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Endocrinology > Male Repro > Flashcards

Male Repro Flashcards

1
Q

what is organic hypogonadism

A

low testosterone due to pituitary or testicular disease (includes low libido)

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2
Q

If total testosterone is less than 150, what imaging needs to be done?

A

PITUITARY MRI

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3
Q

Patient case:

  1. Man found to have low total AM testosterone on repeat measurement. What is the next step?
  2. When is a pituitary MRI indicated?
A
  1. measure gonadotropins to determine whether hypogonadism is primary or secondary, including PRL
    • elevated gonadotropins –> primary testicular failure
    • low or inappropriately normal gonadotropins –> secondary hypogonadism
  2. elevated PRL, symptoms of mass effect (H/A, bitemporal hemianopia), or total T < 150
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4
Q

In men with neurovascular erectile dysfunction (not 2/2 organic hypogonadism), what is the best therapy to improve ED?

A

phosphodiesterase type 5 inhibitor (contraindicated in patients taking nitrates)

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5
Q

Testosterone treatment is positively associated with

A

increase in libido, but NOT with improvement in erectile dysfunction

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6
Q

the Endocrine Society guidelines recommend a urologic consultation for men receiving testosterone therapy if, during the first 12 months of treatment, there is a confirmed increase in the PSA concentration of?

A

> 1.4 ng/ml above baseline,
PSA greater than 4.0 ng/ml,
or a new prostatic abnormality detected on DRE

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7
Q
  1. HAART is often associated with an increase in?
  2. what T formulation is preferred for treatment
A
  1. SHBG. Therefore men with HIV on HAART should have FREE Testosterone measured
  2. IM T (oral T is associated with increased BP)
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8
Q

Men with secondary hypogonadism desiring fertility
1. tx?
2. what additional med can be added and when?
3. how long does it take for spermatogenesis to occur

A
  1. gonadotropin (hCG), a long-acting LH analog, injections are more likely to be successful in POSTpubertal secondary hypogonadism and normal testicular volumes - dose up to 1000-2000 IU 3 times per week
  2. recombinant FSH; can be added after 6 months of hCG therapy
  3. about 72 days, needs adequate testosterone for effectiveness
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9
Q
  1. in men with hyperthyroidism, what happens to SHBG?
  2. what happens to total T and free T
  3. what happens to estradiol
  4. what happens to LH
A
  1. liver makes more, therefore it is increased.
  2. total T increases, but free T is low or low normal
  3. SHBG has a higher affinity for testosterone than estradiol. Therefore, there is a relatively higher amount of free estradiol than free T. In extraglandular tissues, there is also increased aromatization of T to E
  4. it is normal

Total T and E high, free T low/low normal, LH normal

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10
Q

Changes in total testosterone, free testosterone, estradiol, LH:

Estrogen-secreting tumor or estrogen use

A

total testosterone LOW

free testosterone LOW

estradiol HIGH

LH LOW

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11
Q

Changes in total testosterone, free testosterone, estradiol, LH:

Hyperthyroidism

A

total testosterone HIGH

free testosterone LOW/LOW NORMAL

estradiol HIGH

LH NORMAL

In hyperthyroidism: increased SHBG production in the liver → high total T but low/normal free T; high estradiol (since SHBG has a greater affinity for T than E, and also increased aromatization of free E than T)

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12
Q

Changes in total testosterone, free testosterone, estradiol, LH:

HCG-secreting tumor, exogenous testosterone use/abuse, DHEAS from an adrenal tumor, exogenous LH

A

total testosterone HIGH/NORMAL

free testosterone HIGH/NORMAL

estradiol HIGH

LH LOW

testosterone to estradiol ratio is low

HCG stimulates production of both T and E, but preference over E (hence low T to E ratio)

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13
Q

Changes in total testosterone, free testosterone, estradiol, LH:

Androgen insensitivity

A

total testosterone HIGH

free testosterone HIGH

estradiol HIGH

LH HIGH

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14
Q

In men planning to undergo cytotoxic chemotherapy, what are the options for fertility preservation?

A

sperm cryopreservation before chemotherapy
-optimal semen collection: obtain at least 3 samples after abtinence for a min of 48 hrs

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15
Q

are anabolic steroids detected in modern testosteron assays?

A

NO

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16
Q

what enzyme converts T to E?

A

aromatase

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17
Q

what medication used to treat BPH commonly causes retrograde ejaculation

A

alpha blockers (tamsulosin) due to relaxation of bladder sphincter

instead, use 5-alpha reductase inhibitors (“-asteride”)

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18
Q

genetic testing for congenital hypogonadotropic hypogonadism
1. synkinesia (involuntary facial contraction/twitching)
2. dental agenesis
3. digital bony abnormalities/syndactyly
4. hearing loss

A
  1. ANOS 1 (formerly KAL1)
  2. FGF8/FGFR1
  3. FGF8/FGFR1
  4. CHD1
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19
Q

Congenital hypogonadotropic hypogonadism:

This clinical feature is highly associated with what specific gene? synkinesia (involuntary movements accompanied by voluntary movements)

A

ANOS1 (formerly KAL1)

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20
Q

Congenital hypogonadotropic hypogonadism:

This clinical feature is highly associated with what specific gene?

congenital hypogonadotropic hypogonadism and adrenal insufficiency WITHOUT anosmia

A

NR0B1 (formerly DAX1)

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21
Q
  1. Leydig cell tumors secrete?
A
  1. testosterone or estradiol
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22
Q

Klinefelter syndrome
1. karyotype
2. most common cause of what type of hypogonadism?
3. clinical features
4. complications

A
  1. XXY
  2. PRIMARY
  3. infants with hypospadias or micropenis, teenage boys with delayed puberty and small testes (≤4 cc each), and men with low or low-normal serum testosterone and and high serum gonadotropin concentrations FSH and LH.
  4. learning and language disorders, metabolic syndrome and diabetes mellitus, cardiovascular events, thromboembolic disease, autoimmune disease, as well as certain cancers (breast, germ-cell hCG tumors)
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23
Q

men with hypogonadotropic hypogonadism desiring fertility. MAO of:
1. hCG
2. in patients with failure of pubertal onset (testicular vol </= 3 mL) or history of cryptorchidism, early combination therapy with what should be considered?

A
  1. a long-acting LH analog; stimulates testicular testosterone production in Leydig cells –> spermatogenesis
  2. FSH –> acts on seminiferous tubules –> induce and maintain spermatogenesis
    FSH or hMG along are not effective for stimulation of spermatogenesis because neither stimulate Leydig cells (so no adequate intratesticular T production)
24
Q

what are the expected effects of testosterone therapy in older men

A
  • improved bone density
  • sexual function (libido and sexual activity > erectile function)
  • mood and depressive symptoms (small)
  • compared to controls, there was no difference in: BPH, coronary plaque vol, frequency of falls, memory
25
Q
  1. medications/conditions that increase SHBG
  2. decrease SHBG
A
  1. -carbamazepine or phenytoin
    -liver cirrhosis
    -hyperthyroidism
    -HIV
    -acute and chronic pancreatitis
    -alcoholism
    –> total T is high, but free T is low
  2. -T2 diabetes
    -obesity
    -NAFLD
    -hyperprolactinemia
    –> total T is low, but free T normal
26
Q

True or False:
Changing testosterone formulation from injections to transdermal/topical applications causes less erythrocytosis

A

True

27
Q

The DDx of postpubertal secondary hypogonadism includes?

A
  • pituitary macroadenoma
  • Cushing syndrome
  • hyperprolactinemia (should be measured in ALL men with secondary hypogonadism even PRIOR TO MRI, which you get when T < 150)
  • opioid use
  • iron-overload syndromes (hemochromatosis - HFE gene, C282Y)
28
Q

Transfemale patient: options to lower androgens include?

A
  1. antiandrogens: spironolactone and cyproterone acetate
  2. GnRH agonists given every 1-3 months
29
Q

erectile dysfunction treatments
1. first line
2. second-line

A
  1. phosphodiesterase 5 inhibitors (sildenafil, vardenafil, tadalafil)
  2. alprostadil intracavernosal injection (SEs painful erections, priapism, and/or fibrosis)
30
Q

In men with a total motile sperm count of < 5-10 million, what testing is recommended?

A

Y-chromosome microdeletion

-normal spermatogenesis requires the presence of certain genes within the azoospermia factor (or AZF) regions on the Y chromosome. Can be passed on to male offspring

31
Q

F to M testosterone therapy:
what effects are expected?

A
  • reduced gender dysphoria and improved depressive symptoms
  • ovarian hyperplasia (resembles PCOS with >/= 12 follicles per ovary)
  • menses stop by 6 months
  • weight gain (4.8-7.7 lb)
  • decreased estrogen, LH, FSH
32
Q

in men who take anabolic steroids, what do they often use to prevent gynecomastia?

A

an aromatase inhibitor (anastrozole)

gynecomastia occurs because T is converted to E via aromatase

33
Q

cystic fibrosis
1. what kind of azoospermia?
2. pH of ejaculate?
3. how is sperm retrieved?

A
  1. obstructive (due to congenital bilateral absence of the vas deferens)
  2. low pH and low volume
  3. from the epididymis or testis; can perform intracytoplasmic sperm injection for fertility

refer for genetic counseling and testing (CFTR gene)!

34
Q

what estradiol formulations are detected in the estradiol assay?

A

estradiol VALERATE (long-acting form of estrogen, dissolved in oil and is metabolized in the body to estradiol) AND 17-BETA estradiol

35
Q

once congenital hypogonadotropic hypogonadism is diagnosed, consider?

A

TARGETED GENETIC TESTING

36
Q

Congenital hypogonadotropic hypogonadism:

This clinical feature is highly associated with what specific gene?

dental agenesis or digital bony abnormalities

A

FGF8/FGFR1

37
Q

Congenital hypogonadotropic hypogonadism:

This clinical feature is highly associated with what specific gene?

hearing loss, Kallman syndrome

A

CHD7

38
Q

Congenital hypogonadotropic hypogonadism:

This clinical feature is highly associated with what specific gene?

syndactyly

A

FGFR1

(“FINGERS”)

39
Q

This clinical feature is highly associated with what specific gene? familial and sporadic congenital combined pituitary hormone deficiency (GH, TSH, LH, FSH)

A

PROP1

40
Q

This clinical feature is highly associated with what specific gene?

hypogonadism

A

GNRHR

41
Q

ingestion of a nonaromatizable androgen would cause what levels in testosterone and estradiol?

A

LOW testosterone and estradiol

42
Q

Hyperprolactinemia leads to?

A

suppression of GNRH hormone

43
Q

What subgroups of men are at increased risk of prostate cancer, and at what level PSA warrants a urology referral?

A

African American men and men with a first-degree relative with prostate cancer. Referral to a urologist is recommended if PSA is > 3.0

44
Q

What is the most common adverse effect of testosterone therapy in older men?

A

erythrocytosis

45
Q

Before initiating testosterone therapy, what should be measured?

A

baseline hematocrit. DO NOT start T therapy in patients with baseline hct >48% (or >50% in men living at higher altitudes). Need to investigate underlying causes of erythrocytosis first. Once T therapy is started, check hct in 3-6 months and then annually. If hct level is >54%, stop T replacement and evaluate for sleep apnea or hypoxia. Then resume T at a lower dose once hct normalizes.

46
Q

acquired hypogonadotropic hypogonadism:

  1. normal seminal fluid volume and pH indicate?
  2. Men that have acquired this condition after puberty and with testes 12 ml or larger can often respond to?
  3. men that have acquired this condition before puberty and with tests <6 mL would need?
A
  1. nonobstructive azoospermia 2. hCG alone; typical response is within 6-12 months 3. LH (usually in the form of hCG) and FSH replacement therapy; may take 12-18 months for a response
47
Q

Testosterone undecanoate 1. common side effect?

A
  1. cough and shortness of breath following the injection (due to pulmonary oil microembolism) -other symptoms include: urge to cough, dyspnea, throat tightening, chest pain, dizziness, and syncope. -must be administered in an office or hospital setting to monitor for adverse reactions for 30 minutes after the injection
48
Q

Secondary hypogonadism (ITE 2020 Q33):

  1. All patients who are interested in fertility should first have?
  2. What is a prerequisite for GnRH treatment? 3. When to give hCG treatment?
A
  1. A semen analysis
  2. an intact pituitary gland (therefore not appropriate for a patient how has had a hypophysectomy). Give to a patient with a defect in hypothalamus. GnRH stimulates LH and FSH, which in turn stimulate the testes to make testosterone and sperm.
  3. For a patient without an intact pituitary/defect in the pituitary. Can give hCG alone or in combination with FSH. Patients who have congenital hypogonadotropic hypogonadism and prepubertal testes (<4 ml) need combination therapy to stimulate growth of seminiferous tubules.
49
Q

Both endogenous and exogenous hypercortisolism are associated with [what] in both sexes?

A

hypogonadism

Suppression of gonadal hormones can occur as early as 3 days after initiation of glucocorticoids. Recovery of the gonadax axis may take months.

50
Q
  1. erectile dysfunction is a strong marker of?
  2. before initiating pharmacotherapy for ED, what must be confirmed?
A
  1. cardiovascular disease
  2. confirm that the patient has exercise capacity to safely have sexual intercourse. An exercise tolerance test should be considered.
51
Q
  • In older men > 65 yo, what are the results of testosterone therapy?
  • at what testosterone level can T be given?
  • What to give to increase libido?
  • what to give for erectile dysfunction?
A
  • improved: libido, erectile function, and overall sexual activity
  • < 275
  • Testosterone for libido
  • PDE inhibitor for ED
52
Q

how do glucocorticoids affect the following:
1. LH
2. FSH
3. SHBG
4. total testosterone

A
  1. decrease
  2. decrease
  3. decrease
  4. decrease
53
Q

workup of azoospermia
1. distinguish between?
2. imaging used?
3. condition associated with obstructive azoospermia

A
  1. distinguish between obstructive and nonobstructive causes. Can palpate the vas deferens to see if it present or absent (ropelike structure within the spermatic cord. If it is absent, then cause is obstructive.
  2. transrectal ultrasound - to see if vas deferens is present
  3. congenital absence of vas deferens, associated with CFTR pathogenic variant: low ejaculate volume, absent fructose (which is made in the seminal vesicles), low pH
54
Q

Fertility options: steps to consider (3)

A
  1. primary vs secondary hypogonadism
  2. pituitary vs hypothalamic disease
  3. acquired (post-pubertal, testes > 20 ml) vs congenital (pre-pubertal, testis < 4 ml)
55
Q

Transgender woman with hyperTG. What is the most appropriate management option?

A

GnRH agonist + 0.05 mg estradiol patch

Endocrinology (8 decks)

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