production, prostate growth, erections
3 - sperm production, prostate growth, ejaculatory duct development
4 - sperm production, prostate growth, sperm capacitation

A

2 - sperm production, prostate growth, erections

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14
Q

What 2 affects does testosterone have on skeletal muscle?

A

1 - increased muscle strength

2 - increased muscle mass

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15
Q

What 3 affects does testosterone have on brain function?

A

1 - contributes towards libido
2 - positive feelings
3 - aids cognition and memory

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16
Q

What 2 affects does testosterone have on bone?

A

1 - increased RBC production

2 - increased BMD

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17
Q

Although testosterone is able to directly affect cells, it is more often converted into another androgen steroid hormone. What enzyme facilitates this within cells and what does the enzyme convert testosterone into?

1 - 5-alpha reductase converts testosterone into dihydrotestosterone (DHT)
2 - aromatase converts testosterone into dihydrotestosterone (DHT)
3 - lactate dehydrogenase converts testosterone into dihydrotestosterone (DHT)
4 - creatine kinase converts testosterone into dihydrotestosterone (DHT)

A

1 - 5-alpha reductase converts testosterone into dihydrotestosterone (DHT)

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18
Q

Although testosterone is able to directly affect cells, it is more often converted into dihydrotestosterone (DHT) by 5-alpha reductase contained within cells once it passes through the cell membrane. What do DHT (mainly) and testosterone bind with to cause an affect in the target cell?

1 - bind GPCR and directly bind DNA changing gene expression
2 - cross plasma membrane, binds steroid receptor that then binds to DNA
3 - cross plasma membrane, binds retinoid X receptor that then binds to DNA
4 - crosses plasma membrane, binds AR, that then binds to DNA

AR = androgen receptor

A

4 - crosses plasma membrane, binds AR, that then binds to DNA

  • bind with androgen receptor (AR)
  • DHT and testosterone bound to AR affect gene activation causing proteins to be synthesised
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19
Q

Although testosterone is able to directly affect cells, it is more often converted into dihydrotestosterone (DHT) by 5-alpha reductase contained within cells once it passes through the cell membrane. Here DHT (mainly) and testosterone bind with bind with androgen receptor (AR) and are then able to affect gene activation causing proteins to be synthesised. In addition to DHT, what else can testosterone be converted into?

1 - progesterone
2 - growth hormone
3 - estradiol
4 - inhibin

A

3 - estradiol

- FSH activates aromatase converting testosterone into estradiol

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20
Q

Although testosterone is able to directly affect cells, it is more often converted into dihydrotestosterone (DHT) by 5-alpha reductase contained within cells once it passes through the cell membrane. Here DHT (mainly) and testosterone bind with bind with androgen receptor (AR) and are then able to affect gene activation causing proteins to be synthesised. In addition to DHT, testosterone can be converted into estradiol through the activation of aromatase by FSH. Does estradiol have the same affects as testosterone and DHT?

A
  • can be independent, opposite or synergistic to testosterone
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21
Q

What is hypogonadism?

A
  • inability to produce sufficient androgens
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22
Q

Hypogonadism is the inability to produce sufficient androgens. What is the diagnostic cut off for hypogonadism based n testosterone levels?

A
  • <8.3nmol/L
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23
Q

Hypogonadism is the inability to produce sufficient androgens. What are some common risk factors for hypogonadism?

A
  • age
  • obesity
  • comorbidity
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24
Q

Hypogonadism is the inability to produce sufficient androgens. What is primary hypogonadism?

A
  • primary means issue is at the site of production

- inability of testes to produce normal levels of testosterone

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25
Q

Hypogonadism is the inability to produce sufficient androgens. Primary means issue is at the site of production, so primary hypogonadism is the inability of the testes to produce normal levels of testosterone. What would we expect to see in the levels of the following:

Testosterone
LH
FSH

A
  • Testosterone = low levels
  • LH = high levels to try and stimulate testosterone
  • FSH = high levels to try and stimulate testosterone
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26
Q

Klinefelter’s Syndrome is a common cause of hypogonadism. What is Klinefelter’s Syndrome?

1 - genetic defect affecting men with one extra Y chromosome
2 - genetic defect affecting men with one extra X chromosome
3 - genetic defect affecting women with one less/partially missing X chromosome
4 - genetic defect affecting women with one less/partially missing Y chromosome

A

2 - genetic defect affecting men with one extra X chromosome

  • males normally have 44 the and X and a Y chromosome = 46 chromosomes
  • causes long limbs, mental retardation, causes staining of seminiferous and aspermatogenesis (impaired production of spermatozoa so infertility
  • inability of tests to produce testosterone or inhibin
27
Q

Viral infection that causes mumps is a common cause of hypogonadism. How does mumps cause hypogonadism?

1 - causes inflammation and can destroys testicular tissue
2 - causes inflammation and can destroys prostate tissue
3 - causes inflammation and can destroy penile tissue
4 - causes inflammation and can destroy scrotal tissue

A

1 - causes inflammation and can destroys testicular tissue

  • virus causes orchitis inflammation of one or both testicles
  • severe orchitis can destroy architecture of the testes
  • seminiferous tubules are damaged and don’t produce sufficient testosterone
28
Q

Cryptorchidism which is greek where kryptos = hidden and ὄρχις = testicle, is the most common birth defect of the male genital tract. How can this cause hypogonadism?

A
  • undescended movement of the testes

- environmental factors (temperature) mean testes done function, so no androgens

29
Q

What effect can blunt trauma and radiotherapy have on the gonads?

A
  • damage testes and seminiferous tubules

- can cause hypogonadism

30
Q

What is secondary hypogonadism?

A
  • lack of testosterone not caused by gonads

- generally caused by hypothalamus or pituitary gland

31
Q

Is the majority of Hypogonadism primary or secondary?

A
  • secondary

- up to 85%

32
Q

Hypogonadism is the inability to produce sufficient androgens. In secondary hypogonadism, what would we expect to see in the following hormones:

Testosterone
LH
FSH

A
  • Testosterone = low
  • LH = low or normal
  • FSH = low or normal
33
Q

What are the most common causes of secondary Hypogonadism?

A
  • obesity (adipocytes secretes oestradiol)
  • hyperprolactinaemia (pituitary adenoma)
  • kallmann syndrome (failure to start or complete puberty)
  • congenital GnRH deficiency
  • hypopituitarism (trauma, radiation)
34
Q

How can hyperprolactinaemia caused by a pituitary adenoma cause hypogonadism?

A
  • increased prolactin inhibits gonadotrophin releasing hormone (GnRH)
  • no GmRH means no LH and FSH
35
Q

What is Kallmann syndrome and how can this cause Hypogonadism?

A
  • failure to start or complete puberty meaning low or no testosterone
  • accompanied by loss of smell
36
Q

What effect can the following have on the gonads?

  • congenital GnRH deficiency
  • hypopituitarism (due to trauma, radiation)
A
  • both can cause hypogonadism
37
Q

What is combined hypogonadism?

A
  • combination of primary and secondary Hypogonadism
38
Q

Combined Hypogonadism is a combination of primary and secondary Hypogonadism. What are some of the main causes of this?

A
  • sickle cell disease
  • late onset hypogonadism
  • liver cirrhosis
  • alcoholism
  • steroids
  • hemochromatosis
39
Q

If a patient has hypogonadism pre or post puberty, what symptoms would they present with?

A
  • pre = deficiency leads to development abnormalities

- post = non-specific and can occur in men with normal testosterone

40
Q

If a patient has hypogonadism pre puberty, what symptoms would are some of the most common symptoms they can present with?

A
  • delayed puberty
  • reduced testicular volume
  • cryptorchidism (testicles do not descend)
  • unpigmented scrotum
  • no scrotal rugae
  • gynaecomastia
  • decreased body hair
  • high-pitched voice
  • low hairline
  • decreased bone and muscle mass
41
Q

If a patient has hypogonadism post puberty, what symptoms would are some of the specific to testosterone most common symptoms they can present with?

A
  • decreased spermatogenesis
  • hot flushes
  • loss of libido
  • erectile dysfunction
  • increased body fat
42
Q

If a patient has hypogonadism post puberty, what symptoms would are some of the non-specific to testosterone most common symptoms they can present with?

A
  • reduced energy
  • loss of muscle mass
  • sleep disturbance
  • reduced cognitive function
  • anaemia
43
Q

There is little evidence linking low testosterone with an age affect. however, in older patients what 3 conditions is low testosterone associated with?

1 - diabetes, hypertension, chronic disease
2 - diabetes, CKD, chronic disease
3 - diabetes, hypertension, liver disease
4 - CVD, hypertension, chronic disease

A

1 - diabetes, hypertension, chronic disease

44
Q

What is the normal level of testosterone (free and protein bound)?

1 - 8 - 29.5nmol/l
2 - 4.8 - 25 ng/dl
3 - 40 - 250 ng/dl
4 - 100 - 150 ng/dl

A

1 - 8 - 29.5nmol/l

45
Q

What is the normal level of free testosterone (unbound to protein), also known as active testosterone?

1 - 8 - 29.5nmol/l
2 - 4.8 - 25 ng/dl
3 - 40 - 250 ng/dl
4 - 100 - 150 ng/dl

A

2 - 4.8 - 25 ng/dl

46
Q

Testosterone is bound to Sex-hormone binding globulin (SHBG). If these levels change it can affect the reservoir of testosterone and mean there is less active or too much testosterone bound to SHBG, so not as much active and available. What are 4 common conditions that can reduce SHBG?

1 - obesity, hypothyroidism, renal disease, diabetes
2 - obesity, CVD, renal disease, diabetes
3 - obesity, hypoparathyroidism , renal disease, diabetes
4 - obesity, CKD, renal disease, diabetes

A

1 - obesity, hypothyroidism, renal disease, diabetes

47
Q

The majority of testosterone is bound to Sex-hormone binding globulin (SHBG). If these levels change it can affect the reservoir of testosterone and mean there is less active or too much testosterone bound to SHBG, so not as much active and available. What are 4 common conditions that can increase SHBG?

1 - obesity, hyperthyroidism, renal disease, diabetes
2 - ageing, CVD, renal disease, hyperthyroidism
3 - ageing, hyperthyroidism, HIV, oestrogen’s
4 - obesity, ageing, renal disease, oestrogen’s

A

3 - ageing, hyperthyroidism, HIV, oestrogen’s

48
Q

In addition to a careful medical history what genetic disease can we test for if there is an absence of puberty?

1 - Klinefelter’s Syndrome
2 - Down Syndrome
3 - Metabolic Syndrome
4 - Kallmans Syndrome

A

1 - Klinefelter’s Syndrome

49
Q

In addition to a careful medical history what hormone can we test for if the patient has gynaecomastia?

1 - oxytocin
2 - prolactin
3 - oestrogen
4 - progesterone

A

2 - prolactin

  • assess for hyperprolactinaemia
  • prolactin inhibits gonadotrophin releasing hormone
50
Q

In addition to a careful medical history what imaging modality can we use to assess for secondary or combined Hypogonadism that some patients may also complain about visual impairments?

A
  • MRI imaging

- look for pituitary mass

51
Q

As part of a careful medical history what is one of the most common symptoms men will present with that affects their love lives, which may suggest hypogonadism?

A
  • erectile dysfunction
52
Q

Following a medical history what are some common things to look for on a physical examination which may suggest Hypogonadism?

A
  • amount of body hair
  • breast exam for enlargement/tenderness
  • size and consistency of testes
  • size of the penis
  • signs of severe & prolonged hypogonadism
  • reduced muscle bulk and strength
  • osteoporosis
  • arm span
53
Q

If a patient has low testosterone in the morning, which is generally the 1st test, does it indicate hypogonadism or hypergonadism?

A
  • hypogonadism and low testosterone
54
Q

If a patient has low testosterone in the morning, which is generally the 1st test, which suggests hypogonadism and low testosterone, what would the next step of diagnosis be?

A
  • exclude reversible illness, drugs,
  • assess nutritional deficiency
  • investigate altered SHBG
55
Q

If a patient has low testosterone in the morning, which is generally the 1st test, which suggests hypogonadism and low testosterone, we would need to exclude reversible illness, drugs, assess nutritional deficiency and investigate altered SHBG. If the SHBG is altered what 3 hormone levels would we then assess?

1 - testosterone, LH and progesterone
2 - testosterone, progesterone and FSH
3 - estrogen, LH and FSH
4 - testosterone, LH and FSH

A

4 - testosterone, LH and FSH

56
Q

How is low testosterone normally treated?

A
  • synthetic exogenous testosterone is given
57
Q

Low testosterone is normally treated using a synthetic exogenous testosterone. What are the 4 main contraindications to prescribing someone with testosterone?

A
  • cancer (prostate and breast cancer)
  • sleep apnoea
  • cardiac failure
  • raised haematocrit (proportion of blood in plasma)
58
Q

When starting a patient on testosterone treatment, how often should then be monitored?

1 - review at 1, 3, and 12 weeks, then annually
2 - review at 3, 6, and 12 months, then annually
3 - review at 3, 6, and 12 week, then annually
4 - review at 1, 3, and 12 months, then annually

A

2 - review at 3, 6, and 12 months, then annually

59
Q

When starting a patient on testosterone treatment, they are monitored at 3, 6 and 9 months and then annually. How often do haematocrit levels need to be monitored?

1 - review at 1, 3, and 12 weeks, then annually
2 - review at 3, 6, and 12 months, then annually
3 - review at 3, 6, and 12 week, then annually
4 - review at 1, 3, and 12 months, then annually

A

2 - review at 3, 6, and 12 months, then annually

  • same as testosterone
  • if haematocrit decreases or increases then discontinue therapy
  • can increase viscosity of blood
60
Q

Testosterone has been shown to increase the risk of prostate cancer. What needs to be monitored in relation to the prostate?

A
  • prostate-specific antigen (PSA) (secretes fluid so semen doesn’t coagulate)
  • digital rectal examination
  • assess at baseline and then 3, 6 and 9 months and then annually
61
Q

Testosterone has been shown to increase the risk of prostate cancer, so we need to monitor prostate-specific antigen (PSA), which is important as it secretes fluid so semen doesn’t coagulate. Which part of the prostate secretes PSA?

1 - transitional zone
2 - peripheral zone
3 - central zone
4 - fibromuscular zone

A

1 - transitional zone

  • this is why PSA increases with benign prostate hyperplasia
  • peripheral zone is where cancer is common
62
Q

The drug Jatenzo is a synthetic testosterone therapy that has been confirmed as safe for the treatment of low testosterone. What is unique about this drug?

1 - no side effects
2 - avoids first pass metabolism
3 - increases all male androgen levels
4 - has to be taken intravenously

A

2 - avoids first pass metabolism

- no hepatotoxicity

63
Q

Jatenzo is a synthetic testosterone therapy that has been confirmed as safe for the treatment of low testosterone as it -avoids first pass metabolism and has no hepatotoxicity. What 3 measures should be made prior to starting Jatenzo?

1 - BP, haematocrit, PSA
2 - BP, PSA, LFTs
3 - BP, haematocrit, LFTs
4 - PSA, haematocrit, LFTs

A

3 - BP, haematocrit, LFTs

Year 2 RE (53 decks)

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