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endocrine > reproduction/gondal > Flashcards

reproduction/gondal Flashcards

1
Q

where does HCG come from?

A

the implanted embryo releases HCG

HCG causes hyperemesis = N+V during pregnancy

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2
Q

what use is HCG in practice?

A

hormone used in pregnancy test

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3
Q

Human Placental Lactogen (HPL) is secreted from where?

A

the placenta

also secretes placental progesterone + placental oestrogen

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4
Q

what does HPL do apart from breast development?

A

causes insulin resistance in mother

along with placental progesterones

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5
Q

what hormone does the follicle secrete?

A

ostradiol

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6
Q

what hormone does the corpus luteum (fertilised ovum) secrete?

A

progesterone

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7
Q

what week of pregnancy does organogenesis start?

A

week 5 probs earlier

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8
Q

what increases thyroxine in pregnancy?

A

HCG - excessive hCG mimics hyperthyroidism

increased thyroxine suppresses TSH

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9
Q

function of follicle stimulating hormone in males + females

A

male - causees testes to produce sperm (spermatogenesis)

female - causes growth of ovarian follicles (oogenesis) + ovary to secrete oestrogen

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10
Q

luteinizing hormone effect in males + females

A

male - causes testes to secrete testosterone

female - causes ovulation + causes progesterone production by corpus luteum

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11
Q

how does the pulsatile manner of GnRH release differ between males and females?

A

males - pulses at constant frequency

females - frequency of pulses varies during menstrual cycle

follicular = high frequency
luteal = low
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12
Q

does a high frequency of GnRH pules favour LH release or FSH?

A

LH pulses

low frequency = FSH pulses

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13
Q

effect of oestrogen + progesterone on GnRH pulses?

A

high oestrogen increases GnRH pulses - increasing LH release

high progesterone reduces GnRH pulses

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14
Q

where are oestrogen and progesterone receptors that influence GnRH pulses found?

A

kisspeptin neurones - these indirectly influence GnRH neurones

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15
Q

where is oestrogen secreted from?

A

primarily by ovaries (follicles) + adrenal cortex

and placenta in pregnancy

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16
Q

functions of oestrogen (4)

A

increase thickness of vaginal wall
regulate LH surge
reduce vaginal pH through increase in lactic acid production

decrease viscosity of cervical mucus to facilitate sperm penetration –> FERTILE mucus

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17
Q

where is progesterone secreted from?

A

corpus luteum + placenta during pregnancy

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18
Q

function of progesterone (5)

A

“pro-gestation” (maintain pregnancy)

  • responsible for INFERTILE thick mucus - prevents sperm transport + infection
  • maintain thickness of endometrium
  • relaxes myometrium (smooth muscle)
  • inhibits secretion of LH
  • increase basal body temp
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19
Q

what does the LH surge lead to?

A

ovulation
regulates formation of corpus luteum
regulates progesterone production + secretion
–> increasing progesterone decreases LH secretion by influecing GnRH pulses

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20
Q

LH surge

A

preceds ovulation by approx 34-36hrs
thershold of oestrogen (200pg/ml) is required for LH surge - via increase GnRH pulses

increase LH levels -> progesterone levels begin to increase

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21
Q

which follicular cell expresses LH receptors?

A

theca cells - release androgens in response to LH

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22
Q

which follicular cell expresses FSH receptors?

A

granulosa cella

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23
Q

folliculogenesis

A

early stages occur independently of gonadotrophins, once follicle is certain size becomes gandotrophin dependent (MUST coincide with rise in FSH during early follicular phase

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24
Q

describe the formation of corpus luteum

A

occurs under influence of LH
granulosa + theca cells transform to luteal cells
increase in progesterone production (via increased cholesterol - substrate for progesterone synthesis)

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25
Q

histology and function of the cells in the cervix

A

epithelium = columnar epithelium cells = site of mucus production

stroma(behind epithelium) = collagen matrix + fibroblasts = regulates rigidity of cervical wall

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26
Q

what regulates sperms ability to penetrate cervical mucus?

A

thickness of mucus - based on hormonal control
motility of sperm
interaction of oxygen species - produced by WBCs that have infiltrated mucu
interactions with mucins

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27
Q

what is the optimum route for sperm throught the cervix?

A

through primary + secondary grooves avoiding mucucs and imune cells

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28
Q

is cervical mucus thicker in the cervical canal or secondary grooves?

A

thicker in cervical canal

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29
Q

where are the immune cells of the cervix most concentrated?

A

cervical canal

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30
Q

histology of seminiferous tubules

A

inside contains Sertoli cells - protect germ cells

outside surrounded by interstitial tissue, blood vessels, WBCs, fibroblasts

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31
Q

testosterones role during spermatogenesis

A

maintains integrity of blood-testes barrier

release of mature spermatozoa from Sertoli cells - by influencing peritubular myoid cells

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32
Q

pathway of FSH action in males

A

FSH stimulates Sertoli cells

Sertoli cells secretes androgen binding globulin (ABG) (which testosterone binds to) and inhibin

  • inhibin decreases secretion of FSH (via neg feedback)
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33
Q

pathway of LH action in males

A

LH stimulates interstitial Leydig cells to secrete testosterone

  • testoterone inhibits GnRH + LH secretion (via neg feedback)
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34
Q

of the testosterone secrete by interstitial Leydig cells - how much of this is taken up by Sertoli cells?

A

90%

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35
Q

define ooligomenorrhea

A

cycles >42days / <8 periods per year

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36
Q

causes of infertility

A 
tubal disease
fibroids
endometriosis
sperm problems
weight related
unexplained
combination of male + female probs
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37
Q

what is the WHO classification if anovulation?

A

group I = hypothalamic pituitary FAILURE (hypogonadotrophic hypogonadism)

group II = hypothalamic pituitary DYSFUNCTION - commonest

group III = OVARIAN FAILURE (hypergonadotrophic hypogonadism)

38
Q

gonadal hormone levels in group I anovulation

A

hypogonadotrophic hypogonadism

low FSH +LH
low oestrogen

39
Q

investigation for hypogonadotrophic hypogonadism

A

progesterone challenge test
= admin of progesterone to induce a period

–> if no bleeding after 7-10days = oestrogen low

40
Q

causes of hypogonadotrophic hypogonadism

A 
stress
excessive exercise
anorexia / low BMI
brain / pituitary tumours
head trauma
Kallman's syndrome
drugs - steroids, opiates
41
Q

management of hypogonadotrophic hypogonadism

A

stabilie weight / lifestyle advice (reduce caffience etc)

  1. pulsatile GnRH - SC/IV pump worn continuously - pulsatile admin every 90mins
  2. gonadotrophin (LH+FSH) daily injections - higher multiple pregnancy rates

–> both need US monitoring of response (follicle tracking)

42
Q

gonadal hormone levels in group II anovulation

A

all normal

85% of ovulatory disorders
includes PCOS, hyperprolactinemic

43
Q

management of group II anovulation

A 
clomifene citrate (anti-oestrogen) - stimulates ovulation
--> alternatives: letrozole, tamoxifen (aromatase inhibitor)

gonadotrophin daily injections - risk of overstimulation + multiple pregnancy

laparoscopic ovarian diathermy induce ovulation

IVF

44
Q

what is laparocopic ovarian diathermy induced ovulation?

A

key hole surgery delivering heat
disrupts ovarian cortex + stoma

rule of 4: 40W current, 4 seconds, 4 punctures

risks = ovarian destruction/adhesions

45
Q

gonadotrophin levels in group II anovulation

A

hypergonadotophic hypogonadism

high gonadotrphins

46
Q

group III anovulation conditions + management

A

menopausal
5% ovulatory disorders

premature ovarian failure

management = oocyte donation

47
Q

infertility lifestyle advice

A 
400mcg folic acid daily
healthy BMI
no smoking + excessive alcohol
reduce stress
reduce caffiene 
aim for sex every 2-3 days - stop planning, can add stress
48
Q

initial primary care tests for infertility

A

BMI - low could indicate anovulation, high - PCOS

chlamydia screening
semen analysis
rubella immunity in mother
fermale hormone testing

pregnancy test !!

49
Q

what female hormone tests can be done in infertility?

A

serum progesterone on day 21 of cycle - or 7 days before end

day 2-5 of cycle -

  • serum LH + FSH, estradiol
  • prolactin - when symptoms of glactorrhoea or amenorrhoea
  • testosterone / SHBG (free androgen index)

progesterone challenge test - bleed indicates normal oestrogen levels

anti-MUllerian hormone, thyroid function tests

50
Q

what does a high FSH indicate?

A

poor ovarian reserve (number of follicles women have left in her ovaries)

pituitary gland is producing extra FSH in an attempt to stimulate follicular development

51
Q

what does a high LH indicate?

A

PCOS

52
Q

what does a low anti-mullerian hormone indicate?

A

= accurate marker of ovarian reserve - released by granulosa cells in follicles

levels fall when eggs are depleted

53
Q

what does a progesterone rise on day 21 indicate?

A

ovulation has occured + corpus luteum has formed + started secreting progesterone

54
Q

secondary care investigations of infertility

A

ultrasound of pelvis - PCOS, structural

hysterosalpinogram - patency of fallopian tubes

laparoscopy + dye test - endometriosis, treat adhesions

55
Q

what conditions causing infertility is surgery the primary treatment?

A

(laparoscopy/hysteroscopy)

pelvic adhesions
grade 2 endometriosis
chocolate cysts in ovary
tubal block

56
Q

mode of action of clomifene

A

anti-oestrogen (a selective oestrogen receptor modulator)

stops neg feedback of oestrogen on hypothalamus - results in greater release of GnRH + subsequently LH + FSH

given on days 2-6 of menstrual cycle

57
Q

risk of ovulation induction

A

ovarian hyperstimulation
multiple pregnancy - hypertension, low birth weight, prematurity
theoretical risk ovarian cancer

58
Q

management of submucosal, intramural and subserosal respectively

A

submucosal = hysteroscopy

intramural = individualised on a case to case basis

subserosal = conservative, unlikely to impact fertility

59
Q

PCOS presentation (triad)

A

triad = anovulation, hyperandrogenism, polycystic ovaries on US

obesity, hirsutism, acne
insulin resistance

high LH
impaired glucose tolerance

60
Q

how can insulin resistance cause hyperandrogenism?

A

insulin lowers SHBG

–> increased free testosterone = hyperandrogenism

61
Q

diagnostic criteria of PCOS

A

rotterdam criteria, 2 or 3 of -

  • ooligoovulation or annovulation
  • hyperandrogenism - characterised by hirsutism + acne
  • polycystic ovaries on ultrasound
62
Q

PCOS investigations

A

raised LH
raised LH:FSH ratio - high LH compared with FSH
raised free testosterone
raised insulin

transvaginal US = gold standard
– follicles around ovary periphery, 12+

63
Q

causes of premature ovarian failure

A 
Turner's syndrome
chemo, radio
oophorectomy
autoimmune - coeliac, adrenal insufficiency, T1DM
infections - mumps, TB
64
Q

diagnosis of premature ovarian syndrome

A

younger than 40
menopausal symptoms
elevated FSH - persistently on 2 consecutive samples separated by 4 weeks

65
Q

causes of tubal disease

A

infective

  • pelvic inflammatory disease (PID) - chlamydia, gonorrhoea, TB, syphilis
  • transperitoneal spread - appendicitis
  • iatrogenic - coil insertion

non-infective

  • endometriosis
  • fibroids
  • polyps
  • congenital
66
Q

what is a hydrosalpinx and how does it present?

A

fluid filled fallopian tube - can be due to pelvic inflam disease

abdo/pelvic pain
discharge
pain during sex (dyspareunia)
heavy/long periods
severe cramps
infertility
ectopic pregnancy
67
Q

what is endometriosis?

A

presence of endometrial glands outside uterine cavity

20-30% of infertile women

68
Q

causes of endometriosis

A

retrograde menstruation - blood flows backwards into pelvis
altered immune function
abnormal cellular adhesion
genetic

69
Q

endometriosis presentation

A 
severe cramps before menstruation
pain during sex (dyspareunia)
heavy periods (menorrhagia)
painful defaecation
chronic pelvic pain
infertility

chocolate cysts
gunpowder appearance on laparoscopy

70
Q

causes of male infertility

A 
non-obstructive
- hypogonadism
- hypothyroidism
- hyperprolactinaemia
- diabetes
- Klinefelter
- undescended testes
Y deletions
heat, radiation, chemo
torsion/variocele

obstructive - congenital, infection, vasectomy

71
Q

drugs causing male infertility

A 
marijuana
anabolic steroids
SSRI antidepressants
cocaine
alcohol, tobacco
72
Q

treatment of male infertility

A 
surgery to obstructed vasdeferens
intrauterine insemination
intracytoplasmic sperm injection (ICSI)
surgical sperm aspiration from epididymis or testicle combined with ICSI
donor sperm insemination
73
Q

male hypogonadism presentation

A

gynaecomastia
decreased body hair, high pitch voice, low libido
decreased testicular volume
decreased bone + muscle mass
pre-pubertal = eunuchoidal habitus (tall, slim, long arms + legs)

++ symptoms associated with cause

74
Q

male hypogonadism investigation

A

measure AM testosterone twice - peaks in morning

total testosterone can be misleading - only free portion is biologically active

75
Q

if LH/FSH were high in suspected male hypogonadism, what further investigation would you do?

A

primary (hypergonadotrophic hypogonadism)

karyotyping, iron studies

76
Q

if LH/FSH were low in suspected male hypogonadism, what further investigation would you do?

A

seconday (hypogonadotropic hypogonadism)

exclude medications
iron studies
MRI, prolactin + pituitary hormones

77
Q

management of male hypogonadism

A

testosterone replacement
-> transdermal, oral, IM

requires monitoring

  • 3-6 monthly when starting then annually after that
  • DRE + PSA, haematocrit, sleep apnoea, general health
78
Q

different types of testosterone replacement

A

transdermal - applied daily, mimics circadian rhythm, skin irritation, compliance issues

undecanoate

  • oral - daily, nauses, variable testosterone levels, compliance
  • IM - every 10-14weeks, improved compliance, steady testosterone levels, hard to withdraw

sustanon (IM) - every 2-3 weeks, easy to withdraw, sekf admin, variable testosterone levels

79
Q

disadvantages of IM testosterone replacement treatment

A

contraindicated in bleeding disorders
local pain at injection sight
coughing following injection

80
Q

testosterone replacement therapy contraindications

A

hormone responsive cancer - prostate/breast
possible prostate cancer - raised PSA, sus DRE

haematocrit >50%
severe sleep apnoea / heart failure

81
Q

causes of primary hypogonadism

A

congenital

  • Klinefelters
  • cryptorchidism (testicles not descending)
  • Y chromosome microdeletions

acquired

  • testicle trauma / torsion
  • chemo/radio
  • variocele
  • orchitis (mups infection)
  • infiltrative disease - sarcoidosis, haemochromatosis
  • medications - glucocorticoids, ketoconazole
82
Q

medications that can cause primary hypogonadism?

A

glucocorticoids

ketoconazole

83
Q

Klinefelters syndrome

A

not inherited, caused by nondisjunction
usually 47XXY but varies - variations mean late/misdiagnosis
1/550 birth

84
Q

Klinefelters presentation

A

infertile - due to tubage damage
small firm testes
cryptorchidism
learning siability, psychosocial issues

85
Q

diagnosis of Klinefelters

A

karyotyping

86
Q

Klinefelters associated risks

A

increased risk of breast cancer + non-hodgkin lymphoma

87
Q

how are spermatogenesis + testosterone production affected in primary vs secondary hypogonadism?

A

primary - spermatogenesis is affected more than testosterone production

secondary - both are affected equally

88
Q

causes of secondary hypogonadism

A

congenital

  • Kallmann’s
  • Prader-Wili syndrome

acquired

  • pituitary damage - tumours, sarcoidosis, infection, trauma
  • obesity, diabetes
  • hyperprolactinaemia
  • medications - steroid, opiods
  • acute systemic illnes
  • eating disorders, excessive exercises
89
Q

medications that cause secondary hypogonadism

A

steroids

opiods

90
Q

Kallmans syndrome

A

isolated GnRH deficiency + loss/change in smell (hyposmia/anosmia)

91
Q

Kallman’s presentation

A

unilateral renal angenesis (lack of organ)
red-green colour blindness
cleft lip
bilateral synkinesis (face muscle twitches)

+ symptoms associated with hypogonadism

endocrine (15 decks)

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