Menopause, Infertility and PCOS Flashcards
What is menopause
permanent cessation of menstruation, 12 months of amenorrhea without any pathological cause
What can cause premature menopause before the age of 40
- primary ovarian insufficiency
- premature ovarian failure
What are the stages of menopause
preimenopause–> menopause—> post menopause
What is the pathophys behind menopause
- decline in the quantity and quality of follicles and oocytes
- granulosa cells stop making estrogen and inhibin–>loss of the negative feedback loop–> FSH and LG production increased with no response from the ovary
Signs and symptoms of menopause
- vasomotor sx’s
- sleep disturbances
- mood changes
- cognitive changes
- breast pain/tenderness
- joint aches and pains
PE findings of menopause
- fusion/ resorption of labia minora
- vagina–> atrophic, pale, lack of rugae, diminished elasticity, shorter/ narrower
- cervix–>atrophic, decreases in size, flush with top of vaginal vault, can become stenotic
What are long term effects of menopause
- dementia
- cardiovascular disease
- osteoperosis
Lifestyle modifications to treat menopause
- lower room temp
- use fans
- dress in layers
- avoid triggers
- smoking cessation
- exercise
- weight loss
- lubricants
- vaginal dilators or intercourse
When is hormone replacement therapy indicated
women whose sx’s cannot be controlled by lifestyle modifications
Hormone replacement therapy is not indicated for what two things
- long term use
- prevention of disease
Contraindications of hormone replacement therapy
- CAD
- VTE
- CVA
- TIA
- liver/gallbladder disease
- breast/endometrial cancer
- unexplained vaginal bleeding
- hypertriglyceridemia
- known thrombophilias
Administration forms of estrogen for HRT
- oral
- transdermal
- topical gels and lotions
- intravaginal creams and tablets
- vaginal rings
Why do you start on a low dose and then titrate with HRT
the lower doses have fewer effects on coagulation and inflammatory markers —> possible lower risk of stroke and VTE
Which type of estrogen is best for lipid profiles
oral 17-beta estradiol
Which medication for HRT has a lower risk for VTE and stroke
transdermal 17-beta estradiol
First line for HRT
oral micronized progesterone
All women with a uterus need ___ to prevent ___ (HRT)
need progestin to prevent endometrial hyperplasia
What are the side effects of progestin
- mood changes
- bloating
Benefits of topical vaginal estrogen replacement
- can be used indefinitely
- low risk for adverse effects
Topical vaginal estrogen only treats, ___ not ___
only treats vaginal atrophy, not hot flashes
What are SERMs used for
treatment of menopausal vasomotor sx’s and osteoperosis prevention
Do you need to give progestin with SERMs? Why or why not?
No because SERMs prevent estrogen induced endometrial hyperplasia
Which women are candidates for SERMs
women with moderate-to severe hot flashes who have breast tenderness w/ standard EPT
-women that cannot tolerate progestin therapy because of side effects
SERMs increase what risk
VTE risk
When are OCPs used for menopause
- used in perimenopausal women who also desire contraception
- women who need control o fheavy bleeding
OCPs should be avoided in which women
- obese d/t VTE risk
- hx of smoking, HTN or migraines
What are some non hormonal options for menopause treatment
- clonidine
- SSRIs (paroxeinte, fluoxetine)
- venlafaxine
- gabapentin
- bellergal
What is infertility based on
fecundability
What is fecundability
the probability of being pregnant in a single menstrual cycle
What is primary infertility
inability to conceive in a couple who has never been pregnant
What is secondary infertility
inability to conceive in a couple with a hx of prior pregnancy
What type of work up is done for infertility
- history and physical
- evaluation of lifestyle
- female evaluation
- male evaluation
Labs to evaluate a female for infertility
- TSH
- prolactin
- STI testing
- prenatal screening
- genetic testing
Ovarian evaluation for infertility
-first need to confirm evaluation
Ovarian reserve testing
- FSH and estradiol day 3 labs
- clomiphene citrate challanges test
- anti mullerian hormone
- antral follicle count
Uterine evaluation for infertility
- hysterosalpingogram
- hysterosalpingo contrast sonography
- hysteroscopy
- sonohystogram
- pelvic US
- laparoscopy
What things are done for a male evaluation for infertility
- scrotal US
- semen analysis
- STI testing
- genetic testing
- endocrine labs in indicated
What is the most frequent cause of male infertility
oligiospermia
What is oligiospermia
low concentration of sperm in ejaculate
What is azoospermia
complete absence of sperm
What is asthenospermia
abnormal sperm motility
What is teratospermia
abnormal sperm morphology
All infertility therapies center around what
manipulation of the physiologic HPO axis
What are the two ways that the HPO axis can be manipulated
- ovulation induction
- controlled ovarian stimulation
What are the 3 classes of drugs used for ovulation induction
- SERMs (clomiphene citrate, tamoxifen)
- Aromatase inhibitors (letrozole)
- dopamine agonist (bromocriptine, cabergoline)
How does clomiphene cirtrae work
competes with estrogen in the body to bind with estrogen receptors–> inhibits and depletes the available receptors–> block the negative feedback of endogenous estrogen on hypothalamus—> higher plasma levels of FSH and LH–> stimulation of ovarian follicular growth
What is the first line treatment for ovulation induction
clomiphene citrate
What population is clomiphene citrate most successful in
women with oligio or anovulation who are normogonadotrophic
When is clomiphere citrate given
in the early follicular phase
If your patient is taking clomiphene citrate what should you monitor
- urinary LH
- retrospectively with basal body temperature charting
- tranvaginal US
Why are transvaginal US done on women that are taking clompihene citrate
to assess follicular response and timed administration of hCG to trigger ovulation
When do pregnancy rates decrease with clomiphene citrate
after 6 cycles
Side effects of clomiphene citrate
- vasomotor sx’s
- mood swings
- visual sx’s (blurred or double vision)
What are adverse effects of clomiphene citrate
- miscarriage
- birth defects
- ovarian cancer if used for >12 months
- increased risk of multiples
Tamoxifen might increase the risk of what
miscarriage
How do aromatase inhibitors work
block the enzyme that converts androgens to estrogens–> decreases estrogen levels–> decreases negative feedback and increases release of FSH
Aromatase inhibitors may be more effective than Clomid in women with what
PCOS
Side effects of aromatase inhibitors
- hot flashes
- GI upset
Aromatase inhibitors have what effect on the uterus
anti estrogen effects
When are dopamine agonists used in infertility
restoration of ovulation in women with hyperprolactinemia
Out of the two options for dopamine agonists which is better. Why?
cabergoline because it is more elective and has fewer side effects
How do dopamine agonists work
acts like dopamine which suppresses prolactin synthesis and release–> normilization of prolactin returns HPO axis to normal
When should you expect a drop in prolatin when using dopamine agonists
2-3 weeks
What should accompany normalization of prolactin levels when using dopamine agonists
normal menstrula cycles
Side effects of dopamine agonists
- dizziness
- nausea
- hypotension
What can be done to improve side effects of dopamine agonists
administer vaginally
How is intrauterine insemination done
semen is spun down in lab, washed and injected into uterine cavity via catheter threaded through the cervix
Steps to IVF
- medication given to control ovulation stimulation
- ovarian follicle development is done
- HCG or lupron is given to trigger maturation
- Oocyte is retrieved
- oocyte and sperm is placed in IVF culture medium
- fertilization and embryo transfer
What is intracytoplasmic sperm injection
procedure where a sinlge sperm is directly injected into each mature egg
When is ICSI used? Why?
“severe male factor”
because the probability the sperm will penetrate the oocyte on its own is low
What is assisted hatching
a procedure in which a hole is made in the zona pellucida just prior to embryo transfer to facilitate hatching of the embryo
Assisted hatching is used in….
- older women
- couples who have had unsuccessful prior IVF attempts
When is preimplantation genetic screening done? What does it screen for
used in couple that are both chromosomally normal with recurrent pregnancy loss
screens embryos for aneuploidy
When is preimplantation genetic diagnosis done? What does it screen for?
used when one or both parents carry a specific known genetic mutation or defect
screens for that specific defect
Women with PCOS have an increased risk of what types of things
- CV disease
- obesity
- glucose intolerance/T2DM
- metabolic syndrome
- dyslipidemia
- fatty liver disease
- obstructive sleep apnea
What are common signs and syndromes of PCOS
- irregular menstrual cycles
- obesity
- acanthosis nigrans
- hyperandrogenism
- elevated serum testosterone
- “string of pearls” on ovaries
- mood changes
What criteria is used to diagnose PCOS
rotterdam criteria
What is the rotterdam criteria
2/3 of the following
- ovulatory dysfunction
- chemical and/or biochemical signs of hyperandrogenism
- polycystic ovaries on ultrasound
What are the goals of PCOS treatment
- improve hyperandrogenic symptoms
- manae underlying metabolic abnormalities and reduce risk factors
- prevention of endometrial hyperplasia and endometrial carcinoma
First line intervention for PCOS
weight loss via diet and exercise
Treatment for PCOS is women not pursuing pregnancy
- OCPs
- metformin (alternative)
- spironolactone
- GnRH agonist
Treatment for PCOS in women pursuing pregnancy
- clomid
- letrozole
- metformin
