Infertility in Males and Females Flashcards by Unknown J

What is the genomic structure of HPV?

A. ssDNA

B. dsDNA

C. RNA

D. Plasmid DNA

B. dsDNA

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What are the peak age risk groups for HPV?

A. 8-16

B. 18-30

C. 30-40

D. 20-40

B. 18-30

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Which of the following HPV viruses is most likely to cause anogenital warts?

A. HPV 16

B. HPV 18

C. HPV 4

D. HPV 6

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Which of the following HPV viruses is most likely to cause cancer?

A. HPV 12

B. HPV 18

C. HPV 4

D. HPV 11

B. HPV 18

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Which of the following HPV viruses is most likely to cause cancer?

A. HPV 12

B. HPV 16

C. HPV 4

D. HPV 11

B. HPV 16

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Outline the process of pathogenesis for HPV to Cancer.

Sexual contact -> taken up L1-receptor -> viral replication -> Infected cell leaves SC compartment to become more active (E6 + E7 oncogenes + viral replication + inhibition of p53 and pRB) ≈ immortalise keratinocyte -> oncogene activation causes transition from CIN to ICC ≈ cancer risk; Viral-laden cells ready for desquamation

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List 3 risk factors for HPV

HPV +ve
Smoking
STIs
COCs > 8 years
Immunodeficiency

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List the clinical features of Cervical Cancer.

Pelvic pain/tenderness
Weight loss
Vaginal bleeding
Vaginal discharge
Dysuria

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What stage of Cervical Cancer involves 2/3 of the epithelia affected?

A. CIN 1

B. CIN 2

C. ICC Stage 1

D. ICC Stage 2

B. CIN 2

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What stage of Cervical Cancer involves 1/3 of the epithelia affected?

A. CIN 1

B. CIN 2

C. ICC Stage 1

D. ICC Stage 2

A. CIN 1

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What stage of Cervical Cancer involves the cervix only?

A. CIN 1

B. CIN 2

C. ICC Stage 1

D. ICC Stage 2

C. ICC Stage 1

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What stage of Cervical Cancer involves the cervix and vagina only?

A. CIN 1

B. CIN 2

C. ICC Stage 1

D. ICC Stage 2

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What stage of Cervical Cancer involves the cervix, vagina and pelvis only?

A. CIN 1

B. ICC Stage 3

C. ICC Stage 1

D. ICC Stage 2

B. ICC Stage 3

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Which of the following is a pathological change from HPV resulting in irregular cell shape?

A. Dysplasia

B. Chromosomal aneuploidy

C. Hyperchromasia

D. Koilocytosis

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Which of the following is a pathological change from HPV resulting in increased DNA content?

A. Dysplasia

B. Chromosomal aneuploidy

C. Hyperchromasia

D. Koilocytosis

C. Hyperchromasia

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Which of the following is a pathological change from HPV resulting in abnormal chromosomal number?

A. Dysplasia

B. Chromosomal aneuploidy

C. Hyperchromasia

D. Koilocytosis

B. Chromosomal aneuploidy

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Which of the following is a pathological change from HPV resulting in more than one natural type at different stages?

A. Dysplasia

B. Chromosomal aneuploidy

C. Hyperchromasia

D. Pleomorphism

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Which of the following is a pathological change from HPV resulting in an abnormal cell type?

A. Dysplasia

B. Chromosomal aneuploidy

C. Hyperchromasia

D. Pleomorphism

A. Dysplasia

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In what stage of Cervical Cancer is hydronephrosis a likely/potential complication?

A. CIN 1

B. CIN 2

C. CIN 3

D. ICC 2

C. CIN 3

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What is the type of epithelium of the ectocervix?

A. Keratinised Stratified Squamous Epithelium

B. Non- Keratinised Stratified Squamous Epithelium

C. Simple Columnar Epithelium

D. Simple Squamous Epithelium

B. Non- Keratinised Stratified Squamous Epithelium

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What is the type of epithelium of the endocervix?

A. Keratinised Stratified Squamous Epithelium

B. Non- Keratinised Stratified Squamous Epithelium

C. Simple Columnar Epithelium

D. Simple Squamous Epithelium

C. Simple Columnar Epithelium

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What is the type of epithelium of the transition zone?

A. Keratinised Stratified Squamous Epithelium

B. Non- Keratinised Stratified Squamous Epithelium

C. Simple Columnar Epithelium changing to Stratified Squamous Non-Keratinised Epithelium

D. Simple Squamous Epithelium

C. Simple Columnar Epithelium changing to Stratified Squamous Non-Keratinised Epithelium

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What is the vascular supply

and drainage of the testes?

Testicular arteries (br. Abdominal aorta L2) via inguinal canal  - Anastomosis with cremasteric artery and artery to Vas  
Testicular veins  - Pampiniform plexus —> Testicular vein —> L Testicular Vein to Renal vein + R Testicular Vein to IVC

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What spinal level is the testicular artery branching from the abdominal aorta?

A. L1

B. T12

C. L2

D. L3

C. L2

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Which vein does the R testicular vein drain into? A. R Renal Vein B. IVC C. SVC D. Splenic vein

B. IVC

Which vein does the L testicular vein drain into? A. L Renal Vein B. IVC C. SVC D. Splenic vein

A. L Renal Vein

Which lymphatics drain the testes? A. Para-aortic nodes B. Superficial inguinal nodes C. Femoral nodes D. Pelvic nodes

A. Para-aortic nodes

Which lymphatics drain the scrotum? A. Para-aortic nodes B. Superficial inguinal nodes C. Femoral nodes D. Pelvic nodes

B. Superficial inguinal nodes

What is the order of route of sperm out of the testes?

SEVEN UP ``` Seminiferous tubules  (Sertoli Cells) Epididymis   Vas Deferens   Ejaculatory ducts (Vas deferens + Seminal Vesicle)   Nothing  ``` Urethra  Penis

What is the function of the blood-testis barrier? A. Prevent blood entering the testes B. Deliver nutrients to the testes C. Prevent infection spread D. Prevent autoimmune reaction to spermatozoa

D. Prevent autoimmune reaction to spermatozoa

What is not a function of Sertoli cells? A. Spermatogenesis B. Secretion of Anti-Mullerian Hormone, Secretion of Inhibins, Secretion of ABP and Secretion of Aromatase C. Secretion of Anti-Mullerian Hormone, Secretion of Inhibins, Secretion of ABP and Secretion of Oestrogen D. Phagocytosis

C. Secretion of Anti-Mullerian Hormone, Secretion of Inhibins, Secretion of ABP and Secretion of Oestrogen Oestrogen secreted by Leydig Cells

Which of the following is not a function of the Leydig cells? A. Testosterone production B. Androstenedione production C. Production of Anti-Mullerian hormone D. Production of oestrogen

C. Production of Anti-Mullerian hormone Produced by Sertoli Cells

What is Spermatogenesis?

Undifferentiated germ cells (primordial germ cells) --> Mature spermatozoa via spermatocytogenesis + meiosis + Spermiogenesis

Which of the following is not a stage of spermatogenesis? A. Spermatocytogenesis B. Meiosis C. Fertilisation D. Spermiogenesis

C. Fertilisation

Which of the following is directly derived from a primordial germ cell? A. Spermatozoa B. 2º Spermatozoa C. Spermatid D. A or B Spermatogonium

D. A or B Spermatogonium

Which of the following is directly derived from a Spermatogonium? A. Spermatozoa B. 2º Spermatozoa C. Spermatid D. Primordial germ cell

A. Spermatozoa

Which of the following is directly derived from a Spermatozoa? A. Spermatogonium B. 2º Spermatozoa C. Spermatid D. Primordial germ cell

B. 2º Spermatozoa

Which of the following is directly derived from a 2º Spermatozoa? A. Spermatogonium B. 1º Spermatozoa C. Spermatid D. Primordial germ cell

C. Spermatid

Through what process is a B spermatogonium created? A. Meiosis B. Mitosis C. Spermiogenesis D. None of the above

B. Mitosis

Through what process is a 2º Spermatozoa created? A. Meiosis II B. Mitosis C. Spermiogenesis D. Meiosis I

D. Meiosis I

Through what process are spermatids created? A. Meiosis II B. Mitosis C. Spermiogenesis D. Meiosis I

A. Meiosis II

Through what process is a 1º spermatozoa created? A. Meiosis II B. Mitosis and differentiation C. Spermiogenesis D. Meiosis I

B. Mitosis and differentiation

At which phase of meiosis do chromosomes condense? A. Prophase B. Metaphase C. Anaphase D. Telophase

A. Prophase

At which phase of meiosis do chromosome spindles between centrioles and tetrads line on spindles at metaphase plate ? A. Prophase B. Metaphase I C. Metaphase II D. Telophase

B. Metaphase I

At which phase of meiosis do spindles pull homologous chromosomes apart to opposite ends? A. Prophase B. Anaphase I C. Anaphase II D. Telophase

B. Anaphase I

At which phase of meiosis do Chromosomes reach poles and nuclear membrane develops? A. Prophase B. Anaphase I C. Anaphase II D. Telophase

D. Telophase

At which phase of meiosis do sister chromatids join at centromere? A. Prophase II B. Prophase I C. Anaphase II D. Telophase

A. Prophase II Prophase I, chromosomes condense and bivalents with chiasmata form featuring crossing over

At which phase of meiosis do sister chromatids pull towards separate poles?? A. Prophase II B. Anaphase I C. Anaphase II D. Telophase

C. Anaphase II

How do spermatids get into the epididymis? A. They swim via tail B. They are pushed by fluid secreted by Sertoli Cells C. They are pushed by fluid secreted by Leydig Cells D. They are produced in epididymis

B. They are pushed by fluid secreted by Sertoli Cells Note: motile capacity suppressed by epididymal fluid thus movement aided by reproductive peristaltic contractions

What is the significance of the capacitation reaction? A. Allows sperm to fertilise egg B. Allows sperm to remove glycoprotein coat and initiate acrosome reaction then fertilise egg C. Allows sperm to add glycoprotein coat and initiate across reaction then fertilise egg D. Allows sperm to swim further

B. Allows sperm to remove glycoprotein coat and initiate acrosome reaction then fertilise egg

What hypothalamic hormone controls spermatogenesis? A. FSH B. LH C. GnRH D. DA

C. GnRH

What Anterior Pituitary hormone controls spermatogenesis? A. FSH but not LH B. LH and FSH C. LH but not FSH D. DA

B. LH and FSH

What Testicular hormone controls spermatogenesis? A. FSH but not LH B. LH and FSH C. Testosterone D. DA

C. Testosterone

What Testicular hormone controls spermatogenesis? A. FSH but not LH B. Testosterone and Oxytocin C. Oxytoxcin D. DA

B. Testosterone and Oxytocin

What Testicular hormone controls spermatogenesis? A. Testosterone, Oxytocin and Inhibin B. Testosterone and Oxytocin C. Oxytoxcin D. DA

A. Testosterone, Oxytocin and Inhibin

Which cell is responsible for testosterone production? A. Sertoli cell B. Leydig cell C. Sperm cell D. None

B. Leydig cell

Which cell is responsible for oxytocin production? A. Sertoli cell B. Leydig cell C. Sperm cell D. None

B. Leydig cell

Which cell is responsible for Oestrogen production? A. Sertoli cell B. Leydig cell C. Sperm cell D. None

A. Sertoli cell

Which cell is responsible for Inhibin production? A. Sertoli cell B. Leydig cell C. Sperm cell D. None

A. Sertoli cell

Which of the following is most accurate? A. LH binds Sertoli cells to produce Oestrogen B. FSH binds Sertoli cells to produce Oestrogen (via Aromatase production) and Inhibin C. FSH binds Sertoli cells to produce Oestrogen (via Aromatase production) but not Inhibin D. FSH binds Leydig cells to produce Oestrogen (via Aromatase production) but not Inhibin

B. FSH binds Sertoli cells to produce Oestrogen (via Aromatase production) and Inhibin

Which of the following is most accurate? A. LH binds Leydig cells to produce Oestrogen B. LH binds Leydig cells to produce Oestrogen (via Aromatase production) and Inhibin C. LH binds Leydig cells to produce Oxytocin and Testosterone D. LH binds Leydig cells to produce Oxytocin but not Testosterone

C. LH binds Leydig cells to produce Oxytocin and Testosterone

Absent sperm production is... A. Azoospermia B. Oligoospermia C. Hypospermia D. Asthenozoospermia

A. Azoospermia

Reduced volume of sperm production is... A. Azoospermia B. Oligoospermia C. Hypospermia D. Asthenozoospermia

C. Hypospermia

Reduced concentration of sperm production is... A. Azoospermia B. Oligoospermia C. Hypospermia D. Asthenozoospermia

B. Oligoospermia

Reduced motility is... A. Azoospermia B. Oligoospermia C. Hypospermia D. Asthenozoospermia

D. Asthenozoospermia

Abnormal morphology of sperm is... A. Azoospermia B. Oligoospermia C. Tetrazoospermia D. Asthenozoospermia

C. Tetrazoospermia

Tetrazoospermia is... A. Abnormal morphology (< 4% normal) B. Abnormal morphology (< 40% normal) C. Abnormal morphology (< 14% normal) D. Abnormal morphology (< 44% normal)

A. Abnormal morphology (< 4% normal)

Hypospermia is... A. Reduced volume (< 15ml) B. Reduced volume (< 1.5ml) C. Reduced volume (< 5ml) D. Reduced volume (< 150ml)

B. Reduced volume (< 1.5ml)

Oligoospermia is... A. Low count (<15 million/ml) B. Low count (<150 million/ml) C. High count (>15 million/ml) D. High count (>150 million/ml)

A. Low count (<15 million/ml)

Asthenozoospermia is... A. Reduced motility (< 4% moving) B. Reduced motility (< 40% moving) C. Increased motility (> 40% moving) D. Increased motility (> 4% moving)

B. Reduced motility (< 40% moving)

Tetrazoospermia is... A. Abnormal morphology (< 40% normal) B. Abnormal morphology (< 4% normal) C. Normal morphology (> 4% normal) D. Normal morphology (> 40% normal)

B. Abnormal morphology (< 4% normal)

List the two types of infertility. Which is more common?

* 1º Infertility (70%): Unable to conceive after 1 year regular unprotected sex in absence of known reproductive pathology having never had a pregnancy with live birth * 2º Infertility (30%): Unable to conceive after 1 year regular unprotected sex in absence of known reproductive pathology having previously had a pregnancy with a live birth

Define infertility

inability to conceive when having regular, every other day, and unprotected sexual intercourse in the absence of any reproductive pathology for 1-2 years

What is the incidence of infertility? A. 1 in 3 B. 1 in 2 C. 1 in 10 D. 1 in 7

D. 1 in 7

List 3 risk factors for infertility

* Age * Smoking * Alcohol (F < 2 units/week; M <3-4 units/week) * Obesity (BMI > 30) * Tight underwear * Drugs * Medication (NSAIDs inhibit ovulation)

Outline the aetiology of Infertility broadly

``` Mnemonic: SAUDI TEEN Structural Autoimmune Uterine factors Drugs Idiopathic ``` ``` Testicular dysfunction Endocrine Environmental No Egg (Anovulation) ```

Which of the following is least likely a common presenting complaint in a history regarding infertility? A. Menstrual change B. Vaginal dryness C. Dyspareunia D. Low mood

D. Low mood

Which of the following is least likely a common presenting complaint in a history regarding infertility? A. Menstrual change B. Vaginal dryness C. Dyspareunia D. Anhedonia

D. Anhedonia

Which of the following is least likely a common presenting complaint in a history regarding infertility? A. Menstrual change B. Vaginal dryness C. Dyspareunia D. Weight stability

D. Weight stability

Outline the process of taking an Infertility history in a Female.

``` 1. PC • Menstrual change • Weight gain/loss • Headaches/visual changes • Galactorrhoea • Hirsutism • Hot flushes • Vaginal dryness • Breast problems • Dyspareunia • Post-coital bleeding ``` ``` 2. PMHx: Menstrual/Gynaecological/ Obstetric/ Sexual History • Infertility • Weight gain/loss • Headaches • Hirsutism • Hot flushes • Smear history ``` i. Menstrual History • Duration • Frequency • Flow: Change/Amenorrhoea/Oligomenorrhoea/Dysmenorrhoea/Clots (10p)/Pain/Impact on ADL ii. Gynaecological • Cervical screening iii. Obstetric • Gravidity • Parity • Pregnancy: Gestation/Live-birth/Stillbirth/Ectopic/Miscarriage/Termination foetal movements/Delivery/Postpartum haemorrhage (PPH) ``` iv. Sexual History • Last sexual contact • Timing • Consent • Formality: Relationship/Casual • Partner: Origin + Sex • Type of sex • Dyspareunia • Post-coital bleeding • Contraception • Last 3 months ``` ``` HIV risk? • Sex with contact • MSM • IVDU • Partners injected drugs • Paid or been paid for sex ``` 3. DHx • OTC • Pre-contraceptive: Folic Acid 500mcg + Vitamin D 10mcg • Allergies 4. FHx • Relevant conditions 5. SHx • Smoking (cessation aim) • Alcohol (1-2 units/week) • Recreational drugs Examination: • BMI • Sphygmomanometry • Endocrine signs: Acne/Hirsutism/Virilisation/Visual field defects/Goitre/Exomphalos ``` Investigations: • Urinary hCG • Reproductive hormones: FSH/LH/PRL/TFTs/E2/T • Ovulation • Ovarian reserve • TVUS • HSG • Laparoscopy and dye test • Rubella immunity • Chlamydia trachomatis ```

Outline the process of taking an Infertility history in a Female.

1. PC • Unable to conceive • Testicular pain • Cannot ejaculate 2. PMHx • General health • Medical history: Mumps/STIs/Trauma/Torsion/Systemic illness • Surgical history: Vasectomy/Undescended testes ``` i) Sexual History • Last sexual contact • Timing • Consent • Formality: Relationship vs Casual • Partner: Origin + Sex • Type of sex involved • Contraception • Last 3 months ``` ``` ii) HIV Risk History • Sexual contact – HIV positive? • MSM sex • IVDU • Partners injected drugs? • Paid or been paid for sex? ``` ``` 3. DHx • Drugs • OTC • Allergies • Recreational ``` 4. FHx • FH of relevant medical conditions ``` 5. SHx • Smoking • Alcohol • Recreational drugs • Tight underwear • Hot baths • Occupational history ```

What is PCOS?

Leading cause of infertility caused by elevated androgens in females with multiple fluid-filled cysts in the ovaries, amenorrhea/oligomenorrhea/hirsutism/acne/pelvic pain and skin pigmentation

Mrs. Jones, a 34 year old Waitress presents with oligomenorrhea. She says she has no major morbidities other than Hypertension, Obesity and Insulin Resistance. In her history she says she has a gravidity of 0 and parity of 0 but has had difficulty trying to conceive and would like children. She says she has a history of precocious puberty and that on her mother's side, all the women have had a problem with their ovaries but cannot remember what. O/E you notice hair in male-like regions, acne and her obesity. i) What are her risk factors? ii) What are her clinical features? iii) What investigations may you order? Her serum testosterone comes back raised, DHEAS is raised. iv) What additional, radiographic test may you order? Give two blood tests you may want to order as a test of exclusion. The radiographic test shows a positive find in the ovaries. v) What is your Differential Diagnosis? What diagnostic criteria will you use to formulate your differential? vi) Outline your management plan. vii) Should she not desire fertility, changing her mind, what treatment would you give?

i) • FHx PCOS • Precocious puberty • Obesity ``` ii) • Oligomenorrhea/Amenorrhea • Hirsutism • Acne • Infertility • Obesity/MetS ``` iii) • Serum Testosterone (Total and Free): Hyperandrogenemia > 2SD** • Serum DHEAS: Hyperandrogenemia > 2SD** • Lipid Panel: High Cl/High LDL/ High TG/ Low HDL** • Serum 17-hydroxyprogesterone: No change -> Exclude 21-hydroxylase adrenal hyperplasia • USS-Pelvis: Cysts ** iv) • Serum 17-hydroxyprogesterone: No change -> Exclude 21-hydroxylase adrenal hyperplasia • Pregnancy test: ßhCG • USS-Pelvis: Cysts ** ``` v) PCOS Diagnosis Criteria: Rotterdam Criteria 2/3 • Hyperandrogenemia • Anovulation (Oligo/Amenorrhoea) • Pelvic US > 12 follicles ``` vi) Desiring Fertility • Clomifene: 50mg PO OD 5/7; increase by 50mg until 150mg in cycles + • Metformin ``` vii) • COC: Drospirenone/Ethinylestradiol: 3mg/30mcg PO OD + • Metformin + • Mechanical hair removal ```

In a patient desiring fertility with PCOS, what treatment would you recommend? A. Weight loss (4.5kg) + Metformin B. Clomifene C. Clomifine + Weight loss (6.5kg) + Metformin D. COCP + Metformin + Weight loss (6.5kg)

C. Clomifine + Weight loss (6.5kg) + Metformin

In a patient not desiring fertility with PCOS, what treatment would you recommend? A. Weight loss (4.5kg) + Metformin B. Clomifene C. Clomifine + Weight loss (6.5kg) + Metformin D. COCP + Metformin + Weight loss (6.5kg)

D. COCP + Metformin + Weight loss (6.5kg)

What is Primary Ovarian Insufficiency? A. Cessation of menses for more than 2 year before 40 years old secondary to loss of ovarian function B. Cessation of menses for more than 1 year before 40 years old secondary to loss of ovarian function C. Cessation of menses for more than 2 year before 30 years old secondary to loss of ovarian function D. Cessation of menses for more than 2 year before 20 years old secondary to loss of ovarian function

B. Cessation of menses for more than 1 year before 40 years old secondary to loss of ovarian function

List 3 risk factors for Primary Ovarian Insufficiency

* FHx of POF * FHx Fragile X Syndrome * Exposure to chemotherapy/radiotherapy * Autoimmune disease

What is the pathophysiology of Primary Ovarian Insufficiency?

Idiopathic/Autoimmune/Turner’s Syndrome/ Gonadotropin resistance --> Impaired follicular development ≈ reduced oestrogen levels ≈ loss of feedback inhibition of oestrogen on FSH and LH --> elevated FSH and LH (FSH > LH) Note: GnRH resistance -> Reduced Oestrogen -> Reduced Oestrogen feedback ≈ FSH > LH cf PCOS

Janice, a 27 year old Radiographer presents with sleep disturbances and amenorrhoea. She says she has worked as a Radiographer for 5 years which gives her great purpose however her home life is difficult with her boyfriend. She says she has become irritable. She also mentions she has to use a lot of lube to have sex. Additionally, she has trouble sleeping and has been experiencing hot flushes She has a remarkable PMHx apart from IBD. Additionally, she mentions she is a smoker and drinks 18 units a week. She has a balanced diet but admits she eats a lot of processed foods. Her family history contains CVD on the paternal side and a reproductive problem causing infertility due to hormones on her maternal side. i) What are her risk factors? ii) What are her clinical features? iii) What investigations may you order? Her oestrogen is low and her LH and FSH are elevated. Additionally, her AMH is low. iv) What additional, radiographic test may you order? The radiographic test shows a positive find in the ovaries. v) What is your Differential Diagnosis? vi) Outline your management plan. vii) Should she not desire fertility, changing her mind, what treatment would you give?

i) • Exposure to chemotherapy/radiotherapy • Autoimmune disease • FHx of POF ``` ii) • Amenorrhea • Hot flushes • Sleep disturbance • Irritability • Vaginal dryness ``` iii) • Pregnancy test: Negative** -> Test of exclusion • Serum FSH: Elevated; Re-test at 4-6 weeks** • Serum LH: Elevated** -> LH >>> FSH consider autoimmune oophoritis • Serum Estradiol: Low < 50picomol/L** • Anti-Mullerian Hormone (AMH): Low ** • US-TV: Small ovaries with minimal activity -> Streaky ovaries if Turner Syndrome iv) • US-TV: Small ovaries with minimal activity -> Streaky ovaries if Turner Syndrome v) Primary Ovarian Insufficiency ``` vi) • HRT: Oestrogen: 0.3mg/1.5mg PO OD + • Counselling + • Vaginal oestrogen: 2g OD 3/52 + • Testosterone: 2.5-7.5mg/24 hour patch 2x week ``` vii) • Egg donation OR • Adoption

What is Hypothalamic Hypogonadism?

Cause of infertility due to umbrella term of diseases of defective HPG axis resulting in deficiency of GnRH with reduced FSH and LH secretion reducing folliculogenesis and ovulation

What are the types of Hypothalamic Hypogonadism?

• Congenital HH i) Anosmic HH (Kallman Syndrome) ii) Normosmic HH • Acquired HH

Ms. Johnson, a 32 year old Radiographer presents with amenorrhoea. She mentions she has hot flushes and vaginal dryness as well. Recently she has had marital discord due to her mood changes which she believes are relatively recent, following a lung infection which presented with Erythema Nodosum, Bilateral Lymphadenopathy and Migratory Polyarthritis. She says she has been under excessive stress at work recently. Additionally, she has had chronic ankylosing spondylitis. Additionally, her BMI is 16 and she has had depression, anxiety and low libido for a year. O/E you find nothing remarkable apart from vaginal dryness. i) What are her risk factors? ii) What are her clinical features? iii) What investigations would you order? The investigations show low T, low E, low GnRH, low LH and low FSH. iv) What is your DDx? v) Outline your management

``` i) • Excessive stress • Anorexia • Environmental: Radiation • Chronic disease • Recent infection: TB/Sarcoidosis ``` ``` ii) - Amenorrhoea - Vaginal Dryness Hot flushes - Mood changes ``` ``` iii) • Serum testosterone: Low* • Serum GnRH: Low* • Serum LH: Low* • Serum FSH: Low* • Serum oestrogen: Low* ``` ``` iv) Hypothalamic Hypogonadism • Serum testosterone: Low* • Serum GnRH: Low* • Serum LH: Low* • Serum FSH: Low* • Serum oestrogen: Low* ``` v) • GnRH pump: 100-400ng/kg per 2 hours OR • Gonadotropin: 1000-2500 IU 2x per week for 12/52

A patient presents with headache, oligomenorrhea, and galactorrhea. Investigations show serum PRL elevated, low LH and low FSH. What is the likely diagnosis? A. Hyperprolactinaemia B. PCOS C. Hypothalamic Hypothyroidism D. Primary Ovarian Insufficiency

A. Hyperprolactinaemia

A patient presents with headache, oligomenorrhea, and galactorrhea. Investigations show serum PRL elevated, low LH and low FSH. What is the first line treatment? A. Treat underlying cause B. Treat underlying cause + Bromocriptine C. Transphenoidal surgery D. Cabergoline and Bromocriptine

B. Treat underlying cause + Bromocriptine

A patient presents with headache, oligomenorrhea, and galactorrhea. Investigations show serum PRL elevated, low LH and low FSH. An MRI shows a prolactinoma of 1.1cm. What is the first line treatment? A. Treat underlying cause B. Transphenoidal surgery C. Transphenoidal surgery + Radiotherapy D. Cabergoline and Bromocriptine

C. Transphenoidal surgery + Radiotherapy

A middle-aged, female patient with a Grave's Disease presents with weakness, lethargy and cold sensitivity. O/E you notice she has gained weight (6kg) to take her to a BMI of 32 since her last consultation 6 months ago. Additionally you notice a heart rate of 62bpm when previously it was around 72bpm. Her blood pressure is 144/98mmHg. What is her most likely diagnosis? A. Hypothyroidism B. Hypothalamic Hypothyroidism C. Hyperthyroidism D. Hashimoto's Thyroiditis

A. Hypothyroidism

A middle-aged, female patient with a known Iodine deficiency presents with weakness, lethargy and cold sensitivity. O/E you notice she has gained weight (6kg) to take her to a BMI of 32 since her last consultation 6 months ago. Additionally, you notice she is sensitive to the stethoscope, more-so than other patients. What is the sensory symptom present most indicative of hyperthyroidism. A. Lethargy B. HTN with narrow pulse pressure C. Weakness D. Constipation

C. Weakness

A middle-aged, female patient with a known Iodine deficiency presents with weakness, lethargy and cold sensitivity. O/E you notice she has gained weight (6kg) to take her to a BMI of 32 since her last consultation 6 months ago. Additionally, you notice she is sensitive to the stethoscope, more-so than other patients. What is the constitutional symptom present most indicative of hyperthyroidism. A. Lethargy B. HTN with narrow pulse pressure C. Hypothyroidism D. Constipation

A. Lethargy

A middle-aged, female patient with a known Iodine deficiency presents with weakness, lethargy and cold sensitivity. O/E you notice she has gained weight (6kg) to take her to a BMI of 32 since her last consultation 6 months ago. Additionally, you notice she is sensitive to the stethoscope, more-so than other patients. What would the investigations show for this patient (anticipated)? A. TSH elevated, T4 elevated B. TSH low, T4 low C. TSH elevated, T4 low D. TSH normal, T4 low

C. TSH elevated, T4 low

A middle-aged, female patient with a known Iodine deficiency presents with weakness, lethargy and cold sensitivity. O/E you notice she has gained weight (6kg) to take her to a BMI of 32 since her last consultation 6 months ago. Additionally, you notice she is sensitive to the stethoscope, more-so than other patients. What is the advised management for this patient? A. Propylthiouracil: 500-1000mg PO loading dose + 250mg PO every 4 hours B. Propylthiouracil: 250-500mg PO loading dose + 250mg PO every 4 hours C. Levothyroxine: 1.6mcg/kg/day PO D. Levothyroxine: 1.6mcg/kg/day IV

C. Levothyroxine: 1.6mcg/kg/day PO

Which of the following directly reduces synthesis of T3/T4? A. Lithium B. Amiodarone C. Iodine excess D. Excess TSH

B. Amiodarone

Which of the following directly reduces secretion of T3/T4? A. Lithium B. Amiodarone C. Iodine excess D. Excess TSH

A. Lithium

What is hyperthyroidism?

Condition whereby excessive production of thyroid hormones by thyroid gland (thyrotoxicosis)

D. T3 high/ T4 high/ TSH low / US-Thyroid enlarged

A female, middle-aged patient presents with a worry regarding weight loss. She says she has also been having feeling of an irregular heart rate. O/E you see she is sweating, you can see there is marked tachycardia and a wide pulse pressure on her blood pressure. Investigations show a low TSH, high T3 and T4 and an US-Thyroid shows an enlarged thyroid What is the management for this patient? A. Propylthiouracil 500-1000mg PO (250mg PO every 4 hours) + Hydrocortisone: 300mg IV then 100mg QDS + Propanolol: 60-80mg QDS + Potassium iodide: 5%/15% 5 drops per 6 hours B. Propylthiouracil 250-1000mg PO (250mg PO every 8 hours) + Hydrocortisone + Propanolol + Potassium iodide C. Levothyroxine: 1.6mcg/kg/day D. Propylthiouracil: 500-1000mg PO (250mg every 4 hours) + Hydrocortisone: 300mg IV then 100mg TDS + Propanolol: 60-80mg PO QDS + Potassium iodide: 5%/10% 5 drops per 6 hours

D. Propylthiouracil: 500-1000mg PO (250mg every 4 hours) + Hydrocortisone: 300mg IV then 100mg TDS + Propanolol: 60-80mg PO QDS + Potassium iodide: 5%/10% 5 drops per 6 hours

What is endometriosis?

Condition where endometrium begins to grow in other places in the reproductive tract

C. TV-US

A 24 year old woman who has a gravidity of 0 and party of 0 presents with abdominal pain and oligomenorrhea. She says she has had this pelvic pain for the past 6 months. Additionally, she is very tired. Finally, she is worried about her relationship as her boyfriend has cheated on her following their lack of sexual intercourse due to her experiencing deep pain upon sex. O/E you notice a pelvic mass and fixed uterus which is tender on examination. Her TV-US shows low-level echoes and hypoechoic linear thickening. What do each of these show? A. Low level echoes = deep pelvic endometriosis whilst Hypoechoic linear thickening shows ovarian endometrioma B. Low-level echoes (ovarian endometrioma) and Hypoechoic linear thickening (deep pelvic endometriosis) C. Low-level echoes (ovarian endometrioma) and Hypoechoic linear thickening (superficial pelvic endometriosis) D. Endometriosis

B. Low-level echoes (ovarian endometrioma) and Hypoechoic linear thickening (deep pelvic endometriosis)

A 24 year old woman who has a gravidity of 0 and party of 0 presents with abdominal pain and oligomenorrhea. She says she has had this pelvic pain for the past 6 months. Additionally, she is very tired. Finally, she is worried about her relationship as her boyfriend has cheated on her following their lack of sexual intercourse due to her experiencing deep pain upon sex. O/E you notice a pelvic mass and fixed uterus which is tender on examination. Her TV-US shows low-level echoes and hypoechoic linear thickening. What is the likely diagnosis? A. Endometriosis B. Pelvic Inflammatory Disease C. PCOS D. Hyperthyroidism

A. Endometriosis

A 24 year old woman who has a gravidity of 0 and party of 0 presents with abdominal pain and oligomenorrhea. She says she has had this pelvic pain for the past 6 months. Additionally, she is very tired. Finally, she is worried about her relationship as her boyfriend has cheated on her following their lack of sexual intercourse due to her experiencing deep pain upon sex. O/E you notice a pelvic mass and fixed uterus which is tender on examination. Her TV-US shows low-level echoes and hypoechoic linear thickening. What is the gold standard management should she want children? A. Clomifene: 50-200mg PO OD 5/7 B. Clomifene: 50-200mg PO OD 5/7 + Mefenamic Acid C. Laparoscopic diathermy D. Hysterectomy

A. Clomifene: 50-200mg PO OD 5/7

A 24 year old woman who has a gravidity of 0 and party of 0 presents with abdominal pain and oligomenorrhea. She says she has had this pelvic pain for the past 6 months. Additionally, she is very tired. Finally, she is worried about her relationship as her boyfriend has cheated on her following their lack of sexual intercourse due to her experiencing deep pain upon sex. O/E you notice a pelvic mass and fixed uterus which is tender on examination. Her TV-US shows low-level echoes and hypoechoic linear thickening. What is the gold standard management should she not desire children? A. COCP (Drospirenone/Ethinylestradiol 30mg/3mcg) + Mefenamic Acid B. Clomifene: 50-200mg PO OD 5/7 + Mefenamic Acid C. Clomifene: 50-200mg PO OD 5/7 D. Propylthiouracil

A. COCP (Drospirenone/Ethinylestradiol 30mg/3mcg) + Mefenamic Acid

What is pelvic inflammatory disease?

Infection of female upper genital tract: womb, fallopian tubes and ovaries which may be asymptomatic or present with abdominal pain and abnormal discharge

List 3 risk factors for Pelvic Inflammatory Disease.

* Young age of sexual activity * UPSI * IUD use * STIs

Outline the pathophysiology of PID.

• Infection (N. gonorrhoea/C. trachomatis/Dysbiosis) -> Epithelial damage with microbial entry -> ascension into upper genital tract disrupt protective to introduce bacteria into endometrial cavity ≈ inflammatory conditions: endometritis/Salpingitis/tubo-overian abscess and pelvic peritonitis

A 18 year old girl who is in Upper Sixth presents with lower abdominal pain and abnormal vaginal discharge. She says she currently has a Mirena coil in so doesn't think she needs to use condoms. She mentions how she has had 5 sexual partners, the first of which was when she was 13. She currently has no fixed partner and has sex with more than one person regularly. O/E she exhibits cervical motion tenderness. Which investigations would you want to run in this patient? A. TV-US B. FBC/CRP/NAAT/TV-US C. NAAT/CRP/FBC D. NAAT What would you expect to see for the tests you've run?

B. FBC/CRP/NAAT/TV-US FBC: Leukocytosis CRP: Elevated NAAT: Positive? TV-US: Tubal wall thickening

A 18 year old girl who is in Upper Sixth presents with lower abdominal pain and abnormal mucopurulent vaginal discharge. She says she currently has a Mirena coil in so doesn't think she needs to use condoms. She mentions how she has had 5 sexual partners, the first of which was when she was 13. She currently has no fixed partner and has sex with more than one person regularly. O/E she exhibits cervical motion tenderness. Her investigations come back with leukocytosis, raised CRP, NAAT positive for Gonorrhoea from VVS and TV-US showing tubal thickening. What is your DDx? A. Hyperthyroidism B. PCOS C. Endometriosis D. Pelvic Inflammatory Disease secondary to N. gonorrhoea infection

D. Pelvic Inflammatory Disease secondary to N. gonorrhoea infection

A 18 year old girl who is in Upper Sixth presents with lower abdominal pain and abnormal mucopurulent vaginal discharge. She says she currently has a Mirena coil in so doesn't think she needs to use condoms. She mentions how she has had 5 sexual partners, the first of which was when she was 13. She currently has no fixed partner and has sex with more than one person regularly. O/E she exhibits cervical motion tenderness. Her investigations come back with leukocytosis, raised CRP, NAAT positive for Gonorrhoea from VVS and TV-US showing tubal thickening. What is your management? A. Ceftriaxone (250mg IM) + Doxycycline (100mg PO BD 2/52) B. Benzathine Benzylpenicillin (2.4 MU IM) + Remove IUD + Place on barrier contraception + Trace contacts + Remove IUD C. Ceftriaxone (250mg IM) + Doxycycline (100mg PO BD 2/52) + Trace contacts + Remove IUD + Advise on barrier contraception D. Benzathine Benzylpenicillin (2.4 MU IM) + Remove IUD + Place on barrier contraception

C. Ceftriaxone (250mg IM) + Doxycycline (100mg PO BD 2/52) + Trace contacts + Remove IUD + Advise on barrier contraception

What are uterine fibroids?

Non-cancerous uterine growths (leiomyomas/myomas) caused by genetic and environmental drivers resulting in monoclonal tumours in the myometrium (intramural)

What is the term for a uterine fibroid? A. Adenocarcinoma B. Squamous cell carcinoma C. Leiomyoma D. None of the above

C. Leiomyoma

A 35 year old African American woman presents with menorrhagia and a pelvic pain. She says she went through puberty early, has a gravidity of 4 and a parity of 3 and has been trying to lose weight. O/E her blood pressure is 145/95mmHg, pulse is 74bpm and her BMI is 32. You notice a pelvic mass which is irregular, firm and moveable. What would the gold-standard imaging technique be? What might be seen? A. CT B. XR C. US-Pelvis D. MRI

C. US-Pelvis Heterogeneous echoes with variable blood supply and symmetrical enlargement showing leiomyomas

A 35 year old African American woman presents with menorrhagia and a pelvic pain. She says she went through puberty early, has a gravidity of 4 and a parity of 3 and has been trying to lose weight. O/E her blood pressure is 145/95mmHg, pulse is 74bpm and her BMI is 32. Should the patient present with uterine fibroids, what type of clinical find would be typical? A. Fibroids which are soft and immoveable B. Fibroids which are firm, regular and immoveable C. Fibroids which are regular, firm and moveable D. Fibroids which are irregular, firm and moveable

D. Fibroids which are irregular, firm and moveable

A 35 year old African American woman presents with menorrhagia and a pelvic pain. She says she went through puberty early, has a gravidity of 4 and a parity of 3 and has been trying to lose weight. O/E her blood pressure is 145/95mmHg, pulse is 74bpm and her BMI is 32. You notice a pelvic mass which is irregular, firm and moveable. What is the medical management for this patient? A. Myomectomy B. Mifepristone: 5-50mg PO OD 6/12 C. Misoprostrol D. Clomifene: 50mg PO OD 5/7

B. Mifepristone: 5-50mg PO OD 6/12

A 35 year old African American woman presents with menorrhagia and a pelvic pain. She says she went through puberty early, has a gravidity of 4 and a parity of 3 and has been trying to lose weight. O/E her blood pressure is 145/95mmHg, pulse is 74bpm and her BMI is 32. You notice a pelvic mass which is irregular, firm and moveable. What is the surgical management for this patient? A. Myomectomy B. Mifepristone: 5-50mg PO OD 6/12 C. Misoprostrol D. Clomifene: 50mg PO OD 5/7

A. Myomectomy

What type of uterine fibroid is most likely to cause inward protrusions? A. Subserosal B. Submucosal C. Ovarian D. Uterine

B. Submucosal

What is the eponymous disease Asherman Syndrome?

Intrauterine Adhesions Scar tissue accumulating in the inner walls of the uterus causing walls to bind together

What is the pathophysiology of intrauterine adhesions? A. Activation of fibrocytes B. Activation of SMCs and deposition of collagen fibres C. Activation of BM-SCs and differentiation into Fibroblasts D. None of the above

B. Activation of SMCs and deposition of collagen fibres

A 43 year old African American lady who has never had children presents with amenorrhoea and periodic abdominal pain. O/E you identify she has diffuse abdominal pain. What investigation might you order? For the option you select, state what you may expect to see in Intrauterine Adhesions. A. Pregnancy test/Serum FSH B. Pregnancy test/Serum FSH/Serum LH C. Hysterosalpingography D. Pregnancy test/Serum FSH/Serum LH/Hysterosalpingography

D. Pregnancy test/Serum FSH/Serum LH/Hysterosalpingography Pregnancy: no/low ßhCG Serum FSH: Normal Serum LH: Normal HSG: Uterine adhesions

A 43 year old African American lady who has never had children presents with amenorrhoea and periodic abdominal pain. O/E you identify she has diffuse abdominal pain. What is the first line management of intrauterine adhesions? A. Myomectomy B. Hysterectomy C. Hysteroscopic resection D. Mifepristone

C. Hysteroscopic resection

A 43 year old African American lady who has never had children presents with amenorrhoea and periodic abdominal pain. O/E you identify she has diffuse abdominal pain. Her investigations show normal LH, FSH, GnRH however HSG shows stenosis in regions. What is the most likely Diagnosis? A. Endometriosis B. PID C. Intrauterine adhesions D. Uterine fibroids

C. Intrauterine adhesions

What is cryptorchidism?

Absence of one or both of the testes in the scrotum

What two types of cryptorchidism are there?

* Retractile: Pulled into scrotum and remains | * Undescended: Palpable after 6 months but absent from scrotum

List 3 RF of Cryptorchidism.

* FHx * Low birth weight * Prematurity

A 14 year old boy of Caucasian ethnicity presents with an intimate problem. He says that he is worried about his scrotum as it is not an equal shape and he worries about them. You ask for a Chaperone to be in the room for the examination. O/E you notice an absent testis which is a palpable cryptorchid testis, testicular asymmetry and scrotal hypoplasia. What investigation is required for an accurate diagnosis? A. Clinical diagnosis B. CT C. MRI D. US

A. Clinical diagnosis

A 14 year old boy of Caucasian ethnicity presents with an intimate problem. He says that he is worried about his scrotum as it is not an equal shape and he worries about them. You ask for a Chaperone to be in the room for the examination. O/E you notice an absent testis which is a palpable cryptorchid testis, testicular asymmetry and scrotal hypoplasia. The diagnosis is clinical but a supporting MRI shows the testis is located along the normal path of descent in the inguinal canal, attached to the spermatic cord. What is your differential? A. Cryptorchidism B. Retractile Cryptorchidism C. Undescended Cryptorchidism D. Varicocele

C. Undescended Cryptorchidism

A 14 year old boy of Caucasian ethnicity presents with an intimate problem. He says that he is worried about his scrotum as it is not an equal shape and he worries about them. You ask for a Chaperone to be in the room for the examination. O/E you notice an absent testis which is a palpable cryptorchid testis, testicular asymmetry and scrotal hypoplasia. The diagnosis is clinical but a supporting MRI shows the testis is located along the normal path of descent in the inguinal canal, attached to the spermatic cord. What is your Management? A. Annual follow-up B. Orchiopexy C. Supportive D. Counselling

B. Orchiopexy

A 14 year old boy of Caucasian ethnicity presents with an intimate problem. He says that he is worried about his scrotum as it is not an equal shape and he worries about them. You ask for a Chaperone to be in the room for the examination. O/E you notice an absent testis which is a palpable cryptorchid testis, testicular asymmetry and scrotal hypoplasia. You pull the testes into the scrotum and it remains, The diagnosis is clinical. What is your Management? A. Annual follow-up B. Orchiopexy C. Supportive D. Counselling

A. Annual follow-up

What is the karyotype of a patient with Klinefelter Syndrome?

47 XXY

What is Klinefelter Syndrome?

Genetic disease caused by non-disjunction of sex chromosomes providing an additional X chromosome for a male (47 XXY) resulting in female sex characteristics

A 15 year old boy presents with poor testicular development and small testicles. He says this has affected his confidence and libido. O/E, you ask for a Chaperone, and confirm Testicular dysgenesis and a relatively asexual growth pattern. What type of growth pattern can be described here? A. Normal B. Eunochoid C. Short D. Excessive

B. Eunochoid

A 15 year old boy presents with poor testicular development and small testicles. He says this has affected his confidence and libido. O/E, you ask for a Chaperone, and confirm Testicular dysgenesis and a relatively asexual growth pattern. What investigation would you order to confirm your suspected Diagnosis? A. CT B. Genotype analysis C. NAAT D. PCR

B. Genotype analysis Karyotype 47 XXY

Which of the following genotypes is seen in Klinefelter Syndrome? A. 47 XY/XX + 21 B. 47 XY/XX + 18 C. 47 XXY D. 45 X

C. 47 XXY

A 15 year old boy presents with poor testicular development and small testicles. He says this has affected his confidence and libido. O/E, you ask for a Chaperone, and confirm Testicular dysgenesis and a relatively asexual growth pattern. A karyotype analysis shows 47 XXY. What is your treatment? A. GH B. Testosterone C. Mifepristone D. GnRH (Gonadotropin)

B. Testosterone

What is a varicocele?

Enlargement of pampiniform plexus of scrotum causing low sperm production (hypospermia), reduced concentration (oligoospermia) and low sperm quality (tetrazoospermia/asthenozoospermia)

A 18 year old patient presents with a painless scrotal mass. He complains that his asymmetrical testes have caused embarrassment previously. O/E you describe his testes to feel like a 'bag of worms'. What is the most likely differential? A. Hydrocele B. Testicular lump query Testicular cancer C. Varicocele D. Normal, undescended testicle

C. Varicocele

A 18 year old patient presents with a painless scrotal mass. He complains that his asymmetrical testes have caused embarrassment previously. O/E you describe his testes to feel like a 'bag of worms'. What investigation would you do to assess his chance of fertility/infertility? A. US-scrotum B. Clinical Diagnosis C. Semen analysis D. None

C. Semen analysis

A 18 year old patient presents with a painless scrotal mass. He complains that his asymmetrical testes have caused embarrassment previously. O/E you describe his testes to feel like a 'bag of worms'. What is the treatment for Varicocele? A. Supportive B. Orchiopexy C. Testosterone D. Supportive + Surgery

D. Supportive + Surgery

What is obstructive azoospermia?

Absence of spermatozoa in ejaculation despite normal spermatogenesis

Give 3 risk factors for Obstructive Azoospermia.

* Trauma * Surgery * Infection * FHx Obstructive Azoospermia

A 26 year old Caucasian male presents with testicular pain following recent abdominal surgery following trauma to the same region. He developed a post-operative nosocomial infection which was treated with Doxycycline. O/E you observe reduced facial and body hair (alopecia areatis), urethral discharge and testicular pain. Which of the following is not a risk factor for Obstructive Azoospermia? A. Trauma B. Infection C. Abdominal Surgery D. Caucasian ethnicity

D. Caucasian ethnicity

A 26 year old Caucasian male presents with testicular pain following recent abdominal surgery following trauma to the same region. He developed a post-operative nosocomial infection which was treated with Doxycycline. O/E you observe reduced facial and body hair (alopecia areatis), urethral discharge and testicular pain. What investigations would you wish to conduct to confirm your suspected DDx? A. FSH B. LH C. Testosterone and FSH and LH D. Semen analysis, FSH, LH and Testosterone

D. Semen analysis, FSH, LH and Testosterone

A 26 year old Caucasian male presents with testicular pain following recent abdominal surgery following trauma to the same region. He developed a post-operative nosocomial infection which was treated with Doxycycline. O/E you observe reduced facial and body hair (alopecia areatis), urethral discharge and testicular pain. The investigations come back showing normal FSH, normal LH and FSH and testosterone being normal. However, the semen analysis shows azoospermia. What is your differential? A. Cryptorchidism B. Hypothalamic Hypogonadism C. Obstructive Azoospermia D. Varicocele

C. Obstructive Azoospermia

A 36 year old Caucasian male presents with testicular pain following recent abdominal surgery following trauma to the same region. He developed a post-operative nosocomial infection which was treated with Doxycycline. He has previously had a vasectomy. O/E you observe reduced facial and body hair (alopecia areatis), urethral discharge and testicular pain. The investigations come back showing normal FSH, normal LH and FSH and testosterone being normal. However, the semen analysis shows azoospermia. The differential is Obstructive Azoospermia. What is the management for this condition? A. Testosterone B. Vasectomy reversal C. Orchiopexy D. Supportive

B. Vasectomy reversal

What is hypogonadootropic hypogonadism?

Cause of infertility due to umbrella term of diseases of defective HPG axis resulting in deficiency of GnRH with reduced FSH and LH secretion reducing folliculogenesis and ovulation

What is hypogonadootropic hypogonadism? A. Deficiency in LH B. Deficiency in LH and FSH C. Deficiency in LH, FSH and GnRH D. Deficiency in GnRH causing reduced LH and FSH

D. Deficiency in GnRH causing reduced LH and FSH

Give 3 risk factors for Hypogonadotropic Hypogonadism.

* Drugs * Radiation/Chemotherapy * Genetic disorders * Neoplasm * Infection * Eating disorders (functional hypothalamic hypogonadism)

A 21 year old Caucasian male presents with a complaint of shrinking testes. He says he has lost weight also. He has no other PMHx other than previous treatment for a neoplasm with radiotherapy. Additionally, when he was 18 he developed an eating order. O/E you notice he has delayed puberty with testicular hypoplasia, reduced body hair growth, high pitched voice and lean body mass. Which of the following is not a risk factor for Hypogonadotropic Hypogonadism? A. Neoplasm B. Caucasian C. Radiotherapy/Chemotherapy D. Eating disorder

B. Caucasian

A 21 year old Caucasian male presents with a complaint of shrinking testes. He says he has lost weight also. He has no other PMHx other than previous treatment for a neoplasm with radiotherapy. Additionally, when he was 18 he developed an eating order. O/E you notice he has delayed puberty with testicular hypoplasia, reduced body hair growth, high pitched voice and lean body mass. What is your differential? A. Obstructive Azoospermia B. Hypogonadotropic Hypogonadism C. Cryptorchidism D. Varicocele

B. Hypogonadotropic Hypogonadism

* Serum testosterone: Low** * Serum GnRH: Low** * Serum LH: Low** * Serum FSH: Low** * Brain MRI: SOL?

A 21 year old Caucasian male presents with a complaint of shrinking testes. He says he has lost weight also. He has no other PMHx other than previous treatment for a neoplasm with radiotherapy. Additionally, when he was 18 he developed an eating order. O/E you notice he has delayed puberty with testicular hypoplasia, reduced body hair growth, high pitched voice and lean body mass. Investigations come back with testosterone low, GnRH low, serum LH low and serum FSH low. An MRI is performed to exclude a SOL. What is the management for this patient? A. GnRH pump: 100-400ng/kg per 2 hours B. Trans-sphenoidal surgery C. Testosterone D. Orchiopexy

A. GnRH pump: 100-400ng/kg per 2 hours

A 21 year old Caucasian male presents with a complaint of shrinking testes. He says he has lost weight also. He has no other PMHx other than previous treatment for a neoplasm with radiotherapy. Additionally, when he was 18 he developed an eating order. O/E you notice he has delayed puberty with testicular hypoplasia, reduced body hair growth, high pitched voice and lean body mass. Investigations come back with testosterone low, GnRH low, serum LH low and serum FSH low. An MRI is performed to exclude a SOL. What is the management for this patient? A. Gonadotropin: 1000-2500 IU 2x per week for 4/12 B. Trans-sphenoidal surgery C. Testosterone D. Orchiopexy

A. Gonadotropin: 1000-2500 IU 2x per week for 4/12

A 21 year old Caucasian male presents with a complaint of shrinking testes. He says he has lost weight also. He has no other PMHx other than previous treatment for a neoplasm with radiotherapy. Additionally, when he was 18 he developed an eating order. O/E you notice he has delayed puberty with testicular hypoplasia, reduced body hair growth, high pitched voice and lean body mass. Investigations come back with testosterone low, GnRH low, serum LH low and serum FSH low. An MRI is performed to show a SOL. What is the management for this patient? A. Gonadotropin: 1000-2500 IU 2x per week for 4/12 B. Trans-sphenoidal surgery C. Testosterone D. Orchiopexy

B. Trans-sphenoidal surgery

A 21 year old Caucasian male presents with a complaint of shrinking testes. He says he has lost weight also. He has no other PMHx other than previous treatment for a neoplasm with radiotherapy. Additionally, when he was 18 he developed an eating order. O/E you notice he has delayed puberty with testicular hypoplasia, reduced body hair growth, high pitched voice and lean body mass. Investigations come back with testosterone low, GnRH low, serum LH low and serum FSH low. What additional investigation might you wish to order to ensure the correct management of this patient? A. CT B. US C. MRI D. XR

C. MRI Rule out SOL

What is Hyperprolactinaemia?

Presence of abnormally elevated prolactin in the blood (>21.5ng/ml (M) or > 23.5ng/ml (F))

List 3 risk factors for Hyperprolactinaemia.

* Stress * Brain tumour (prolactinoma) * Drugs: Antipsychotics/Antiemetics

``` Investigations: • Serum PRL: Elevated* • Serum LH: Low* • Serum FSH: Low* --> PRL inhibits secretion of GnRH (feedback) ``` • MRI: Prolactinoma

A 27 year old male presents with an ED complaint. He says he has experienced a loss of libido recently, experienced headaches and experienced vision changes. O/E you identify gynecomastia and vision change (diplopia). Investigations come back and show LH low, FSH low, PRL elevated. What additional investigation would you want to order to inform management? A. CT B. XR C. MRI D. None

C. MRI

A 27 year old male presents with an ED complaint. He says he has experienced a loss of libido recently, experienced headaches and experienced vision changes. O/E you identify gynecomastia and vision change (diplopia). Investigations come back and show LH low, FSH low, PRL elevated. MRI shows a SOL of 1.2cm. What is your management? A. Bromocriptine: 0.25mg PO BD B. Transphenoidal surgery C. No transphenoidal surgery as it does not meet the criteria D. Testosterone

B. Transphenoidal surgery

A 27 year old male presents with an ED complaint. He says he has experienced a loss of libido recently, experienced headaches and experienced vision changes. O/E you identify gynecomastia and vision change (diplopia). Investigations come back and show LH low, FSH low, PRL elevated. MRI shows no SOL. What is your management? A. Bromocriptine: 0.25mg PO BD + Treat underlying cause B. Transphenoidal surgery C. No transphenoidal surgery as it does not meet the criteria D. Bromocriptine: 0.25mg PO BD

A. Bromocriptine: 0.25mg PO BD + Treat underlying cause

Outline the two main forms of Hypogonadism and the key difference between the two.

1) Hypergonadotropic (primary) hypogonadism = insufficient sex steroid production in gonads   1º: Turner Syndrome, Klinefelter Syndrome, Androgen insensitivity syndrome, Anorchia   2º: Chemotherapy, pelvic irradiation, trauma/surgery, autoimmune disease, infections (mumps, tuberculosis) 2) Hypogonadotrophic (secondary) hypogonadism = insufficiency GnRH or Gonadotropin release at HPA - Genetic: Kallmann Syndrome, Idiopathic HH, PWS, Gaucher’s disease - HPA: Neoplasm (Prolactinoma, Craniopharyngioma, Astrocytoma) - Trauma, surgery, irradiation - Infection

What is Kallmann Syndrome? List the clinical features.

Form of hypogonadotrophic hypogonadism whereby impaired migration of GnRH cells and defective olfactory bulb result in reduced GnRH in Hypothalamus and reduced FSH and LH with reduced testosterone and oestrogen. Sx:   - Failed puberty - Infertility - Anosmia - Syndactyly - Testicular hypoplasia - Lack of male secondary sexual characteristics

Outline the process of IVF.

- Daily FSH with frequent US monitoring. - hCG trigger when at least 3 follicles > 16mm - Egg collection 36-38hr from trigger - Semen collection - Oocytes and sperm incubated overnight or ICSI (intracytoplasmic sperm injection) - Embryo transfer day 3 or day 5 blastocyst - One embryo transfer

How many cycles of IVF can be funded fully in Scotland? A. 4 B. 2 C. 1 D. 3

D. 3

How many cycles are you entitled to under the age of 40? A. 1 B. 2 C. 4 D. 3

A. 1

What criteria for IVF is there in Scotland? A. Must involve a heterosexual couple B. Must have had a child previously C. Must be non-smokers D. Must be able to pay

C. Must be non-smokers

List the risks of IVF.

- Failed cycle - Bowel/vessel injury - Infection - OHSS - Miscarriage - Ectopic - Multiple pregnancy