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REI Flashcards

1
Q

What is congenital adrenal hyperplasia?

A

most common cause of ambiguous genitalia
46 XX, clitoral enlargement, labial fusion, urogenital sinus.
-AR inheritance. 2/2 21 hydroxyls deficiency. obstructs cortisol production and no negative feedback to switch off ACTH. excessive precursor “sidetracks” in direction of androgen production.
-mild to severe disease.

ddx: high 17-OHP.

In new borns, causes shock 2/2 insufficient cortisol. salt-wasting in severe forms 2/2 inadequate aldosterone.

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2
Q

What is puberty?

A

2 main events:
- gonadarche: FSH/LH activate ovaries
- adrenarche: incr androgen production by adrenal cortex.

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3
Q

What are the stages of puberty in chronological order?

A

Growth spurt
thelarche - breasts
Pubarche: pubic hair
Adrenarche: onset of androgen dependent changes - axillary and pubic hair growth, body odor, acne
Menarche: Tanner IV or 2-3 years after thelarche.

  • normal cycle takes 2-3 yrs to become regular after menarche but can take up to 6.
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4
Q

What are situations to evaluate amenorrhea?

A

No menses within 3 years of thelarche
No secondary sex development by age 13
Age 14 w/ hx eating disorder
age 14 w/ hirsutism
Age 15 regardless of development
>90 days without menses in menstruating adolescent.

Precocious puberty: occurs 2.5 standard deviations earlier than mean age. age 7 in whites and age 6 in blacks.

Delayed puberty: no breasts by age 12-13

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5
Q

What is life cycle of hair follicle?

A

ACT!
Anagen - active phase of hair growth
Catagen - involution of epithelial cells surrounding dermal papilla
Telogen - resting phase (hairs fall out with initiation of anlagen)

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6
Q

What is differential diagnosis of hirsutism and what is workup?

A

familial, PCOS, CAH,
Tumor (ovary or adrenal)
drugs (androgens, danazol)
Hypothyroid, elevated prolactin
Cushings

Workup:
- total testosterone (r/o ovarian/adrenal issues)
- DHEAS (r/o abnormal adrenal function)
- 17-OHP (r/o CAH)

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7
Q

What is treatment of hirsutism?

A
  • OCP (decr androgen and incr SHBG so less free androgen)
  • spironolactone (blocks androgen receptor and inhibits 5-alpha reductase)
  • Finasteride (5-alpha reductase inhibitor inhibits conversion of testosterone to DHT)
  • Flutamine (blocks androgen receptor)
  • Vaniqua/eflornithine - blocks ornithine decarboxylase
  • laser hair removal
    -weight loss : increases SHBG
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8
Q

What is primary amenorrhea?

A

No menses by age 13 w/o secondary sex characteristics
- No menses by 15 WITH secondary sex
- no menses before age 15 w/ secondary sex + cyclic pelvic pain (r/o outflow tract obstruction)

Causes are divided into :
1. presence or absence of breast development (marker of estrogen/ovarian function)
2. presence/absence of uterus
3. FSH level

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9
Q

Causes of primary amenorrhea w/ uterus present

A
  1. Breast present (estrogen present)
    - hypothalamic
    -pituitary (prolactinoma)
    - ovarian causes
    - uterine causes/outflow tract obstruction
  2. Breast absent (estrogen absent)
  • Gonadal failure (hypergonadotrophic hypogonadism): Turner’s, mosacisim (X/XX), pure XX/XY gonadal dysgenesis (usually tall), 17-alpha hydroxylate deficiency (rare)
  • CNS-hypothalamic-pituitary (hypogonadotrophic hypogonadism): CNS lesions (pituitary adenoma), Kallman’s (hypothalamic failure 2/2 inadequate GnRH), isolated gonadotrophin deficiency, constitutional delay
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10
Q

Causes of primary amenorrhea w/ uterus absent

A

+breasts:
- vaginal agenesis (Rokitansky-Hauser syndrome): nl pubic hair
- androgen insensitivity (XY): remove gonads after puberty, short/absent vagina, sparse pubic hair.

  • breasts:
  • XY, agondaism, 17 alpha hydroxylate deficiency
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11
Q

What is the workup of primary amenorrhea?

A

physical exam: absence of breasts/uterus
HCG
FSH
TSH
PRL
E2/FT4
Pelvic US
MRI in complex cases

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12
Q

What is secondary amenorrhea and causes?

A

no menses for >3 months in females w/ normal menstrual cycles or >6 months if irregular cycles

  • pregnancy!
  • Thyroid (hypo OR hyper)
  • hyperprolactinemia (lactation, prolactinoma, meds)
  • PCOS
    -CAH
  • Stress/exercise
  • weight loss/anorexia
  • meds (psychotropics)
  • POI + fragile X premutation
  • androgen secreting tumors
    ACTH/GH secreting tumors
    hypothalamic lesions: cranioipharyhgioma/TB
  • Sherman’s syndrome
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13
Q

What is workup of amenorrhea?

A
  • r/o pregnancy
  • History: stress/nutrition/weight/meds/sx of hypo estrogen. If galactorrhea: TSH/PRL
  • Exam: mullerian structures present?

– short/blind ending vagina: Mullerian agenesis (Mayer Rokitansky), androgen insensitivity (Total testosterone and karyotype), vaginal agenesis/transverse vaginal septum. Cervical atresia (pain/hematometra)

– Normal vagina + cervix:
- TSH/prolactin
- FSH/estradiol
- progesterone withdrawal challenge: if +bleed and nl labs=anovulation. If no bleed and nl labs: E+P challenge.
- E+P challenge: estrogen x 14d then estrogen + progesterone x 10d. If bleeds, not making adequate estrogen. If no bleed, abnormal outflow (Sherman’s, anomaly).

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14
Q

What are FSH/LH/estradiol levels?

A

FSH: nl 5-30.
LH: nl 5-20.
Estradiol: low is <50

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15
Q

What is workup of primary ovarian insufficiency?

A

POI: depletion of ovarian follicles w/ cessation of menses before age 40.
2 random tests 1 month apart (CANNOT DO IF ON OCPs):
- elevated FSH/LH and E2 <50 | Typical FSH 30-40, E2<50
- neg pregnancy test
- nl PRL, TSH

If age <30, get karyotype
- 50% is 45 XO=Turner’s
- 25% = 46 XX=Gonadal dysgenesis/agenesis
-25%= 46 XX/XY=Y mosaics (need gonadectomy 2/2 incr cancer risk w/ Y chromosome. eg. gonadoblastoma, dysgermimoma, choriocarcinoma)

If age 30+:
- autoimmune (thyroid, RA, SLE, myasthenias)
- fragile X premutation
- galactosemia
- 17-hydroxylase deficiency (absent secondary sex characteristics)
- perimenopause: incr FSH, nl LH. rpt assays

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16
Q

What is workup of normal FSH/LH assays in amenorrhea?

Workup of low FSH/LH assays?

A

presentation same as pituitary/hypothalamic failure.

For low: suspect pituitary/hypothalamic issue
- MRI pituitary positive: manage tumor/empty sella syndrome
- MRI normal: hypothalamic amenorrhea (suppression of GnRH pulsatile secretion)- stress/weight/exercise/psychiatric/kallaman syndrome.

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17
Q

What is primary ovarian insufficiency?

A

cessation of menses by age 40
- Chromosomal (gonadal dysgenesis +/- Turner’s)
- damage from chemo/radiation
- Endocrinopathies: hypoPTH, hypoadrenalism
- Autoimmune
prior pelvic surgery

If confirmed ddx:
- karyotype, FMR1 permutation, adrenal antibodies (if pos, yearly corticotrophin stem test due to risk of adrenal insufficiency), pelvic US, TSH/TPO Ab (20% develop Hashimoto’s)

18
Q

What is treatment of POI?

A
  • goal: preserve bone, cardiovascular and sexual health
    Risks: hypoestrogenism -> osteoporosis, CVD, cognitive impairment, all-cause mortality, genital atrophy, vasomotor sx.

0.1 mg/day transdermal estradiol + cyclic progesterone x 10-14d/month
- 5-10% can spontaneously conceive. still need contraception
- if adolescent, specialist for hormone therapy for puberty.
- treat until 51-52 years of age.

19
Q

When does fertility decrease?
What is change of live birth for IVF with own eggs for age 40+? With donor eggs
Risk factors associated with premature decline in fertility?

A

Fecundity decreases at age 32! Accelerates at age 37.
40+ can be referred immediately

12% with own eggs, 51% if egg donor.
What if using eggs from egg donor? 51%

Smoking, prior ovarian surgery, chemo/radiation, family history of early menopause, endometriosis

What is risk of miscarriage if iVF preg? 30%

What is mechanism of increase in autosomal trisomy in older women?
Incr risk non-disjunction due to changes in meiosis.

20
Q

What is workup for infertility

A

infertility is failure to achieve pregnancy within 12 months of unprotected intercourse or donor insemination. affects 15% of couples (male factor is 40% of infertile couples).

at any age if anovulatory, male hx infertility or <40
- age <35, 12mo of attempting w/o success. age >35, 6 mo

  • history (menses, intercourse, counseling on costs/multiple visits/REI), PMH, fam hx -genetic issues. any STI, recent US? Any prior form of contraception. How long trying to get pregnant
    Partner testing for infertility.
  1. TEST OVULATORY DYSFUNCTION:
    - mid luteal (day 21) progesterone: nl>3
    - urine LH kit : some false pos/neg
  2. TEST TUBAL STATUS
    - HSG
    - laparoscopy w/ chromopertubation
  3. TEST SEMEN
    - semen analysis
  4. TEST OVARIAN RESERVE
    - day 2-3 FSH >10 or E2>60-80
    - AMH: <1 abnormal - perform anytime
    - antral follicle count day 2-5: <3 abnormal
    - clomid challenge test day 10. If FSH >22, abnormal
  5. UTERINE FACTOR
    - TVUS, HSG, hysteroscopy, saline SIS. look for polyps, synchiae, mullein anomalies.
21
Q

What are risk factors for decreased ovarian reserve?

A
  • age > 35
  • Fam hx early menopause
  • genetic condition (i.e. 45 XO turner)
  • FMR-1 permutation
  • prior ovarian surgery
  • oophorectomy
  • hx chemo/RT
  • smoking

means less response to ovarian stimulation.
- onset of LH surge to ovulation: 36hrs
- LH peak to ovulation: 12 hrs.

22
Q

What is mechanism of action of methotrexate?

A

dihydrofolate reductase inhibitor
- cofactor for DNA and RNA synthesis.
- acts on rapidly dividing trophoblast cells

23
Q

What is mechanism of action for tamoxifen?

A

anti-estrogen and pro estrogen in different parts of body
- Anti-estrogen in breast
- pro estrogen in bones and endometrium

24
Q

What is mechanism of action of clomiphene

A

anti-estrogen (SERM). competes w/ estrogen-binding R.
- partial agonist in hypothalamus, incr GnRH release and FSH/LH to stimulate follicle development

  • dose: 50mg for 5d on day 5. If no ovulation, increase to 100mg/d for 5 days. monitor ovulation by predictor kit or mid-luteal progesterone. Once ovulated, continue dose for 4-6 cycles.
    sex every other day starting 5d after last dose. for 5-7d.
  • ovulation occurs 5-10d after last tablet.
  • test ovulation w/ menses or with serum progesterone
  • 70% will ovulate, of those who ovulate, 30-40% will conceive.
  • SE: vasomotor sx, HA, dizziness, blurred vision (STOP bc could be optic neuropathy), decreased cervical mucous and thin endometrium
25
Q

What is mechanism of letrozole?

A

Aromatase inhibitor
- blocks synthesis of estrogen which reduces feedback at pituitary and increases FSH.
- 1st line for oligo-ovulatory w/ PCOS.
- SE: hot flashes, fatigue, dizziness
- benefits: higher rate mono follicular development (less multiples), no direct anti-estrogen effects on endometrium.

  • dose 2.5mg/d for 5d on day 3 of cycle, increase at 2.5mg increments.
26
Q

What is mechanism of action of gonadotropin?

A

FSH or combination of FSH and LH
- acts on fSH receptors to stimulate follicular growth
- use LH w/ hypothalamic amenorerhea

27
Q

what is mechanism of action of leuprolide (lupron)?

A

GnRH agonist produces CONTINUOUS exposure (not pulsatile) of GnRH -> reduces FSH.

Indications:
- tx endometriosis or CPP, shrink fibroids pre-surgery, increase blood count pre surgery, precocious puberty to switch off stimulation, thin out endometrium prior to ablation.
- SE: osteoporosis if use >6 mo, vasomotor sx, vaginal dryness.

28
Q

What is mechanism of action of GnRH antagonists

A

competitively and reversibly bind GnRH-R in pituitary, block FSH and LH.
- SE: hypoestrogenic sx
-Indications: endometriosis, fibroids, infertility for SUBQ injection

29
Q

What are the copper and progesterone IUD?

A

Copper: 10yrs, inhibits sperm migration, +emergency contraception

Progesterone: Levonorgestrel, use for 8 years. SE: hormonal (breast tenderness, nausea, depression). inhibits sperm migration, alters cervical mucus, suppresses endometrium.
– decreases HMB, dysmenorrhea, anemia, endometriosis pain, risk of PID, risk of endometrial cancer, treats endometrial hyperplasia.

CONTRAINDICATIONS: pregnancy, PID, undiagnosed vaginal bleeding, genital tract malignancy, uterine anomalies, copper allergy, any of this in past 3 months (PP endometritis, septic AB, PID).

30
Q

What are the non-contraceptive benefits of the OCP?

A

regular menses
less blood loss esp w/ fibroids
decr IDA
decr PID
decr dysmenorrhea
decr endometrial and ovarian cancer
decr functional ovarian cysts and benign breast disease
tx for endometriosis
tx for hyperandrogenism

31
Q

What are recs for OCPs w/ common medical issues?

A

OK to use to age 50-55 if no contraindications
- HTN: not if >160/100 or vascular disease. POPs ok.
- lipid disorder: low dose (<35mcg ) ok if well controlled. monitor lipids frequently. oral estrogen incr TG
- DM acceptable unless microvascular disease. avoid depo
- migraine w/ aura: stroke risk increased. use pOP or IUD
- fHx breast cancer: okay! doesn’t incr risk for BRCA 1 and 2.

32
Q

What are absolute contraindications for OCP?

A
  • breast cancer
  • any estrogen sensitive tumor
  • pregnancy
  • unexplained vaginal bleeding
  • known inherited thrombophilia.
  • thrombosis
  • smoker age 35+
  • liver disease
  • CHD
  • first 21days postpartum
  • migraines w/ aura
  • severe HTN
  • DM w/ vascular dz or disease <20yr duration
  • SLE w/ APL Ab
33
Q

How do you counsel on elevated FSH in infertility?

A

ovarian reserve is decreased, decreases ability to respond to ovarian stimulation.

34
Q

What is workup for primary ovarian insufficiency?

A

rule out genetic causes: karyotype, FMR1 premutation, adrenal Ab
- Pelvic US

If Turner’s, pregnancy contraindicated 2/2 high cardiac risks.
Donor egg IVF best option or adoption.

35
Q

what is the evaluation for primary amenorrhea?

A

H&P
Confirm normal vagina, cervix, uterus (US or MRI)

  1. If blind vagina, obtain karyotype and testosterone (Mullein agenesis vs androgen insensitivity
  2. If normal outflow tract: hormonal eval (HCG, TSH, FSH, PRL)
  3. If hyperandrogenism: testosterone, DHEA-S, 17-OHP
  4. If normal/low FSH: central hypothalamic or pituitary process: consider cranial MRI
  5. If high FSH: karyotype for Turner’s, FMR1 permutation and adrenal Ab for POI

Treatment:
- remove gonads if Y chromosome 2/2 cancer risk
- correct outflow tract obstruction (transverse vaginal septum)
- hormone replacement for gonadal dysgenesis
- correct underlying abnormality: TSH, PRL.

36
Q

What is the differential for abdominal pain/distension?

A

Pregnancy, PID, fibroids, TOA, ectopic pregnancy. GI: diverticulitis, post-op ileus, constipation, IBS.

37
Q

If pt had recent ovarian stimulation w/ REI, how would you manage new onset abdominal pain/distension?

A

Concern for ovarian hyperstimulation syndrome. Shift of serum from intravascular space to abdominal cavity 2/2 follicular stimulation

If mild: CBC, BMP, US. abdominal distension, mild N/V, diarrhea. Tx=tylenol, AVOID NSAIDS
Mod: US w/ ascites. Monitor weight and urine uOP
Severe: Hct>55, Cr>1.6, severe abdominal pain, N/V, rapid weight gain, VTE, oliguria. VTE prophylaxis. Resolves in 10-14d, longer if pregnant. Can cause stroke, loss of perfusion to extremities.
anticoagulation, correct electrolyte abnormalities. Inform their REI.

38
Q

What increases risk for OHSS?

A

PCOS, prior episode, AMH>3, antral follicle count >8, high # oocytes retrieved, pregnancy, high estradiol level,

39
Q

How many oocytes at birth?

42 y/o with desired fertility. What is chance of live birth with IVF?

What if IVF with eggs from young healthy donor?

A

1-2 million. Declining number as we age.
At menopause: thousands.

12%
51%

40
Q

What factors affect fertility?

A
  1. Ovarian factor: prior chemo/RT
  2. Uterine factor: Prior pelvic surgery, Asherman’s, Mullerian abnormality , Leiomyoma, Endometriosis, Pelvic infection
  3. Tubal factor: PID
  4. Male factor - know specifics on semen analysis
    Sperm count: 39 million is minimum for normal
  5. Female factor: age, Smoking, obesity, meds, Fragile X
41
Q

Besides fertility, what risks increased for older women attempting to conceive?

What is the mechanism by which autosomal trisomy increased in older women?

A

HDP, DM, SAB, fetal anomalies, CD

Changes in meiotic spindle predispose to non-disjunction

42
Q

Diagnostic criteria for PCOS?

A
  • Hyperandrogenism
  • ovulatory dysfunction
  • polycystic ovaries (in one or both ovaries, either 12+ follicles measuring 2-9mm or increased ovarian volume (greater than 10cm3)

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