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BRS YR2 > Reproductive Treatments > Flashcards

Reproductive Treatments Flashcards

1
Q

How to diagnose low testosterone?

A

At least 2 low measurements of testosterone before 11am

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2
Q

When is testosterone replacement done?

A
  • when fertility is not desired

- used to treat the symptoms of low testosterone

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3
Q

What are the symptoms of low testosterone?

A
  • loss of early morning erections
  • low libido
  • decreased energy
  • reduced frequency of shaving
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4
Q

What are the options for testosterone replacement?

A
  • Daily (gel - contact awareness)
  • 3 x week IM injection
  • 3 x monthly IM injection
    LESS COMMON:
  • implants
  • oral preparations
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5
Q

What is an example of daily gel testosterone treatment?

A

Tostran

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6
Q

What is an example of 3 x weekly IM injection?

A

Sustanon

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7
Q

What is an example of 3 x monthly IM injections?

A

Nebido

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8
Q

What needs to be monitored when on testosterone replacement therapy?

A
  • Increased haematocrit (increased risk of hyperviscosity and stroke)
  • Prostate (Prostate Specific Antigen/PSA) levels
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9
Q

How to induce spermatogenesis in primary hypogonadism?

A

Difficult to treat

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10
Q

How to induce spermatogenesis in secondary hypogonadism?

A

treat with Gonadotrophins (LH and FSH)

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11
Q

How does LH induce spermatogenesis?

A

stimulates Leydig cells to increase intratesticular testosterone to much higher levels than circulation (100x)

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12
Q

How does FSH induce spermatogenesis?

A

FSH stimulates seminiferous tubule development and spermatogenesis

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13
Q

What to avoid when treating low testosterone in those desiring fertility?

A

testosterone

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14
Q

Why should you avoid using testosterone to treat those low in testosterone and desiring fertility?

A
  • additional testosterone will further lower LH/FSH

- also will reduce spermatogenesis

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15
Q

What is the treatment for men low in testosterone desiring fertility?

A
  • hCG injections (act on LH receptors)

- if no response after 6 months, add FSH injections

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16
Q

What are the physiological features of PCOS?

A
  • hyperandrogenism (hirstuism or acne)
  • PCO morphology on Ultrasounds
  • irregular periods
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17
Q

What are the clinical and biochemical features of hypothalamic amenorrhoea?

A
  • low body weight
  • excessive exercise
  • stress
  • genetic susceptibility
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18
Q

What is the aim of ovulation induction?

A
  • develop one ovarian follicle (more risks multiple pregnancy)
  • by causing a small increase in FSH
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19
Q

How to restore ovulation in Anovulatory PCOS?

A
  • lifestyle/weight loss/metformin
  • letrozole (aromatase inhibitor)
  • clomiphene (oestradiol receptor modulator)
  • FSH stimulation
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20
Q

What is the mechanism of action of letrozole for ovulation induction?

A

FIRST LINE

  • inhibits aromatase
  • stops the conversion of testosterone to oestradiol
  • low concentrations of oestradiol, means decreased negative feedback for the hypothalamus and pituitary gland
  • therefore, increase FSH and LH
  • high FSH stimulates follicle growth
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21
Q

What is the mechanism of action of clomiphene?

A
  • blocks oestradiol receptors
  • reduced negative feedback
  • increased LH and FSH from the pituitary
  • Increased FSH stimulates follicle growth
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22
Q

What is the process of IVF?

A
  • oocyte retrival
  • fertilisation in vitro
  • embryo incubation
  • embryo transfer
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23
Q

What is Intra-cytoplasmic Sperm Injection (ICSI)?

A

injection of sperm due to male factor failure

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24
Q

What are the two main things involved in hormone therapy for transgender women?

A
  • Oestrogen

- reduce testosterone

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25
Q

How is Oestrogen administered for transgender women?

A
  • transdermal, oral and IM
  • high dose (4-5mg/day)
  • aim: estradiol levels of 734pmol/L
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26
Q

What are the side effects of administering Oestrogen for transgender women?

A
  • VTE
  • hypertension
  • CVD
  • high triglycerides
  • hormone sensitive cancers (breast)
  • abnormal liver function tests (3%)
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27
Q

How is testosterone reduced in transgender women?

A
  • GnRH agonists (induces desensitisation of HPG axis)

- Anti-Androgen medications (eg: Cyproterone acetate, Spironolactone)

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28
Q

What will not change due to testosterone reduction in transgender women?

A
  • height
  • voice
  • adam’s apple
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29
Q

What is important to consider before starting hormone therapy in transgender women?

A

Sperm Banking

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30
Q

What will happen in the first 3 months of reduced testosterone levels in trans women?

A
  • reduced sexual desire
  • reduced function (incl: erections)
  • slowed or reversed baldness
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31
Q

What happens 3-6 months after starting to reduce testosterone levels in trans women?

A
  • softer skin
  • change in body fat distribution
  • reduced testicular size
  • breast development
  • tenderness
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32
Q

What happens 6-12 months post starting testosterone reduction therapy in trans women?

A

softer and finer hair

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33
Q

What is given to transgender individuals pre puberty?

A

GnRH agonist to supress puberty, and then sex steroids

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34
Q

What is the rate of regret post hormone therapy?

A

1-2%

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35
Q

When is gender reassignment surgery an option?

A

after 1-2 years of hormonal therapy

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36
Q

What masculinising hormones are given to transgender men?

A

testosterone (injections or gels)

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37
Q

What are the side-effects of giving testosterone to trans men?

A
  • polycythaemia
  • lower HDL
  • Obstructive sleep apnoea (OSA)
  • NO increase in CVD
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38
Q

What can be given to suppress menstrual bleeding in trans men?

A
  • progesterone
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39
Q

What is the risk of taking progesterone to stop menstrual bleeding in trans men?

A

endometrial hyperplasia (15%)

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40
Q

What can happen in the 6 months post starting masculinising hormones?

A
  • balding (family and age dependent)
  • deeper voice
  • acne
  • increased and coarser facial and body hair
  • change in body fat distribution
  • clitoris enlargement
  • menstrual cycle stops
  • increased muscle mass and strength
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41
Q

What is gender?

A
  • social construct

- male, female or non-bonary

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42
Q

What is sex?

A
  • biological sex

- male, female or intersex

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43
Q

What is cisgender?

A

same sex and gender

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44
Q

What is gender non-conforming?

A

gender and assigned sex do NOT match

45
Q

What is gender dysphoria?

A

When gender and sex are mismatched and causes distress

46
Q

What is non-binary?

A
  • gender doesn’t match traditional binary gender

- includes: agender, bigender, pangender and gender fluid

47
Q

What is transgender?

A

transitioning or planning to transition physical appearance from one gender to another

48
Q

What is the general prevalence of transgender individuals?

A
  • trans women 3 x more common than trans men
49
Q

What are the benefits of HRT?

A
  • relief of low oestrogen symptoms
    (flushing, disturbed sleep, low libido, low mood)
  • less osteoporosis related fractures
    (reduced by a third)
50
Q

What are the risks of HRT?

A
  • VTE (DVT or PE)
  • Hormone-sensitive cancers
  • Increased risk (if started 10 years post menopause)
  • Risk of stroke (CVD)
51
Q

Why is there an increased risk of VTE with HRT?

A

oral oestrogens first pass metabolism in the liver, increases:

  • SHBG
  • triglycerides
  • CRP
52
Q

What can reduce the risk of VTE in HRT?

A
  • using transdermal estrogens

- USE WHEN BMI>30

53
Q

What is the general dosage used when starting HRT?

A
  • 0.025mg transdermal prep

- 0.5mg oral estradiol/day

54
Q

What is the dosage if an increase of HRT is required?

A

Dose is increased at monthly intervals to:

  • 0.05mg transdermal estradiol
  • 1mg oral estradiol
55
Q

What is the starting dosage for those with severe hormone failure?

A

0.05mg transdermal estradiol

56
Q

Why is there an increased risk of hormone sensitive cancers in HRT?

A

breast cancer:
- slight increase in those on combined HRT (progesterone and oestrogen)
- dependent on duration (falls once stopped)
- continuous use is worse than sequential use
- INDIVIDUAL RISK ASSESSMENT NECESSARY
ovarian cancer:
- small increase after LT use
endometrial cancer:
- avoidable if progestogens are prescribed

57
Q

What MUST be an adjunct prescription during HRT if an endometrium is present?

A
  • progestogens
58
Q

What are progestogens?

A

synthetic progestins and the natural hormone progesterone

59
Q

How to assess HRT safety and efficacy?

A
  • at 3 months, then annually
  • unscheduled bleeding is common in first 3 months
  • post-menopausal bleeding could indicate endometrial cancer
60
Q

Who does the increased risk of CVD in HRT apply to?

A
  • if started 10 years post menopause
  • NO increased risk if started pre-60yo
  • possible benefits of oestrogen supplementation in young women (POI)
61
Q

What is the increased risk of stroke in HRT associated with?

A
  • small increased risk
  • risk higher in oral than transdermal oestrogens
  • risk higher in combined than oestrogen only
62
Q

What proportion of pregnancies are unplanned?

A

19-30%

63
Q

What are the temporary methods of birth control?

A
  • barrier (condom, diaphragm/cap with spermacide)
  • combined oral contraceptive pill (OCP)
  • progestogen-only pill (POP)
  • long acting reversible contraception (LARC)
  • emergency contraception
64
Q

What are the permanent methods of birth control?

A
  • vasectomy

- female sterilisation

65
Q

What are the positives of condoms?

A
  • STI protection
  • easy to obtain
  • no contraindications
66
Q

What are the negatives of condoms?

A
  • interrupts sex
  • reduced sensation
  • interferes with erections
  • requires skill to use
  • two are not better than one
67
Q

What is the impact of the Combined Oral Contraceptive pill (OCP) on the HPG axis?

A
  • negative feedback on hypothalamus and pituitary gland by progesterone and oestrogen
  • decreased GnRH
  • decreased LH and FSH
  • anovulation
  • thickening of cervical mucus
  • thinning of endometrial lining to reduce implantation
68
Q

What are the positives of the OCP?

A
  • easy to take (1 x daily, any time)
  • effective
  • can take several packets back to back, avoid withdrawal bleeds
  • reduce ovarian and endometrial cancer
  • weight neutral in 80% (10% gain, 10% lose)
69
Q

What are the negatives of the OCP?

A
  • difficult to remember
  • no STI protection
  • P450 enzyme inducers may reduce efficacy
  • not great while breastfeeding
70
Q

What are the possible side effects of taking the OCP?

A
  • spotting (in between periods)
  • nausea
  • sore breasts
  • changes in mood and libido
  • increased hunger
    EXTREMELY RARE
  • blood clots in legs or lungs (2/10,000)
71
Q

What are the non-contraceptive uses of the OCP?

A 
- lighter and less painful periods 
(endometriosis, period pain or menorhagia)
- regular withdrawal bleeds
PCOS
- reduce LH and hyperandrogenism
72
Q

What are the positives of the Progesterone Only pill (POP)?

A
  • less reliably inhibits ovulation
  • easy to take (1 x daily)
  • help heavy/painful periods
  • possibly stop periods
  • can be used while breastfeeding
73
Q

What are the negatives of taking the POP?

A
  • difficult to remember
  • no STI protection
  • short acting, needs to be taken at the same time everyday
74
Q

What are the possible side effects of the POP?

A
  • irregular bleeding
  • headaches
  • sore breasts
  • mood changes
  • sex drive changes
75
Q

What does Nulliparous mean?

A

no previous children

76
Q

When are Coils suitable?

A
  • STI and cervical screening are suitable

- emergency contraception

77
Q

Why are coils preferred in some religions?

A

prevents the implantation of the conceptus

78
Q

What is the main risk involved in coils?

A

can cause ectopic pregnancy

79
Q

How do IUDs work?

A
  • mechanically prevent implantation
  • decreases sperm-egg survival
  • lasts 5-10 years
80
Q

What are the negatives of IUDs?

A
  • can cause heavy periods

- 5% come out, particularly during the first 3 months

81
Q

What are Intra-uterine systems (IUS)?

A
  • coils that secrete progesterone (mirena coil)
82
Q

How do IUS’ work?

A

progesterone secretion thins the lining of the womb and thickens cervical mucus

83
Q

What are the benefits of using an IUS?

A
  • help with heavy bleeding

- lasts 3-5 years

84
Q

What are the 3 main types of Long-Acting Reversible Contraceptives (LARC)?

A
  • IUD
  • IUS
  • progestogen-only injectable contraceptives or subdermal implants
85
Q

What is the most effective emergency contraceptive?

A
  • copper IUD
  • can be fitted 5 days after sex
  • <1% chance of pregnancy
86
Q

What are the 2 types of emergency contraceptive pill?

A 
MOST EFFECTIVE:
- Ulipristal Acetate 30mg (ellaOne)
LEAST EFFECTIVE
(BMI>27)
- Levonogestrel 1.5mg (Levonelle)
87
Q

How does Ulipristal Acetate work?

A
  • stops progesterone working, prevents ovulation

- must be taken within 5 days (the earlier the better)

88
Q

How does Levonogestrel work?

A
  • synthetic progesterone prevents ovulation (no abortion)

- must be taken within 3 days

89
Q

What are the side-effects of the morning-after pill?

A
  • liver P450 enzyme inducer medications makes it less effective
  • if vomit within 2-3 hours of taking it, need to take another one
  • headache
  • abdominal pain
  • nausea
90
Q

What needs to be considered when choosing a contraceptive?

A
  • Risk of VTE/CVD/stroke
  • Other conditions that will benefit from OCP
    (menorrhagia/endometriosis/fibroids)
  • Need for STI protection
  • Concurrent medication
91
Q

How to assess the risk of VTE/CVD/stroke when choosing a contraceptive?

A

AVOID OCP IF:

  • Migraine with aura (stroke)
  • Smoking (>15/day) + age (>35yo)
  • Stroke or CVD history
  • Current breast cancer
  • Liver Cirrhosis
  • Diabetes with complications
92
Q

What concurrent medication should you be aware of when choosing a contraceptive?

A
  • P450 liver enzyme-inducing drugs (anti-epileptics, antibiotics)
  • Teratogenic drugs (lithium, warfarin)
    Consider LARCs NOT the PILL
93
Q

What is the first step of IVF?

A
  • induce the growth of multiple follicles

- large dose of FSH given

94
Q

What is done once the eggs are collected?

A
  • In Vitro Fertilisation

- IntraCytoplasmic Sperm Injection

95
Q

What is intracytoplasmic sperm injection?

A
  • direct injection of a single sperm into the egg
96
Q

When is ICSI done?

A

When there is male factor failure/insufficiency

97
Q

Once fertilised, what happens?

A

3-5 days incubation

transfer to endometrium

98
Q

What does the large dose of FSH cause?

A

Superovulation

99
Q

When egg removal is happening, what needs to be stopped?

A
  • prevent premature ovulation

- done by preventing a premature LH surge

100
Q

How do you prevent premature LH surge?

A
  • SHORT protocol

- LONG protocol

101
Q

What is the SHORT protocol/GnRH antagonist protocol?

A
  • FSH (day 2)
  • GnRH antagonist (day 6)
  • prevents LH surge
102
Q

What is the LONG protocol/GnRH agonist?

A
  • GnRH agonist from day 21 of PREVIOUS cycle

- FSH from day 2 of current cycle

103
Q

How can both a GnRH agonist and antagonist to block an LH surge?

A

GnRH is given in a pulsatile manner to stimulate LH,

but CONTINUOUS GnRH causes desensitisation of the GnRH receptors (leads to `LH inhibition)

104
Q

What is the trigger of oocyte maturation?

A

LH exposure

105
Q

What happens in oocyte maturation?

A

immature (M1): diploid
- post maturation
mature (M2): haploid
- can now be fertilised by the sperm

106
Q

What is used to induce oocyte maturation?

A

hCG

- occasionally GnRH agonists

107
Q

Why is hCG used to induce oocyte maturation?

A
  • long lasting

- acts on LH receptor

108
Q

When is oocyte induced?

A

on day 11

109
Q

When can a pregnancy test be done?

A

11 days after the embryo transfer to the endometrium

BRS YR2 (70 decks)

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