Lecture 48/49

Question 1

symptoms of PCOS

Answer 1

hyperandrogenism
menstrual disturbances
overweight or obese

Question 2

hyperandrogenism symptoms of PCOS

Answer 2

hirsutism
acne
alopecia

Question 3

menstrual disturbances symptoms of PCOS

Answer 3

amenorrhea
oligomenorrhea
anovulation

Question 4

three proposed mechanism of PCOS

Answer 4

inappropriate gonadotropin secretion
insulin resistance with hyperinsulinemia
excessive androgen production

Question 5

inappropriate gonadotropin secretion mechanism

Answer 5

increase in GnRH –> increase in LH surge too soon –> no rise in FSH –> no dominant follicle –> no ovulation –> unopposed estrogen –> luteal phase never entered –> elevated levels of androgen –> PCOS

Question 6

insulin resistance with hyperinsulinemia mechanism

Answer 6

occurs in obese and non-obese women with potential defects in insulin receptor
potentially leads to PCOS

Question 7

first line treatment of menstrual cycle irregularity in PCOS

Answer 7

COCs

Question 8

second line treatment of menstrual cycle irregularity in PCOS

Answer 8

cyclic progestin therapy (medroxyprogesterone or micronized progesterone)
progestin-only OC
LNG IUD
Metformin

Question 9

first line treatment of hirsutism/acne in PCOS

Answer 9

COCs

Question 10

second line treatment of hirsutism/acne in PCOS

Answer 10

anti androgens – spironolactone, finasteride

Question 11

third line treatment of hirsutism/acne in PCOS

Answer 11

topical vaniqa (eflornithine for facial hair only)

Question 12

last line treatment of hirsutism/acne in PCOS

Answer 12

cosmetic treatment like bleaching, plucking, waxing, shaving, or laser

Question 13

first line treatment for ovulation induction in PCOS

Answer 13

letrozole (aromatase inhibitor)

Question 14

four main factors that contribute to female infertility

Answer 14

cervical (<10)
uterine (<10)
tubal and peritoneal (40)
ovulatory (40)

Question 14

second line treatment for ovulation induction in PCOS

Answer 14

clomiphene and metformin
low dose gonadotropin therapy
laparoscopic ovarian drilling (ovarian diathermy)

Question 14

last line treatment for ovulation induction in PCOS

Answer 14

in vitro fertilization (IVF) or in vitro maturation (IVM)

Question 15

cervical factors contributing to infertility

Answer 15

mucus becomes not receptive to sperm

Question 16

uterine factors contributing to infertility

Answer 16

anatomic factors (mass)
non-anatomic factors (subclinical inflammation and chronic endometriosis)

Question 17

tubal and peritoneal factors contributing to infertility

Answer 17

blocked fallopian tubes
interference with normal movement of the fallopian tubes
barrier between fallopian tube and the ovary
alteration of the pelvic environment

Question 18

ovulatory factors contributing to infertility

Answer 18

hypothalamic pituitary failure (abnormal response to or a decrease production GnRH)
dysfunction of hypothalamic pituitary ovarian axis
ovarian failure

Question 19

non-pharmacologic treatment for infertility

Answer 19

weight adjustment
avoid smoking, alcohol, caffeine, and illicit drugs
reduce stress
expectant management

Question 20

weight adjustment in infertility

Answer 20

gain weight if hypothalamic anovulation and BMI under 20
lose weight if high BMI and insulin resistance

Question 21

expectant management

Answer 21

watching of a patient’s condition but not giving treatment unless symptoms appear or change

Question 22

types of test/things to look out for in expectant management

Answer 22

urine ovulation predictor kits
timed intercourse
change in cervical mucus
basal body temperature monitoring
vaginal monitoring
mid-luteal phase progesterone levels
FSH levels on day 3 of cycle

Question 23

pharmacological treatments for infertility

Answer 23

controlled ovarian hyperstimulation
gonadotropins with or without IUI
assisted reproductive techniques

Question 24

controlled ovarian hyperstimulation treatment of infertility

Answer 24

aromatase inhibitor (letrozole) with or without IUI
1. monitor use with tamoxifen and methadone
2. avoid use with CYP2A6 substrate
3. dose 2.5mg to 10mg po x5d starting on day 3 of menses

Question 25

gonadotropin with or without IUI treatment of infertility

Answer 25

develop multiple follicles by increasing FSH (combination of FSH and LH or either alone)
IM or SQ injections
requires careful monitoring
usage of hCG (triggers ovulation with use of aromatase inhibitor afteR)

Question 25

assisted reproductive techniques to treat infertility

Answer 25

intrauterine insemination (IUI)
IVF
intravaginal culture
intracytoplasmic sperm injection (ICSI)

Question 26

intrauterine insemination (IUI) to treat infertility

Answer 26

delivering washed sperm into uterine cavity via soft catheter
less invasive
used when younger than 40 yo
less expensive – cost 865$ per cycle

Question 27

IVF to treat infertility

Answer 27

surgical retrieval of matured eggs from ovaries and fertilized in vitro, embryos transferred back to the uterus 3 to 5 days after fertilization for implantation
success rate of 20 to 30% per cycle
extremely expensive – $8,151 per cycle or $11,000 to $15,000 per cycle with medication

Question 28

intracytoplasmic sperm injection (ICSI) to treat infertility

Answer 28

single sperm injected into egg to achieve fertilization
in conjunction with IVF procedures
overcomes severe male factor infertility (sperm count)
additional costs – $1,544 per procedure