Gonads

Question 1

Define primary hypogonadism

Answer 1

Increase FSH, Lh
Decreased testosterone men, decrease 17B estradiol women and never menstruated

Question 2

Define secondary hypogonadism

Answer 2

Decrease FSH, lh
Decrease testosterone men, decrease 17B estradiol women and had menstruated

Question 3

When should testosterone be measured

Answer 3

Fasting (food decreases), highest at 9 am

Question 4

Name different symptoms at different thresholds of testosterone (4)

Answer 4

< 13: decreased vitality and vigour
<11: decreased morning elections
< 8,5: erectile dysfunction
<8: decreased sexual thoughts

Question 5

Name 3 best predictors of hypogonadism in men

Answer 5

• 3 sexual symptoms
• total test <8 -11 nmol/l
• free test < 0,22

Question 6

Name 2 indications measure free testosterone in men

Answer 6

• Lower end test 6,9 - 13,1 n mol / L
• abnormal shbg

Question 7

Name 7 conditions associated with decreased shbg and associated testosterone levels

Answer 7

(Decreased total test with normal or decreased free test)
• obesity
• diabetes
• use glucocorticoids, progestins, androgen steroids
• nephrotic syndrome
• hypothyroid
• acromegaly
• polymorphisms in shbg gene

Question 8

Name 7 conditions associated with increased shbg and associated testosterone levels

Answer 8

(Normal total test but decreased free test)
• aging
. HIV,
• cirrhosis, hepatitis
• hyperthyroid
. Anticonvulsants
• use of oestrogens
• polymorphisms in shbg gene

Question 9

Management symptoms hypogonadism with low (<8) morning total testosterone? (5)

Answer 9

• Repeat testosterone, measure lh FSH PRL (prolactin)

If high gonadotropins:
• measure hb/hct, perform Dre, confirm PSA < 4 ng/ml
• trial testosterone replacement
• monitor: testosterone level, clinical response, regular hb/ Hct, serum PSA, bone scans

If low/normal gonadotropins
• investigate pituitary and other causes: measure serum PRL, pituitary MRI, serum drug screen, ferritin.

Question 10

Management symptoms hypogonadism with borderline (8-11) morning total testosterone? (3)

Answer 10

• Repeat testosterone, measure shbg, calculate free testosterone
• if free testosterone low (<220) - follow protocol as for low testosterone

•If normal, investigate other causes

Question 11

Name 2 second line tests for male hypogonadism

Answer 11

• hCg stimulation test: check if hypothalamus -pituitary problem, testicular trauma, gonadal dysgenesis eg klinefelter DSD (stimulate Leydig cells,useful delayed puberty after 14 )
• semen analysis: only if infertility

Question 12

What type of testosterone is better to test for in women and children

Answer 12

Free (men total)

Question 13

Name 3 broad causes with 2 examples of hypogonadism due to ovulatory dysfunction

Answer 13

• Hypothalamo-pituitary suppress or disease: low BMI!, high prolactin, idiopathic
. Ovarian disease: PCOS, premature autoimmune ovarian failure
• hyperandrogenism: PCOS, congenital adrenal hyperplasia

Question 14

How test for uterine cause of amenorrhaea

Answer 14

Progestogen challenge test (normal = withdrawal bleed)

Question 15

What is the clinical exam for hirsutism and what is an abnormal score

Answer 15

Ferriman gallWey score >8

Question 16

Name 7 diagnostics tests PCOS

Answer 16

•* test 2,5 -5 nmol /l diagnostic (if > 5 consider ovarian tumour)
• fasting insulin, OGTT, lipogram - metabolic syndrome
. High Framingham risk score
• high 17 - ohp in late onset CAH
• high free test, bat, free androgen index
• 25% have high DHEAS, androstenedione
• ovarian morphology >12 cysts or ovarian volume > 10ml

Question 17

Name 5 lab investigations and results menopause

Answer 17

. Very high fsh, low to normal estradiol
• low AMH, low follicle number, low inhibin
• estriol and estrone become major estrogens (adrenal androgens)
• adverse lipid changes - low HDL, high LDL
• possible osteoporosis due to low estradiol

Question 18

How determine whether secondary hypogonadism is due to pituitary or hypothalamus?

Answer 18

GnRH stimulation test (normal = double baseline FSH and LH)

Increased LH = problem in ovaries or testes, not secondary.
Reduced could be either

Question 19

What is Kallmann syndrome?

Answer 19

Abnormal migration olfactory and GnRH neurons through cribriform plate
Hypogonadotrophic hypogonadism with anosmia; midline facial defects, sensorineural hearing loss, renal anomalies
Decreased GnRH, FSH, LH, testosterone
Slightly feminine physique

Question 20

What is Klinefelter syndrome?

Answer 20

Genetic 47 XXY affect testes
Testicular dysgenesis, decreased Leydig cell and seminiferous tubules function
Tall, feminisation
High LH and FSH , low testosterone, high estrogen

Question 21

Name 6 hormones tested for infertility and how they cause infertility

Answer 21

• prolactin: high (disrupt ovulation and menstrual function)
• LH, FSH; LH:FSH (LH should be lower than FSH. High LH = disrupted follicle development, anovulation)
• E2 (estradiol) (suboptimal follicular development)
• SHBG (low → increased unbound / free testosterone → disturb folliculogenesis)
• testosterone + free androgen index (necessary for normal ovarian function)
• dheas (indicate normal adrenal androgen production - produced in zona reticularis)

Question 22

How Calculate free androgen index

Answer 22

Total testosterone / SHBG x 100%