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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
fecundability
- probability of achieving pregnancy in 1 menstrual cycle | - decreases with time and age
26
primary infertility
- inability to conceive in a couple who has never been pregnant
27
secondary infertility
- inability to conceive in a couple with hx of prior pregnancy - prior pregnancy applies to either pt in couple
28
timeframe to dx pt with infertility
- 12 mo if < 35 y/o and unable to conceive | - 6 mo if 35+ y/o and unable to conceive
29
work up for infertility
- extensive H&P - lifestyle assessment - female and male eval - labs
30
labs included in an infertility work up
- prolactin - TSH - STI screening - prenatal screening - genetic testing- both partners
31
ovarian eval for infertility
- 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
uterine eval for infertility
- hysterosalpingogram* - hysteroscopy - sonohysterogram/ HyCoSy - pelvic US- ovaries - laparoscopy (rare)
33
male eval for infertility
- history and PE - scrotal US - semen analysis* - STI and genetic testing - endocrine eval if indicated
34
what is assessed in semen analysis
- volume - concentration - motility - morphology
35
oligospermia
- low concentration of sperm in ejaculate | - most common cause of male infertility
36
azoospermia
- complete absence of sperm
37
asthenospermia
- abnormal motility of sperm
38
teratospermia
- abnormal morphology of sperm
39
general tx for infertility
- 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
classes of ovulation induction
- SERMs- first line - aromatoase inhibitors - dopamine agonists
41
what is the SERM commonly used for infertility
- clomid | - generic- clomiphene citrate
42
how do SERMs work for infertility tx
- 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
what pt population responds best to SERMs
- PCOS | - d/c if no success after 6 cycles- risk f ovarian cancer
44
aromatase inhibitors for infertility tx
- letrozole, anastrozole - blocks aromatase which conv androgens to estrogens -> reduce estrogen levels - more effective than clomid in PCOS - off label ovulation induction
45
dopamine agonists
- bromocriptine, cabergoline - used for restoration of ovulation in hyperprolactinemia - acts like dopamine which suppresses prolactin synthesis/ release - teratogenic- must d/c with pregnancy
46
controlled ovarian stimulation
- mimics LH | - induce multiple eggs or follicles to develope
47
intrauterine insemination
- aka artificial insemination | - semen injected into uterine cavity via catheter through cervix
48
in vitro fertilization
- 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
intracytoplasmic sperm injection (ICSI)
- 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
assisted hatching
- 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
preimplantation genetic screening (PSG)
- both parents chromosomally normal - screen embryos for aneuploidy - recurrent pregnancy loss
52
preimplantation genetic dx (PGD)
- one or both parents carry specific known genetic mutations | - screen embryos for that defect
53
other infertility options
- donor sperm/ egg - gestational carrier - cryopreservation
54
risk factors in fertility tx
- ovarian hyperstimulation syndrome - ovarian torsion - high order multiples and selective reduction - cost and insurance coverage
55
PCOS cause
- unknown cause | - thought to be due to HPO axis dysfuction -> increased androgen production
56
PCOS increases your risk of dev what diseases?
- CVD - obesity - glucose intol/ DM2 - metabolic syndrome - dyslipidemia - fatty liver disease - obstructive sleep apnea - endometrial hyperplasia
57
si/sx of PCOS
- 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
dx of PCOS
- 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
treatment for PCOS
- 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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