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Endocrine infertility Flashcards

1
Q

What stimulates release of LH and FSH from the pituitary?

A

GnRH pulses from the hypothalamus

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2
Q

What does LH stimulate?

A

Testosterone production in the testes

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3
Q

Which cells does LH specifically stimulate to produce testosterone?

A

Leydig cells

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4
Q

What is testosterone responsible for?

A

Secondary sexual characteristics and aids spermatogenesis

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5
Q

Where does FSH stimulate (including cells)?

A

Sertoli cells in seminiferous tubules -> sperm and inhibin A and B

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6
Q

What does testosterone have a negative feedback effect on?

A

Hypothalamus and pituitary

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7
Q

What does inhibin have a negative feedback effect on?

A

Pituitary FSH secretion

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8
Q

What are the three phases of the menstrual cycle?

A

Follicular phase
Ovulation
Luteal phase

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9
Q

What does LH stimulate in the ovaries?

A

Production of progesterone and oestradiol

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10
Q

What does FSH develop?

A

Follicles and inhibin

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11
Q

After day 10, what happens in terms of follicles?

A

The leading follicle develops into the Graffian follicle

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12
Q

What is the initial effect of oestrogen on LH and FSH?

A

It inhibits their secretion

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13
Q

In the follicular phase, how does a man and woman’s HPG axis compare?

A

They are pretty much the same

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14
Q

When does the effect of oestrogen switch from negative feedback to positive feedback?

A

Once oestrogen levels reach a certain point

This occurs in ovulation– positive feedback

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15
Q

How does oestradiol have a positive feedback effect?

A

Increases GnRH release

Increases LH sensitivity to GnRH– used to mature eggs

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16
Q

What does the positive feedback effect of oestrogen lead to?

A

A mid cycle LH surge which triggers ovulation from the leading follicle

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17
Q

What is the definition of infertility?

A

Inability to conceive after 1 year of regular unprotected sex

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18
Q

How many couples are affected?

A

1/6

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19
Q

What percentage of infertility is caused by abnormalities in men?

A

30%

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20
Q

What percentage of infertility is caused by abnormalities in women?

A

45% (other 25% is unknown)

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21
Q

What happens in primary gonadal failure?

A

Testes or ovaries are not producing testosterone/oestrogen so there’s no negative feedback on HPG axis meaning you get high GnRH and high LH/FSH

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22
Q

What happens in pituitary disease?

A

Inability of the pituitary gland to produce FSH and LH so their levels are low and as a result there is low oestradiol and testosterone

GnRH cannot be measured, FSH/LH and testosterone and oestradiol measured

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23
Q

What are the clinical features of male hypogonadism?

A 
Loss of libido
Impotence
Small testes
Decreased muscle bulk
Osteoporosis
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24
Q

What are the causes of male hypogonadism?

A

Hypothalamic/pituitary disease

  • Hypopituitarism
  • Kallmann syndrome (anosmia and low GnRH)
  • Illness/underweight- mainly due to low levels of leptin
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25
What is an example of congenital primary gonadal disease?
Klinefelter's syndrome XXY
26
What is an example of acquired primary gonadal disease?
Testicular torsion, chemotherapy
27
What is the effect of hyperprolactinaemia on the gonads?
Inhibits function
28
How do you test for male hypogonadism?
Check LH, FSH and testosterone - if they're all low, MRI the pituitary to check for pituitary problem Check prolactin Check sperm count Chromosomal analysis: Klinefelters
29
What is azoospermia?
Absence of sperm in ejaculate
30
What is oligospermia?
Reduced number of sperm in ejaculate
31
How do you treat male hypogonadism?
Replacement testosterone for all patients- For fertility: if hypo/pit disease -s.c gonadotrophins (LH and FSH) To treat hyperprolactinaemia, you need a dopamine agonist as dopamine is main influence on prolactin release and it has a negative effect
32
What are the endogenous sites of production of androgens?
``` Interstitial Leydig cells of the testes Adrenal cortex Ovaries Placenta Tumours ```
33
What are the main actions of testosterone?
Development of the male genital tract Maintains fertility in adulthood Control of secondary sexual characteristics Anabolic effects
34
How does testosterone exist in the blood?
Heavily bound 98%
35
What does dihydrotestosterone act on?
- Active form of testoterone | - Androgen receptors
36
How is dihydrotestosterone formed?
Testosterone is converted by 5 alpha-reductase
37
What does aromatase convert testosterone to?
17beta-oestradiol
38
What does 17beta-oestradiol act on?
Oestrogen receptors
39
In adulthood, what does testosterone increase?
Lean body mass Muscle mass and strength Bone formation and mass Libido and potency
40
What are the three main gonadal disorders in women?
Amenorrhoea Polycystic ovarian syndrome (PCOS) Hyperprolactinaemia
41
What is amenorrhoea?
Absence of periods
42
What is primary amenorrhoea?
Failure to develop spontaneous menstruation by the age of 16 years
43
What is secondary amenorrhoea?
Absence of menstruation in a women for 3 months who has previously had menstrual cycles
44
What is oligomenorrhoea?
Irregularly LONG cycles
45
What are the causes of amenorrhoea?
``` Pregnancy/Lactation Ovarian failure -Premature ovarian sufficiency -Chemotherapy/ovariectomy -Ovarian dysgenesis (Turner's syndrome 45X) Gonadotrophin failure -Hypothalamic/pituitary disease -Kallmann's syndrome -Low BMI -Post-pill amenorrhoea Hyperprolactinaemia Androgen excess: gonadal tumour ```
46
What are some features of Turner's syndrome?
Short stature Cubitus valgus Gonadal dysgenesis
47
What is cubitus valgus?
When the forearm is angled away from the body to a greater degree than normal when fully extended
48
After how long are you advised to stop the pill and why?
4 years and because if you use the pill for a long time then your periods won't come back for around 12 months
49
How would you investigate amenorrhoea?
Pregnancy test Check LH, FSH and oestradiol Day 21 progesterone- should be a rise around this time Prolactin, Thyroid function Androgens Chromosomal analysis Ultrasound scan ovaries/uterus
50
How do you treat amenorrhoea?
- Treat the cause e.g low weight - Primary ovarian failure - infertile, HRT - hypothalamic/pituitary disease- HRT for oestrogen replacement. Fertility: Gonadotrophins (LH and FSH)- part of IVF
51
What proportion of women of reproductive age are affected by PCOS?
1/12
52
What is PCOS associated with?
Increased cardiovascular risk and diabetes
53
What is the criteria to diagnose PCOS?
Need two of the following: Polycystic ovaries on ultrasound Oligoovulation/anovulation Clinical/biochemical androgen excess
54
What are the clinical features of PCOS?
Hirsutism Menstrual cycle disturbance Increased BMI
55
How is PCOS treated?
- Metformin- Insulin sensitiser used in type II diabetes - Clomiphene- Anti-oestrogen effect in hypothalamic-pituitary axis. Binds to oestrogen receptors. Results in increased GnRH and gonadotrophins - Gonadotrophin therapy as part of IVF treatment
56
What is the main influence on prolactin release?
Dopamine- negative effect
57
What is the effect of TRH on prolactin release?
Mild stimulatory
58
What does prolactin stimulate?
Production of milk in lactating women
59
What does prolactin have a negative feedback effect on?
GnRH pulsatility and LH actions on ovaries and testes
60
What are the main causes of hyperprolactinaemia?
``` Dopamine antagonists -anti-emetics (metoclopramides- antisickness) -anti-psychotics (phenothiazines) Prolactinoma Stalk compression due to pituitary adenoma--switches off dopamine PCOS Hypothyroidism Oestrogen (pill), pregnancy, lactation Idiopathic ```
61
What are the clinical features of hyperprolactinaemia?
Galactorrhea Reduced GnRH secretion/LH action leads to hypogonadism Prolactinoma- headache and visual defects
62
How do you treat hyperprolactinaemia?
Treat the cause- stop the drugs if that is what is causing it Dopamine agonists- cabergoline and bromocriptine Will also cause decrease in size of a prolactinoma
63
A young woman presents at clinic with: Secondary amenhorrhea, galactorhea, secondary gonadism What do you expect her blood results
LOW LH, FSH, Oestradiol Secondary amenhhorea-- LH and FSH could be normal end Prolactin is inidcated to be high by her galactorhea-- prolactinoma

RR ENDO (13 decks)

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