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Endocrinology 2 > Reproductive Treatments > Flashcards

Reproductive Treatments Flashcards

1
Q

How is testosterone measured and what is treated?

A

At least 2 low measurements of serum testosterone before 11am needed. Investigate the cause of low testosterone. If fertility not desired, need to treat: loss of early morning erections, libido, decreased energy, shaving.

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2
Q

What are testosterone replacements?

A 
Daily Gel (eg Tostran). Care not to contaminate partner.
3 weekly intramuscular injection (eg Sustanon)
3 monthly intramuscular injection (eg Nebido)
Less Common (Implants, oral preparations)
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3
Q

What safety monitoring needs to be done for testosterone treatment?

A 
Increased Haematocrit (risk of hyperviscosity and stroke)
Prostate (Prostate Specific Antigen (PSA) levels)
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4
Q

How is sperm induction done?

A

If primary hypogonadism, hard to treat. If secondary, hypogonadotrophic hypogonadism treated with gonadotrophins which induces spermatogenesis.

LH stimulates Leydig cells to increases intratesticular testosterone to much higher levels than in circulation (x100).
FSH stimulates seminiferous tubule development and spermatogenesis

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5
Q

Why should testosterone not be given to men desiring fertility?

A

FSH and LH responsible for spermatogenesis. Testosterone will reduce FSH and LH and hence further reduce spermatogenesis. Alternative treatment:
Give hCG injections (which act on LH-receptors)
If no response after 6 months, then add FSH injections.

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6
Q

How is PCOS differentiated from hypothalamic amenorrhoea symptoms wise?

A

Irregular periods feature in both. PCOS also consists of hyperandrogenism (hirsutism/acne) plus polycystic ovaries. Hypothalamic amenorrhoea can be caused by low body weight, excessive exercise, stress or genetic susceptibility.

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7
Q

What is a key consideration in terms of ovarian induction?

A

Aim to create small rise in FSH to develop one ovarian follicle - more can result in multiple pregnancies which holds risks for mother and child during pregnancy.

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8
Q

How is ovulation restored in the case of anovulatory PCOS?

A
  1. Lifestyle / Weight Loss / Metformin
  2. Letrozole (Aromatase inhibitor)
  3. Clomiphene (Oestradiol receptor modulator)
  4. FSH stimulation
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9
Q

How does letrozole work?

A

It is an aromatase inhibitor. Therefore, it prevents the conversion of testosterone to oestradiol and hence there is decreased negative feedback on pituitary and hypothalamus. Therefore, increased FSH induces follicular growth.

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10
Q

How does clomiphene work?

A

It is an oestradiol receptor antagonist. Hence, it prevents the binding of oestradiol to receptors in the pituitary and hypothalamus so negative feedback effect doesn’t take place, increasing FSH and LH levels.

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11
Q

Describe process of IVF

A
  1. Oocyte retrieval occurs
  2. Fertilisation in vitro done - if female factor, done in vitro but if male factor, intracytoplasmic sperm injection used.
  3. Embryos incubated
  4. Embryo transfer done
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12
Q

What are temporary methods of contraception?

A
  1. Barrier: male / female condom / diaphragm or cap with spermicide
  2. Combined Oral Contraceptive Pill (OCP)
  3. Progestogen-only Pill (POP)
  4. Long Acting Reversible Contraception (LARC)
  5. Emergency Contraception
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13
Q

What are permanent methods of contraception?

A
  1. Vasectomy

2. Female sterilisation

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14
Q

What are positives of barrier contraception?

A
  1. Protect against STI’s
  2. Easy to obtain – free from clinics/No need to see a healthcare professional
  3. No contra-indications as with some hormonal methods
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15
Q

What are negatives of barrier contraception?

A
  1. Can interrupt sex
  2. Can reduce sensation
  3. Can interfere with erections
  4. Some skill to use eg correct fit.
  5. Two are not better than one
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16
Q

How does the oral contraceptive pill work?

A

Contains oestrogen and progesterone. These negatively feedback on pituitary and hypothalamus preventing production of FSH and LH, thus causing anovulation. Progesterone thickens cervical mucus and a thinning of endometrial lining occurs to prevent implantation.

17
Q

What are the positives of the combined oral contraceptive pill?

A
  1. Easy to take – one pill a day (any time of day)
  2. Effective
  3. Doesn’t interrupt sex
  4. Can take several packets back to back and avoid withdrawal bleeds
  5. Reduce endometrial and ovarian cancer
  6. Weight Neutral in 80% (10% gain, 10% lose)
18
Q

What are the negatives of the combined oral contraceptive pill?

A
  1. It can be difficult to remember
  2. No protection against STIs
  3. P450 Enzyme Inducers may reduce efficacy
  4. Not the best choice during breast feeding
19
Q

What are possible side effects of the combined oral contraceptive pill?

A
  1. Spotting (bleeding in between periods)
  2. Nausea
  3. Sore breasts
  4. Changes in mood or libido
  5. Feeling more hungry
20
Q

What are non-contraceptive uses of the COCP?

A
  1. Helps make periods lighter and less painful (eg endometriosis or period pain or menorrhagia)
  2. Withdrawal bleeds will usually be very regular
  3. PCOS: help reduce LH and hyperandrogenism
21
Q

What are the positives of the progesterone only pill?

A
  1. Works as OCP but less reliably inhibits ovulation - Often suitable if can’ttake oestrogen
  2. Easy to take – one pill a day, every day with no break
  3. It doesn’t interrupt sex
  4. Can help heavy or painful periods
  5. Periods may stop (temporarily)
  6. Can be usedwhen breastfeeding
22
Q

What are the negatives of the progesterone only pill?

A
  1. Can be difficult to remember
  2. No protection against STIs
  3. Shorter acting – needs to be taken at the same time each day
23
Q

What are possible side effects of the progesterone only pill?

A
  1. Irregular bleeding
  2. Headaches
  3. Sore breasts
  4. Changes in mood
  5. Changes in sex drive
24
Q

What are the positives of Long-Acting Reversible Contraceptives?

A
  1. Coils suitable for most women including nulliparous
  2. Exclude STI’s and cervical screening up to date before insertion
  3. Prevent implantation of conceptus – important for some religions
  4. Rarely can cause ectopic pregnancy
  5. Can be used as emergency contraception
25
Q

What are options of Long-Acting Reversible Contraceptives?

A
  1. Intra-Uterine Device (IUD) ie Copper Coil- mechanically prevent implantation, decrease sperm egg survival. Lasts 5-10yrs. Can cause heavy periods, and 5% can come out especially during first 3months with periods.
  2. Intra-Uterine Systems (IUS)which secretes progesterone (eg Mirena Coil) to thin lining of the womb and thicken cervical mucus (can be used to help with heavy bleeding). Last 3-5yrs.
  3. Progestogen-only injectable contraceptives or subdermal implants
26
Q

What are 3 options of emergency contraception?

A
  1. Copper intrauterine device (IUD) most effective
    can be fitted up to 5 days after unprotected sex (<1% chance of pregnancy)

Emergency contraceptive pill:
2. Ulipristal acetate 30mg (ellaOne)
Ulipristal acetate stops progesterone working normally and prevents ovulation. Must be taken within 5 days of unprotected intercourse (earlier better).

  1. Levonorgestrel 1.5mg (Levonelle) least effective (esp if BMI >27 kg/m2)
    Synthetic Progesterone prevents ovulation (don’t cause abortion). Must be taken within 3 days of unprotected intercourse.
27
Q

What are side effects of emergency contraception?

A

Side effects- headache, abdominal pain, nausea.

Liver P450 Enzyme inducer medications make it less effective. If vomit within 2-3hrs of taking it, need to take another.

28
Q

What are contraindications for OCP?

A 
Migraine with aura (risk of stroke)
Smoking (>15/day) + age >35yrs
Stroke or CVD history
Current Breast cancer
Liver Cirrhosis
Diabetes with complications eg retinopathy/nephropathy/neuropathy

Avoid as these have an increased risk of venous thromboembolism, stroke, CVD.

29
Q

What are 3 considerations when choosing contraception?

A
  1. Other conditions may benefit from OCP eg Menorrhagia / Endometriosis / Fibroids
  2. Need for prevention of Sexually Transmitted Infections (STI’s)
3. Concurrent medication — P450 liver enzyme-inducing drugs (eg anti-epileptics,some antibiotics)
Teratogenic drugs (eg lithium or warfarin), more effective methods of contraception needed 
(eg progestogen-only implant, or intrauterine contraception).
30
Q

What are the risks of hormone replacement therapy?

A
  1. Venous Thrombo-embolism: Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)
  2. Hormone Sensitive Cancers
  3. Concern about increased risk of Cardiovascular disease
  4. Risk of Stroke (cerebrovascular disease)
31
Q

Describe risk of DVT caused by hormone replacement therapy?

A

Oral oestrogens undergo first pass metabolism in liver and so much greater increase in SHBG, Triglycerides, CRP. Transdermal estrogens are safer for VTE risk than oral. Avoid oral oestrogens in BMI > 30 kg/m2.

32
Q

Describe dosage of transdermal oestrogen

A

One can start with 0.025 mg estradiol transdermal preparation or oral estrogen (0.5 mg estradiol daily) depending on the patient’s preference. If required, dose is increased at monthly intervals to 0.05 mg transdermal estradiol or 1 mg oral estradiol. For severe HFs, 0.05 mg transdermal estradiol can be used from the beginning.

33
Q

Who has an increased breast cancer and ovarian cancer risk?

A

Slight increase in risk for breast cancer only in women on Combined HRT (ie oestrogen AND progesterone). Risk related to duration of treatment and reduces after stopping. Continuous worse than Sequential. Assess risk in each individual before prescribing.

Small increase in ovarian cancer risk after long term usage.

34
Q

When must progestogens be prescribed?

A

Must prescribe for all women with an endometrium. Progestogens are synthetic progestins and the natural hormone progesterone.

35
Q

When should HRT safety/efficacy be assessed?

A

At 3 months and then annually. Unscheduled bleeding is common within first 3 months. Post-menopausal bleeding could indicate endometrial cancer.

36
Q

When is risk of cardiovascular disease increased by HRT?

A

No increased risk if started before age 60 yrs. Increased risk if started 10 years after menopause.

37
Q

When is risk of stroke increased by HRT?

A

Small increased risk but this is greater with oral oestrogen vs transdermal. Also greater with combined as compared to progesterone only.

38
Q

What are the benefits of HRT?

A
  1. Relief of symptoms of low oestrogen - eg Flushing, disturbed sleep, decreased libido, low mood
  2. Less osteoporosis related fractures - decreased by 1/3

Endocrinology 2 (11 decks)

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