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Clin Med III > menopause and infertility > Flashcards

menopause and infertility Flashcards

1
Q

menopause

A
  • permanent cessation of menstruation
  • dx retrospectively
  • amenorrhea for 12 mo
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2
Q

what is the average age of menopause

A
  • 51.4 years old
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3
Q

risk factors affecting menopause

A
  • genetics
  • ethnicity/ race
  • toxins/ exposures- tobacco can cause early menopause
  • hysterectomy (even of ovaries are still intact)
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4
Q

peri-menopause

A
  • avg age 47
  • occurs about 4 years before dx of menopause
  • variable or irregular cycles
  • initially increased cycle length -> cycles become shorter
  • changes in lipid metabolism and bone loss start
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5
Q

pathophys of menopause

A
  • decline in quality and quantity of eggs
  • granulosa cells stop making estrogen in inhibin -> loss of neg feedback loop
  • FSH and LH increase
  • ovary cannot respond to FSH
  • permanent amenorrhea once all follicles depleted
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6
Q

work up for pt < 40 with menopause sx

A
  • requires full work up
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7
Q

work up for pts 40-45 with menopause sx

A
  • r/o other causes of menstrual dysfunction

- likely peri-menopause

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8
Q

work up for pts > 45 with menopause sx

A
  • diagnostic testing not recommended

- likely start of menopause

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9
Q

si/sx of menopause

A
  • hallmark= hot flashes
  • sleep disturbances
  • mood changes
  • cognitive changes
  • vaginal dryness (may lead to UTIs)
  • sexual function
  • breast pain/ tenderness
  • joint pain and aches
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10
Q

vaginal changes with menopause

A
  • labia minora fusion or resorption
  • atrophic, pale
  • lack of rugae
  • diminished elasticity and turgor
  • may before shortened and narrower- can prevent with sex
  • pelvic muscle lose tone -> possible prolapse, urge/ stress incontinence
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11
Q

cervical changes with menopause

A
  • atrophic
  • flush with vagina
  • decrease in size
  • can become stenotic
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12
Q

skin and hair changes with menopause

A
  • thinning of skin with decreased elasticity
  • loss of pubic and axillary hair
  • hirsutism d/t increased androgens
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13
Q

long term effects of menopause

A
  • dementia- limited evidence
  • CV disease
  • osteoporosis- accel after menopause
  • rate of bone loss highest 1 year prior to FMP through 2 years after FMP
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14
Q

lifestyle modifications for menopause tx

A
  • lower room temps
  • dress in layers
  • avoid triggers- i.e. spicy food, stress
  • smoking cessation
  • weight loss
  • lubricants, vaginal dilators, intercourse
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15
Q

menopausal hormone therapy (MHT)

A
  • indicated for women whose sx cannot be controlled with lifestyle modifications
  • unopposed estrogen tx is risk for dev endometrial hyperplasia -> increased ca risk
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16
Q

contraindications to MHT

A
  • breast cancer
  • CAD
  • VTE
  • CVA, TIA
  • liver disease
  • unexplained vaginal bleeding
  • endometrial cancer
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17
Q

when is PO estrogen avoided for menopause tx

A
  • hyperTG
  • gallbladder disease
  • thrombophilias
  • migraine HA with aura
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18
Q

considerations for MHT

A
  • calculate CV and breast ca risk before starting tx
  • start with lowest dose and titrate up
  • consider anticonvuslants, alcohol use, ESRD etc.
  • taper meds to d/c- better tolerated
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19
Q

how long do you use MHT for?

A
  • no set duration
  • usu used for 2-3 years
  • max of 5 years or not beyond 60
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20
Q

estrogen formulations

A
  • PO- if baseline VTE and TIA risk low, more favorable effect on lipids
  • transdermal- lower risk VTE, TIA, hyperTG
  • topical gels and lotions
  • intravaginal creams and tablets
  • vaginal rings
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21
Q

progesterone treatment

A
  • PO micronized progesterone given as first line
  • give for 12 d/mo if perimenopause
  • give every day of month after menopause
  • IUD may be considered as off label tx if cannot tolerate PO
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22
Q

SERMS for menopause tx

A
  • used for vasomotor and osteoporosis sx
  • prevents endometrial hyperplasia (progestin not needed)
  • usu use bazedoxifine
  • increased VTE risk
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23
Q

OCPs for menopause tx

A
  • can be used in perimenopausal women who desire contraception or control of heavy leednig
  • avoided in obese, smoker, HTN, migraines
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24
Q

non-hormonal tx for menopause

A
  • used if risk of breast ca or CVD
  • SSRIs, SNRIs, anti-epileptics, centrally acting drugs
  • gabapentin used for hot flashes at night
25
Q

fecundability

A
  • probability of achieving pregnancy in 1 menstrual cycle

- decreases with time and age

26
Q

primary infertility

A
  • inability to conceive in a couple who has never been pregnant
27
Q

secondary infertility

A
  • inability to conceive in a couple with hx of prior pregnancy
  • prior pregnancy applies to either pt in couple
28
Q

timeframe to dx pt with infertility

A
  • 12 mo if < 35 y/o and unable to conceive

- 6 mo if 35+ y/o and unable to conceive

29
Q

work up for infertility

A
  • extensive H&P
  • lifestyle assessment
  • female and male eval
  • labs
30
Q

labs included in an infertility work up

A
  • prolactin
  • TSH
  • STI screening
  • prenatal screening
  • genetic testing- both partners
31
Q

ovarian eval for infertility

A
  • confirm ovulation
  • day 3 labs- FSH and estradiol normally low at this point
  • CCT
  • anti-mullerian hormone- hormone released by egg, levels dont fluctuate
  • antral follicle count- measures how many follicles/ eggs pt has
32
Q

uterine eval for infertility

A
  • hysterosalpingogram*
  • hysteroscopy
  • sonohysterogram/ HyCoSy
  • pelvic US- ovaries
  • laparoscopy (rare)
33
Q

male eval for infertility

A
  • history and PE
  • scrotal US
  • semen analysis*
  • STI and genetic testing
  • endocrine eval if indicated
34
Q

what is assessed in semen analysis

A
  • volume
  • concentration
  • motility
  • morphology
35
Q

oligospermia

A
  • low concentration of sperm in ejaculate

- most common cause of male infertility

36
Q

azoospermia

A
  • complete absence of sperm
37
Q

asthenospermia

A
  • abnormal motility of sperm
38
Q

teratospermia

A
  • abnormal morphology of sperm
39
Q

general tx for infertility

A
  • based on underlying pathology
  • lifestyle modifications
  • psychological/ emotional support*
  • manipulation of HPO axis via ovulation induction or controlled ovarian stimulation
  • timed intercourse
  • intrauterine insemination
  • assisted reproductive technology
40
Q

classes of ovulation induction

A
  • SERMs- first line
  • aromatoase inhibitors
  • dopamine agonists
41
Q

what is the SERM commonly used for infertility

A
  • clomid

- generic- clomiphene citrate

42
Q

how do SERMs work for infertility tx

A
  • competes with estrogen by binding estrogen receptors so native estrogen cannot bind
  • results in higher levels of FSH and LH -> stimulates ovarian follicular growth
43
Q

what pt population responds best to SERMs

A
  • PCOS

- d/c if no success after 6 cycles- risk f ovarian cancer

44
Q

aromatase inhibitors for infertility tx

A
  • letrozole, anastrozole
  • blocks aromatase which conv androgens to estrogens -> reduce estrogen levels
  • more effective than clomid in PCOS
  • off label ovulation induction
45
Q

dopamine agonists

A
  • bromocriptine, cabergoline
  • used for restoration of ovulation in hyperprolactinemia
  • acts like dopamine which suppresses prolactin synthesis/ release
  • teratogenic- must d/c with pregnancy
46
Q

controlled ovarian stimulation

A
  • mimics LH

- induce multiple eggs or follicles to develope

47
Q

intrauterine insemination

A
  • aka artificial insemination

- semen injected into uterine cavity via catheter through cervix

48
Q

in vitro fertilization

A
  • meds admin for controlled ovulation stimulation
  • HCG or leupron given to trigger maturation
  • oocyte retrieval
  • oocyte and sperm placed in IVF culture medium for fertilization to occur
  • embryo transf 3-5 days late
49
Q

intracytoplasmic sperm injection (ICSI)

A
  • single sperm directly injected into each mature egg
  • used for severe male factor because probability of sperm penetrating oocyte on its own is low
  • also used when likelihood of reduced fertilization i.e. failed IVF
50
Q

assisted hatching

A
  • hole is made in zona pellucida just prior to embryo transfer
  • facilitates hatching of embryo
  • can be used in older women or couples who have had unsuccessful IVF attempts
51
Q

preimplantation genetic screening (PSG)

A
  • both parents chromosomally normal
  • screen embryos for aneuploidy
  • recurrent pregnancy loss
52
Q

preimplantation genetic dx (PGD)

A
  • one or both parents carry specific known genetic mutations

- screen embryos for that defect

53
Q

other infertility options

A
  • donor sperm/ egg
  • gestational carrier
  • cryopreservation
54
Q

risk factors in fertility tx

A
  • ovarian hyperstimulation syndrome
  • ovarian torsion
  • high order multiples and selective reduction
  • cost and insurance coverage
55
Q

PCOS cause

A
  • unknown cause

- thought to be due to HPO axis dysfuction -> increased androgen production

56
Q

PCOS increases your risk of dev what diseases?

A
  • CVD
  • obesity
  • glucose intol/ DM2
  • metabolic syndrome
  • dyslipidemia
  • fatty liver disease
  • obstructive sleep apnea
  • endometrial hyperplasia
57
Q

si/sx of PCOS

A
  • obesity*
  • irregular menstrual cycles*
  • hirsutism*, acne
  • male pattern hair loss/ thinning
  • elevated serum testosterone
  • acanthosis nigricans
  • string of pearls appearance on ovaries with US
  • mood changes
58
Q

dx of PCOS

A
  • use rotterdam criteria
  • require 2 of the 3
  • ovulatory dysfunction- oligo and/or anovulation
  • chem and/or biochem signs of hyperandrogenism
  • polycystic ovaries on US
59
Q

treatment for PCOS

A
  • weight loss*
  • screen for metabolic abnormalities regardless of BMI
  • OCPs if not pursuing pregnancy
  • can add spironolactone to OCPs after 6 mo for added anti-androgen
  • ovulation induction if pursuing pregnancy- letrozole

Clin Med III (26 decks)

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