Reproductive

Question 1

What is the difference between primary and secondary hypogonadism?

Answer 1

Primary - problem with the gonads themselves - compensatory rise in FSH/LH/GnRHs
Secondary - problem occurs within the hypothalamic-pituitary axis; FSH/LH/GnRH is low or ‘inappropriately normal’

Question 2

Describe the two main congenital causes of male hypogonadism (Kallmann’s, Klinefelter’s). What is the other major secondary cause?

Answer 2

Kallmann’s - isolated GnRH deficiency, causing hypogonadotrophic hypogonadism.
- associated with an/hyposmia, unilateral renal agenesis, colour blindness, and cleft lip.
———
Klinefelter’s - Nondisjunction, most often resulting in 47XXY (although other karyotypes exist)
- frontal balding, poor beard growth, few chest hairs, gynaecomastia, small/firm testes
———
Other cause: haemochromatosis (iron deposits in ganglion cells)

Question 3

Describe how male hypogonadism should initially be investigated, then treated.

Answer 3

AM testosterone, repeat, then take LH/FSH levels; this can help distinguish primary/secondary
Primary (high LH/FSH) - karyotyping, iron studies (haemochromatosis?)
Secondary (‘normal’ LH/FSH) - any medication causative (e.g. spironolactone)? ; karyotype, iron studies, PRL levels, pituitary MRI
Treat with testosterone - IM, oral, transdermal

Question 4

Describe the normal action of LH and FSH on the male reproductive system.

Answer 4

LH -> (L)eydig cells -> Testosterone
F(S)H -> (S)ertoli cells -> (S)permatogenesis, along with (S)ex hormone binding globulins (SHBG) and inhibin (negative feedback effect)

Question 5

Describe the normal action of LH and FSH on the developing follicle in the female reproductive system. What happens after ovulation?

Answer 5

LH -> theta cells -> cholesterol -> [androgens]
FSH -> granulosa cells ([androgens] -> oestrogen) via aromatase
After ovulation, both types become luteal and induce angiogenesis for increased cholesterol delivery

Question 6

Describe the classification of infertility, including primary and secondary (couple) and gynae / non-gynae (female).

Answer 6

Primary - couple never conceived
Secondary - pregnancy did not continue (e.g. stillbirth)
——-
3 types in each category (gynae / non-gynae)
Gynae: hypothalamic, pituitary (tumours. PRL, Sheehan), ovarian (PCOS 85%, endometriosis)
Non-gynae: physiologyical (before puberty, during pregnancy etc.), systemic disease, and with drugs (e.g. OCP)

Question 7

How should infertility be treated?

Answer 7

Lifestyle advice (BMI <30, limit alcohol, caffeine, smoking)
Have sex every 2-3 days. ? psychosexual or infection status (rubella?)
Folic acid 400ug, vitamin D 10ug
—–
if hypothalmic-pit: give injections of LH/FSH
PCOS may need clomifene citrate or surgery

Question 8

Define oligo- and amenorrhoea (and the latter’s subclassifications, primary and secondary).

Answer 8

Oligo- (periods >42 days, <8 periods/year)

Amenorrhoea (lack of periods). Primary - never started, secondary - started then stopped

Question 9

Name the main effects of progesterone, oestrogen, and the two main physiological changes that occur near ovulation.

Answer 9

Oestrogen - fertile mucus (thin), and thickening of the endometrium
Progesterone - infertile mucus (thick), and continued thickness of the endometrium, smooth muscle relaxation, thermogenic effects
At ovulation, spinnbarkeit and BBT rises 0.2 - 0.4 degC