Infertility + Insomnia Flashcards by Kelsi Taylor

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

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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

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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

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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

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Lifestyle management of infertility

Folic acid
Smoking cessarion
Wt control
Avoiding alcohol

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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

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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

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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

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Female causes

PCOS
Hyperprolactinemia (prolactinoma)
Thyroid disease
Cushings
PID
Adhesions
Prev ectopic
Uterine abnormality
Fibroids
Endometriosis

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Male causes

Varicocele
STI
Mumps
TB
Klinefelters
Torsion
RT
Hernia repair
Drugs: cannabis

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Rx to induce ovulation

Clomiphene citrate
Gonadotrophin
Metformin (PCOS)
Bromocriptine (for hyperprolactinemia)

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Rx for males

Selective estrogen receptor modulators
Aromatase inhibitors
hCG
Testosterone

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Surgical management for female

Tuboplasty
Lysis of adhesions

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When to refer a couple

<35: after 1 yr trying
35-40: after 6mo
>40: immediately

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Sx of PCOS

Hirsutism
oligomenorrhea
infertility
insulin resistance
acne
obesity
poly cystic ovaries
acanthosis nigracans
metabolic syndrome

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PCOS is considered a risk factor for the potential development of…

Diabetes (through insulin resistance)
Endometrial Hyperplasia/Carcinoma (through unopposed estrogen excess)

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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