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Year 2 Endocrinology > Endocrine infertility > Flashcards

Endocrine infertility Flashcards

1
Q

What is the definition of infertility?

A

The inability to conceive after 1 year of regular unprotected sex

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2
Q

How common is infertility?

A

Happens in 1 in 6 couples

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3
Q

What are the clinical features of hypogonadism in men?

A 
Loss of libido - sexual interest/desire
Impotence
Small testes
Decrease in muscle bulk
Osteroporosis
Basically all the features of low testosterone
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4
Q

What are causes of male hypogonadism?

A

Hypothalamic pituitary disease
Primary gonadal disease
Hyperprolactinaemia
Androgen receptor deficiency

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5
Q

What are examples of hypothalamic pituitary diseases that can cause male hypogonadism?

A

hypopituitarism
Kallmans syndrome (anosmia and low GnRH)
Illness/underweight

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6
Q

What are examples of primary gonadal diseases that can cause male hypogonadism?

A

Congential - kleinfelters syndrome XXY

Aquired - testicular torsion, chemotherapy

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7
Q

What are investigations for male hypogonadism?

A

If LH, FSH and testosterone are low - MRI pituitary
Prolactin levels - if high will switch off reproductive function
Sperm count
Chromosomal analysis eg kleinfelters

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8
Q

What is azoospermia?

A

Absence of sperm in ejactulate

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9
Q

What is oligospermia?

A

Reduced number of sperm in ejaculate

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10
Q

What is the treatment for hypogonadism?

A

Replacement testosterone for all patients
For fertility - if hypo/pituitary disease subcutaneous gonadotrophins LH and FSH
Hyperprolactinaemia - dopamine agonist

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11
Q

What are endogenous sites of production of androgens

A 
Interstitial leydig cells of the testes
Adrenal cortex in males and females
Ovaries
Placenta
Tumours
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12
Q

What are the main actions of testosterone?

A
  • development of male genital tract
  • maintains fertility in adulthood
  • control of secondary sexual characteristics
  • anabolic effects (muscle, bone)
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13
Q

How much of the circulating testosterone is protein bound?

A

98%

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14
Q

How is dihydrotestosterone (DHT) made

A

by 5 alpha reductase via tissue specific processing

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15
Q

How is 17b oestradiol (E2) made from testosterone?

A

Aromatase enzyme via tissue specific processing

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16
Q

How does dihydrotestosterone act?

A

via the androgen receptor

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17
Q

How does 17b oestradiol act?

A

via oestrogen receptor (ER) eg brain and adipose tissue

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18
Q

What is the mechanism of action of DHT and E2 via?

A

Nuclear receptors

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19
Q

What are nuclear receptors?

A

a class of proteins found within cells that are responsible for sensing steroid and thyroid hormones and certain other molecules.

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20
Q

What are clinical uses of testosterone?

A 
In adulthood it will increase:
Lean body mass
Muscle size and strength
Bone formation and bone mass (in young men)
Libido and potency
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21
Q

What is required to restore fertility?

A

Treatment with gonadotrophins to restore normal spermatogenesis

22
Q

What is amenorrhoea?

A

Absence of periods

23
Q

What is primary amenorrhoea?

A

Failure to begin spontaneous menstruation by age 16 years

24
Q

What is secondary amenorrhoea?

A

Absence of menstruation for 3 months in a women who has previously had cycles

25
Q

What is oligomenorrhoea?

A

Irregular long cycles

26
Q

What are causes of amenorrhoea?

A 
Pregnancy/lactation (high prolactin)
Ovarian failure
Gonadotrophin failure
Hypoprolactinaemia
Androgen excess: gonadal tumour
27
Q

What are causes of ovarian failure that can lead to

amenorrhoea?

A 
Premature ovarian insufficiency
Ovariectomy/chemotherapy
Ovarian dysgenesis (turners 45 XO) - lacking one chromosome
28
Q

What are examples of causes of gonadotrophin failure?

A

Hypo/pit disease
Kallmann’s syndrome (anosmia, low GnRH)
Low BMI
Post pill amenorrhoea

29
Q

What are investigations for amenorrhoea?

A 
Pregnancy test
LH, FSH, oestradiol levels
day 21 progesterone
Prolactin, thyroid function tests
Androgens (testosterone, androstenedione, DHEAS)
Chromosomal analysis (turners 45 XO) 
Ultrasound scan ovaries/uterus
30
Q

What are treatment options for amenorrhoea?

A

Treat cause - eg low weight
Primary ovarian failure - infertile, HRT
Hypothalamic pituitary disease - specific treatment

31
Q

What are the treatment options for hypothalamic/pituitary disease?

A

HRT for oestrogen replacement

Fertility: gonadotrophins (LH and FSH) - part of IVF treatment

32
Q

What is PCOS (polycystic ovarian syndrome) associated with?

A

Increased cardiovascular risk and insulin resistance - don’t know why

33
Q

What is the criteria to diagnose PCOS?

A

Need two of the following:
Polycystic ovaries on USS
Oligo-/anovulation
Clinical/biochemical androgen excess

34
Q

What are clinical features of PCOS

A

Hirsuitism
Menstrual cycle disturbance
Increased BMI

35
Q

What are the two drugs you can use to treat PCOS

A

Metaformin and clomiphene

36
Q

What is clomiphene?

A

It is a fertility drug that is anti-oestrogenic in the hypopthalamo-pituitary axis

37
Q

What is the action of clomiphene?

A

Binds to oestrogen receptors in the hypothalamus thereby blocking the normal negative feedback, resulting in an increase in secretion of GnRH and gonadotrophins

38
Q

What are treatment options for PCOS

A

Metaformin
Clomiphene
Gonadotrophin therapy as part of IVF treatment

39
Q

What are causes of hyperprolactinaemia?

A 
Dopamine antagonist drugs 
Stalk compression due to pituitary adenoma
PCOS
Hypothyroidism
Oestrogens (OCP), pregnancy, lactation
Idiopathic
40
Q

Examples of dopamine antagonist drugs?

A

antiemetics - metoclopramide and antipsychotics - phenothiazines

41
Q

What are clinical features of hyperprolactinaemia?

A

Galactorrhoea
Reduced GnRH secretion/LH action&raquo_space; hypogonadism
Prolactinoma - headache, visual field defect

42
Q

What is the treatment of hyperprolactinaemia?

A

Treat the cause - eg stop the drugs and treat with dopamine agonist
Prolactinoma - dopamine agonist therapy
Pituitary surgery rarely needed

43
Q

What are examples of dopamine agonists?

A

Bromocriptine

Cabergoline

44
Q

What happens in the reproductive axis in men?

A

Hypothalamus secretes GnRH which stimulates the pituitary to secrete gonadotrophins which stimulates the testis to make the appropriate hormone - then neg feedback

45
Q

What happens in the reproductive axis in females in the follicular phase?

A

Hypothalamus secretes GnRH which stimulates the pituitary to secrete gonadotrophins which stimulates the ovary to make the appropriate hormone - then neg feedback

46
Q

What happens in the reproductive axis in females during ovulation?

A

High levels of estradiol produced cause positive feedback after the ovary is stimulated by gonadotrophins, causing an LH surge

47
Q

What happens in the reproductive axis in females during luteal phase if implantation does not occur

A

Endometrium is shed - menstruation

48
Q

What is primary gonadal failure?

A

When testes or ovaries have failed for some reason

49
Q

How can primary gonadal failure be diagnosed

A

Low testosterone/oestradiol (end organ hormone secretion), less neg feedback and high GnRH and high LH and FSH

50
Q

What happens in hypopituitary disease on endocrine infertility?

A

Failure of hypothalamus or pituitary leading to less trophic action on testes/ovary so low sex hormone and low LH or FSH and low testosterone/oestrodiol

51
Q

Why do you have to give subcutaneous gonadotrophins if a male with hypogonadism wants to get pregnant?

A

Because just giving them testosterone will not produce sperm

Year 2 Endocrinology (21 decks)

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