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BRS - Year 2 > 🧪Endocrinology🧪 - Reproductive treatments > Flashcards

🧪Endocrinology🧪 - Reproductive treatments Flashcards

1
Q

How can a man with low testosterone (hypogonadism) be diagnosed?

A

Confirm minimum 2 low fasting serum testosterones - measured in the morning

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2
Q

What are the symptoms for male hypogonadism?

A

Loss of early morning erections
Changes in libido
Decreased energy
Decreased shaving frequency

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3
Q

What are the treatment drug options for male hypogonadism, where fertility is not required?

A

Daily - gel, care not to contaminate partner
3 weekly - IM testosterone injection
3 monthly - IM injection
Less common - Implants, oral preparations

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4
Q

What are some of the risks of testosterone replacement?

A

Increased haematocrit (risk of hyperviscosity and stroke)
Prostate damage/enlargment (Prostate specific antigen levels - PSA, acts as a biomarker)

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5
Q

A 35-year old man presents with infertility, accompanied by his partner. He has low sperm, morning testosterone, LH/FSH, as well as fatigue and reduced shaving frequency. Him and his partner have been attempting to conceive for 2 years, with no success. Should he be given testosterone to improve his fertility?

A

No - testosterone alleviates symptoms but will not improve fertility
LH and FSH required for spermatogenesis
LH stimulates Leydig cells to increase intratesticular testosterone levels to up to 100x that of in circulation
FSH stimulated seminiferous tubule development and spermatogenesis

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6
Q

Why could giving testosterone to a male presenting with infertility who wants to have children be potentially counterproductive?

A

Giving testosterone could further decrease LH/FSH levels, further worsening spermatogenesis

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7
Q

What treatments can induce spermatogenesis?

A

hCG injections (act on LH-receptors)
If no response after 6 months, add FSH injections

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8
Q

What is the goal of ovulation induction?

A

To develop one ovarian follicle
Aim is to cause a small increase in FSH

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9
Q

Why do we only want to develop one ovarian follicle when inducing ovulation?

A

If >1 follicle develops, risks multiple pregnancies (i.e. twins, triplets)
Multiple pregnancies are inherently much riskier than normal pregnancies for both mother and child(ren)

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10
Q

What is the mechanism of action of letrozole?

A

It inhibits aromatase in the ovaries, therefore stopping testosterone from being converted to oestradiol, and so decreasing the negative feedback on the hypothalamus

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11
Q

What is the mechanism of action of clomiphene?

A

It acts as a competitive inhibitor of oestradiol on the oestrogen receptors in the hypothalamus, decreasing the negative feedback

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12
Q

What is the mechanism of action of gonadotrophin injections?

A

Injection can be given either subcutaneously or intramuscularly
Injected gonadotropins act directly to increase FSH and LH levels

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13
Q

What is hypothalamic amenhorroea?

A

Hypothalamic amenorrhea (HA) is a condition in which menstruation stops due to a disruption in the normal function of the hypothalamus

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14
Q

What similarities does hypothalamic amenorrhoea have with PCOS?

A

Patients will present with similar menstrual symptoms - oligo/amenorrhoea and infertility

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15
Q

What are the differences in symptoms between PCOS and hypothalamic amenorrhoea?

A
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16
Q

What is the treatment sequence for ovulation restoration in PCOS?

A
  1. Lifestyle/weight loss by 5%
  2. Metformin
  3. Letrozole (aromatase inhibitor)
  4. Clomiphene (oestradiol receptor modulator)
  5. FSH stimulation
    Steps are sequential, when one doesn’t work, add the next step and so on until ovulation is achieved
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17
Q

What is the treatment sequence for restoration of ovulation in hypothalamic amenorrhoea?

A
  1. Lifestyle/weight gain/reduce exercise
  2. Pulsatile GnRH pump
  3. FSH stimulation
  4. Letrozole (Aromatase inhibitor)
  5. Clomiphene (Oestradiol receptor modulator)
    Steps are sequential, when one doesn’t work, add the next step and so on until ovulation is achieved
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18
Q

What is the difference in steps between stimulation ovulation in PCOS and hypothalamic amenorrhoea?

A

FSH is given before letrozole and clomiphene in HA, and afterwards in PCOS
2nd step for PCOS is metformin, and 2nd step in HA is pulsatile GnRH pump

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19
Q

Outline the steps for in vitro fertilisation (IVF) treatment

A
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20
Q

What percentage of pregnancies are unplanned?

A

19-30%

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21
Q

What are the contraception methods available?

A

Barrier: male/female condom, diaphragm, cap with spermicide
Combined oral contraceptive pill (OCP)
Progestogen-only pill (POP)
Long-acting reversible contraception (LARC)
Emergency contraception

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22
Q

What are the permanent methods of contraception?

A

Vasectomy
Female sterilisation (many methods)

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23
Q

What are the advantages of barrier contraception (condoms)?

A

Protects against STIs
Easy to obtain - free from clinics/no need to see healthcare professional
No contra-indications (unlike some hormonal methods)

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24
Q

What are the disadvantages of barrier contraception (condoms)?

A

Can interrupt sex
Can reduce sensation
Can interfere with erections
Relies on proper use/personal skill
Two are not better than one

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25
What is the mechanism of function of the oral contraceptive pill?
Contains oestrogen and progesterone Activates the negative feedback system, stopping the release of GnRH and LH/FSH, resulting in anovulation
26
What is the result of using the OCP?
Anovulation Thickening of cervical mucus Thinning of endometrial lining to reduce implantation
27
What are the advantages of the OCP?
Easy to take - one pill a day at any time Effective No interruption of sex Can take several packets back to back and **avoid withdrawal bleeds** Reduces endometrial and ovarian cancer Weight neutral in 80% (10% gain and 10% lose)
28
What are the **dis**advantages of the OCP?
Easy to forget No protection against STIs Additional medications with induce P450 enzymes can reduce the efficacy of the OCP (e.g. rifampicin, some anti-epileptics, anti-retrovirals)
29
What are some side-effects of the OCP?
Spotting (bleeding between periods) Nausea Sore breasts Changes in mood or libido Hunger *Extremely rare* Blood clots in legs or lungs (2 in 10,000)
30
What are some of the non-contraceptive uses of the OCP?
Help makes periods lighter and less painful Helpful with endometriosis/fibroids Dysmenorrhoea (painful periods) Menorrhagia (heavy periods) Regular withdrawal bleeds/ no bleeds PCOS: helps reduce LH and hyperandrogenism (treats acne/hirsutism)
31
What are the advantages of the progesterone only pill (POP)? | Also known as the "Mini-Pill"
Works similarly to the OCP (slightly less reliably inhibits ovulation however) **Often suitable if person can't take oestrogen** Easy to take - one pill per day with no break Doesn't interrupt sex Can help heavy or painful periods Periods may stop (temporarily) **Can be used while breastfeeding**
32
What are the **disadvantages** of the progesterone only pill (POP)?
Easy to forget Shorter acting - needs to be taken at the same time each day No protection against STIs
33
What are the possible side effects of the POP?
Irregular bleeding Headaches Sore breasts Changes in mood Changes in sex drive
34
What are the main long-acting reversible contraceptives (LARC)?
Coils Intra-Uterine Devices - IUD (i.e. copper coil) INtra-Uterine Systems - IUS which secrete progesterone (e.g. Mirena coil) Progesterone-only injectable contraceptives/subdermal implants
35
Outline coils as a form of contraception
Suitable for most women Prevent implantation of conceptus – important for some religions Rarely can cause Ectopic Pregnancy Can be used as emergency contraception
36
Outline IUDs
Mechanically prevent implantation, decrease sperm / egg survival Lasts 5-10yrs. Can cause heavy periods, and 5% can come out especially during first 3months with periods
37
Outline IUS
Thins lining of the womb and thicken cervical mucus (can be used to help with heavy bleeding) Lasts 5yrs
38
What is the main drawback of progestogen-only injectable/subdermal implants?
Long lasting effects, so not best option if desiring fertility soon/changes mind
39
What is emergency contraception?
Contraceptions which can be taken **after** unprotected sex to prevent pregnancy
40
What are the main options of emergency contraception?
Copper IUD (most effective) Pills: Ulipristal acetate 30mg (ellaOne) Levonorgestrel 1.5mg (Levonelle)
41
Why are copper IUDs so effective?
Can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)
42
Outline the 2 types of pill that can be taken as emergency contraceptives
Ulipristal acetate 30 mg (ellaOne) Ulipristal acetate stops progesterone working normally and prevents ovulation Must be taken within 5 days of unprotected intercourse (earlier has better efficacy) 1-2% can get pregnant if ovulation has already occurred. Levonorgestrel 1.5 mg (Levonelle) Less effective (especially if BMI >27 kg/m2) Synthetic Progesterone prevents ovulation (doesn't cause abortion, so ineffective if ovulation has occurred) Must be taken within 3 days of unprotected intercourse. 1-3% failure rate
43
What are the side effects of the emergency contraceptive pills?
Headache, abdominal pain, nausea Liver P450 Enzyme inducer medications make it less effective If vomit within 2-3hrs of taking it, need to take another
44
What considerations should be taken for choice of contraception?
Contraindications for OCP (e.g. risk of venous thromboembolism (VTE)/CVD/Stroke) Other conditions that may benefit from OCP Need for protection against STIs Concurrent medication Ease of use
45
What are some contraindications for the OCP?
Risk of VTEs, CVD or stroke Migraines with aura (sensory disturbances), indicates risk of stroke Smoking (15>/day) at age 35 or older Stroke or CVD history Current breast cancer Liver cirrhosis Diabetes with nephropathy/neuropathy/retinopathy
46
What other conditions may benefit from the OCP?
Menorrhagia / Endometriosis / Fibroids PMS (Pre-Menstrual Syndrome) Acne or hirsutism
47
What concurrent medications would make the OCP a poor choice?
P450 liver enzyme-inducing drugs (e.g. anti-epileptics, antibiotics) Teratogenic drugs (eg lithium or warfarin), more effective methods of contraception needed (e.g progestogen implants/IUD/IUS)
48
Why is it so important to have a more effective contraception when someone is using teratogenic drugs?
Can cause great harm/deformities to the foetus
49
What are the benefits of HRT (aka Menopause Hormone Treatment (MHT))
Symptom relief from symptoms due to low oestrogen (e.g. flushing, sweats, disturbed sleep, joint pains, brain fog, decreased libido, low mood) Reduction in osteoporosis severity (and so reduced osteoporosis related fractures)
50
What are the risks of HRT?
Venous thromboembolisms Hormone sensitive cancers (including endometrial cancers) CVD Stroke
51
Expand on VTEs as a risk of HRT
Venous thromboembolism: Deep vein thrombosis (DVT) or Pulmonary Embolism (PE) Oral oestrogens undergo first pass metabolism in the liver Oral increases clotting factors Transdermal oestrogens safer in terms of VTEs (avoid oral oestrogens if BMI>30)
52
Expand on hormone sensitive cancers as a risk of HRT
Breast cancer - slight increase in risk in women with on combined HRT Risk related to duration of treatment - reduces after stopping HRT Continuous poses more risk than sequential Ovarian cancer - small increase in risk after long term use
53
Expand on endometrial cancers as a risk of HRT
All women undergoing HRT who have not had their uterus removed (i.e. still have an endometrium) need progestogens to simulate endometrial shedding Post-menopausal bleeding could indicate endometrial cancer
54
Expand on CVD as a risk of HRT
Improved risk in younger Women & sooner after Menopause Increased risk if started later i.e. 10 years after menopause Likely benefit to CVD risk in younger women e.g. Premature Ovarian Insufficiency (POI)
55
Expand on stroke as a risk of HRT
Small increased risk Oral have more risk than transdermal oestrogens Combined (E2+P) more risk than oestrogen only
56
Summarise HRT risks
57
Summarise the benefits vs risks of HRT
58
What is "sex"?
Biologically defined (i.e. male, female, or Intersex)
59
What is gender?
A social construct How an individual sees themself/identifies
60
Define non-binary
Gender does not match to traditional binary gender understanding, includes agender, bigender, pangender, gender fluid
61
Define cis-gender
Cis meaning same Birth sex and gender are aligned
62
Define gender non-conforming
Gender does not match assigned sex
63
Define gender dysphoria
Gender does not match assigned sex, **causing distress**
64
Define transgender
Transitioning from one gender to another
65
Define a transgender man
A person who is assigned female sex at birth, but transitions to male gender
66
Define a transgender woman
A person who is assigned male sex at birth, but transitions to female gender
67
What is the prevalence of transgender men vs women?
3x more transgender women than men
68
How should transgender men be treated?
Masculinising hormones Testosterone (injections, gels) Progesterone to suppress menstrual bleeding if needed (endometrial hyperplasia 15%)
69
How should transgender women be treated?
Reduce Testosterone: GnRH agonists (induce desensitisation of HPG axis) Anti-Androgen medications Oestrogen: Transdermal, oral, intramuscular High dose oestrogen (e.g. 4-5mg per day (side-effects: higher risk of VTE 2.6%))

BRS - Year 2 (75 decks)

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