Infertility + Insomnia Flashcards
Primary + secondary amenorrhea definition
Primary = no menarche by 16 or no secondary sexual characteristics + no menarche by 14
Secondary = no menses in 3mo with prev normal menstruation or no menses for 9mo in pt with prev oligomenorrhea
Differential?
Pregnancy
Hypothalamic dysfunction (low FSH, LH, estrogen)
Anorexia
Exercise
Stress
Nutritional deficit
Pituitary dysfunction
Brain tumor
Sheehan’s syndrome
Ovarian dysfunction
Menopause
Turner’s
PCOS
Endocrine
Hyperprolactinemia
Thyroid dz
Cushings
Questions to ask in history of amenorrhea
History
Sexual Hx
How long been trying
Coital frequency + timing
Lubricants
Menstrual hx
LMP
Cycle
Regularity
PMH
STI hx
Obs hx
Miscarriages
Past surgeries
Meds
Teratogenic meds
Prev contraeption
Stats for infertility
75% couples pregnant in 6 months
85% in 1 year
90% in 2 years
Causes: ⅓ male, ⅓ female, ⅓ combined
10% cases idiopathic
Lifestyle management of infertility
Folic acid
Smoking cessarion
Wt control
Avoiding alcohol
What to educate pts on?
Ovulation
Optimal intercourse timing (6d prior to ovulation q2-3d)
Reduced fertility with age
Adoption
Risk of pregnancy loss, chromosomal abnormalities, ASD, schizophrenia with increasing age
Ix for females
Rubella
Varicella
STIs inc HIV + hepatitis B + C
Day 3 LH/ FSH/ prolactin/ TSH/ estradiol/ testosterone
Day 21 progesterone
Pelvic US, HSG or hysteroscopy
Ix for males, and what further tests would you order if a) you found normal volume azoospermia and b) you were concerned for a tumor?
STIs inc HIV + hepatitis B + C
Rubella
Semen analysis
If normal volume azoospermia: LH, FSH, prolactin, estradiol
US if concerned for obstruction or tumors
Female causes
PCOS
Hyperprolactinemia (prolactinoma)
Thyroid disease
Cushings
PID
Adhesions
Prev ectopic
Uterine abnormality
Fibroids
Endometriosis
Male causes
Varicocele
STI
Mumps
TB
Klinefelters
Torsion
RT
Hernia repair
Drugs: cannabis
Rx to induce ovulation
Clomiphene citrate
Gonadotrophin
Metformin (PCOS)
Bromocriptine (for hyperprolactinemia)
Rx for males
Selective estrogen receptor modulators
Aromatase inhibitors
hCG
Testosterone
Surgical management for female
Tuboplasty
Lysis of adhesions
When to refer a couple
<35: after 1 yr trying
35-40: after 6mo
>40: immediately
Sx of PCOS
Hirsutism
oligomenorrhea
infertility
insulin resistance
acne
obesity
poly cystic ovaries
acanthosis nigracans
metabolic syndrome
PCOS is considered a risk factor for the potential development of…
Diabetes (through insulin resistance)
Endometrial Hyperplasia/Carcinoma (through unopposed estrogen excess)
Rotterdam criteria for PCOS
Oligomenorrhea/Anovulation
Clinical/Biochemical Signs of Hyperandrogenism
Polycystic Ovaries on Ultrasound
Ix for PCOS
FSH, LH, free testosterone, DHEAS, SHBG, fasting glucose
Management of PCOS
weight loss, OCP, POP, metformin, IUD, spironolactone
screening: monitor lipids, BP, a1c
Pregnancy optimisation PCOS
metformin, clomiphene, exogenous gonadotrophins, letrozole (aromatase inhibitor)
Secondary causes of amenorrhea
Pregnancy
Anorexia Nervosa
Menopause
Peri-Menopause
Stress
Weight Changes
Exercise
Hyperprolactinemia
Hypothyroidism
Hyperthyroidism
Diabetes
Premature Ovarian Failure
Anabolic Steroids
Cushing’s Syndrome
Addison’s Disease
Hypopituitarism
Congenital Adrenal Hyperplasia
Acromegaly
Turner Syndrome
Endometrial Scarring or Injury
Treatment for insomnia
brief behavioural therapy for insomnia over 2 sessions
Infant, toddler and teen causes of insomnia
Infants: usually behavioural, GERD
Toddlers: associated w/ fears, tx w/ behavioural intervention
Adolescents: delayed sleep phase syndrome
Management of insomnia in peds
Sleep hygiene: no naps during day, dinner 2hrs before bed, screen time d/c 1hr before bed, bedtime routine, regular wake up times, sleeping in own bed, dark sleep environment, quiet, no caffeine
Melatonin 1-5mg
DDx for insomnia
Sleep apnea
Depression/ anxiety
HF, COPD, asthma, GERD, thyroid, Parkinsons, dementia, pain, nocturia, menopause
Meds: SSRIs, SNRIs, stimulants, ACEi, BB, diuretics, statins, bronchodilators, levodopa, opioids, caffeine, alcohol, nicotine, steroids
Periodic limb movement
Restless leg syndrome
Sleepwalking
Sleeptalking
Sleep hygiene for adults
No caffeine or alcohol within 6hrs of bedtime
No nicotine close to bedtime
Avoid heavy exercise 3hrs before bedtime
No excess liquids or heavy meals prior to bed
No naps
No screen time 1 hr before bed
Limiting bedroom activities to sleep and sex
Regular schedule
CBT approach
Identify dysfunctional sleep cognition
Challenge validity
Replace with appropriate cognition
When would it be appropriate to prescribe meds, and how to go about it
Educate pt on risks
Prescribe only when insomnia has severe impact on function
Negotiate reduction and cessation plan
When presenting for renewal, reassess, education, discuss tapering or alternative therapies
Long term intermittent (<3 times weekly)
Which insomnia meds are better for elderly pts?
Doxepin, short acting GABA agonist (Sublinox), melatonin
Which insomnia meds are better for pregnant pts?
nortriptyline or trazodone
Rx (pharm + non-pharm) for nocturnal leg cramps
Non-pharmacological treatment
Daily stretching
Stationary bicycle before sleeping
Keep bed covers loose
Avoid alcohol, caffeine, dehydration
Pharmacological treatment
Vitamin B complex TID
Vitamin E 800 units qHS
May consider iron and magnesium (although no evidence)
Diphenhydramine
Diltiazem or Verapamil
Gabapentin
Rx of restless legs (inc if associated w/ comorbid depression or pain and if pt has ESRD)
Trial of oral iron therapy if ferritin<75mcg/L
Comorbid depression, obesity/metabolic syndrome - Dopamine agonist (Pramipexole, rotigotine)
Comorbid pain, anxiety, insomnia - Gabapentin
If ESRD, consider Vitamin C or E (alone or in combination)
When does nipple DC become worrisome?
unilateral, uniductal, spontaneous, bloody, breast mass, >40yo
DDx for nipple DC
Hyperprolactinemia:
Meds: antipsychotics, antidepressants, antiemetics, antihypertensive, estrogen, verapamil, opioids, cocaine
Pathologic - pituitary adenoma, chronic renal failure, cirrhosis, hypothyroid, Cushing disease, acromegaly
Physiological - lactation, pregnancy, stress, stimulation, macroprolactin
Lactation (Pregnancy, postpartum 6mo after delivery or 6mo after cessation of breastfeeding)
Papilloma, duct ectasia
Malignancy (DCIS)
What does azoospermia, oligozoospermia, asthenozoospermia and teratozoospermia mean?
Azoospermia: 0 sperm
Oligozoospermia: <15m sperm
Asthenozoospermia: <32-40% motile
Teratozoospermia: <4% normal form
Restless legs RF
uremia, neuropathy, low iron, fam hx, pregnancy, PD, MS
Rx for restless legs
iron, magnesium, stretch calves, avoid caffeine, massage, heat, exercise, pramipezole, gabapentin,
Periodic limb movement disorder - dx + rx
dx w/ sleep study, regular exercise, massage, dopamine agonists (ropinirole)
Nocturnal leg cramps rx
regular exercise, stretching, vitamin B complex, Mg, diphenyhydramine, CCB (diltiazem), gabapentin
Name some sleep disorders
nacrolepsy, restless leg syndrome, sleep terrors, sleep walking, insomnia disorder
Insomnia meds
benzos, dayvigo, lunesta
