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yr2 Lily BRS Endo > reproductive treatments > Flashcards

reproductive treatments Flashcards

1
Q

when is testosterone replacement used?

A

in people not requiring fertility
treats the symptoms of testosterone deficiency (low libido, loss of early morning erections, decreased shaving)

must have at least 2 measurements of low serum testosterone before 11 am
investigations into the cause should be done

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2
Q

how can testosterone be replaced?

A

daily gel - take care not to contaminate partner

3 weekly IM injection

3 monthly IM injection

implants, oral preparations - less common

safety monitoring must be carried out:
haematocrit - T increases risk of hyperviscosity and stroke
prostate - prostate specific antigen levels (PSA)

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3
Q

how is sperm induction done?

A

primary hypogonadism - difficult to treat

secondary hypogonadism - (in hypogonadotrophic hypogonadism) treat with LH and FSH (gonadotrophins) to induce spermatogenesis

LH - stimulates Leydig cells to increase intratesticular testosterone to much higher levels than in circulation. hCG injecitons act on LH receptors

FSH - acts on Sertoli cells to stimulate seminiferous tubule development and spermatogenesis

(avoid giving testosterone to men desiring fertility)
, as this fill further lower the levels of LH and FSH, further reducing spermatogenesis)

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4
Q

what are the most common causes of amenorrhoea?

A

secondary amenorrhoea (after pregnancy and menopause)

PCOS:
hyperandrogenism clinical (hirsuitism, acne) and biochemical signs
PCO morphology on US

hypothalamic amenorrhoea:
low body weight
excess exercise
stress
genetic susceptibility 
all cause hypothalamus to decrease in function
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5
Q

what is ovulation induction?

A

aim to develop one ovarian follicle
in >1 develops it risks multiple pregnancy
this has risks for both mother and baby during pregnancy

ovulation induction methods aim to cause a small increase in FSH

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6
Q

how is ovulation induction done in anovulatory PCOS?

A

restore ovulation:
1. lifestyle/weight loss/metformin

  1. letrozole (aromatase inhibitor - blocks formation of oestrogen from T. less negative feedback on HPG axis. more kisspeptin, so more GnRH, so more LH/FSH, which induce ovulation)
  2. clomiphene (oestradiol receptor modulator - decreases negative feedback effect of oestrogen )
  3. FSH stimulation
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7
Q

how does letrozole induce ovulation?

A

it is an aromatase inhibitor

blocks testosterone -> oestrogen reaction

less oestrogen means less negative feedback on HPG axis

so more GnRH
:. more LH/FSH

increased FSH stimulates follicle growth

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8
Q

what is a basic overview of IVF?

A
  1. oocyte retrieval
  2. fertilisation in vitro (if male factor infertility - intra-cytoplasmic sperm injection (ICSI))
  3. embryo incubation for 3-5 days
  4. embryo transfer into uterus
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9
Q

what hormones are given to start IVF?

A
  1. FSH - to stimulate ovulation (day 1-10)
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10
Q

what are the IVF long and short protocols and why are they used?

A

FSH will cause an LH surge. this has to be prevented or it wall cause premature ovulation

a) Short protocol: GnRH antagonist (days 6-10)
b) Long protocol: GnRH agonist (days -7 - 9)

the long protocol works as normal GnRH secretion is pulsatile, resulting in a pulsatile secretion of LH
however continuous high dose GnRH desensitises the GnRH receptor, this causes an initial flare of LH (but as you start on day -7 this will finish before FSH commences) but it then inhibits LH

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11
Q

what step of IVF comes after prevention of premature ovulation?

A

day 11 the follicle is made to mature using LH exposure.

this mimics the LH surge seen in normal physiology when ovulation occurs

day 13 - oocyte removal from ovary and fertilisation

day 18 - transfer embryo to endometrium

day 30 - pregnancy blood scan

day 44 - pregnancy US

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12
Q

what are some methods of contraception?

A

temporary:
barrier (condom/ diaphragm/ cap with spermacide)
combined oral contraceptive pill
progesterone only pill
long acting reversible contraception (IUDs and implant)
emergency contraception

permanent:
vasectomy
female sterilisation

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13
Q

wha tare pros and cons of the barrier method?

A

pros:
STI protection
easy to obtain
no contra indications as with some hormonal methods

cons:
can interrupt sex
can reduce sensation
can interfere with erection

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14
Q

how does the oral contraceptive pill work?

A

contains oestrogen and progesterone

these have a negative feedback effect on GnRH and LH/FSH

this leads to anovulation

also mainly progesterone leads to:
thickening of cervical mucus
thinning of endometrial lining to reduce implantation

can also be used to lighten or make periods less painful
or help with PCOS to reduce LH and hyperandrogenism

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15
Q

what are pros and cons of the OCP?

A 
pros:
easy to take
effective
doesnt interrupt sex
can take several packs back to back so no bleeding
reduces risk of endometrial cancer
doesnt actually cause weight gain

cons:
may forget to take
no STI protection
P450 enzyme inducers (eg antibiotics) may reduce efficacy
not best choice during pregnancy
side effects (spotting, nausea, mood and libido changes etc)
blood clots (very rare)

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16
Q

what are the pros and cons of the progesterone only pill?

A

pros:
works same as OCP but less reliably inhibits ovulation
suitable if you cant take oestrogen
other pros same as OCP

cons:
forget to take
STIs
shorter acting - needs to be taken within the same hour every day
side effects (irregular bleeding, headaches, sore breasts, changes in mood and libido)

17
Q

what are long acting reversible contraceptives?

A

LARC for example coils (which are the most suitable for women)

exclude STIs and do cervical screening before insertion
prevents implantation of conceptus
can rarely cause ectopic pregnancy
can be used as emergency contraception

  1. IUD - copper coil
    mechanically prevents implantation
    decreases sperm egg survival
    lasts 5-10 years (may cause heavier periods so may be taken out earlier
  2. IUS - progesterone secreting pill
    thins lining of the womb and thickens cervical mucus
    can be used to help with heavy bleeding
    lasts 3-5 years
  3. progestogen only injections or implants
18
Q

what are modes of emergency contraception?

A
  1. copper IUD:
    most effective
    fitted up to 5 days after unprotected sex
emergency contraceptive pill
2. Ulipristal acetate 30mg (ellaOne)
stops progesterone working normally and prevents ovulation
earlier the better but up to 5 days
3. levongesterel 1.5mg (levonelle)
least effective, especially in bmi >27
synthetic progesterone prevents ovulation 
must take within 3 days
19
Q

what are the side effects of emergency contraceptives?

A

headache
abdominal pain
nausea

Liver P450 enzyme inducer medications make is less effective (eg. some antibiotics)

if you vomit within 3-4 hours of taking it you need to take another

20
Q

what considerations are taken into account when choosing a contraceptive?

A 
1. risk of venous thromboembolism (VTE)/CVD/stroke
migraine with aura (stroke risk)
smoking
history of stroke/CVD
current breast cancer
liver cirrhosis
diabetes with complications
  1. other conditions that may benefit from OCP
    eg menorrhagia/endometriosis/fibroids
  2. need for prevention of STIs
  3. concurrent medication
    P450 liver enzyme inducing drugs (eg. antibiotics)
    teratogenic drugs (eg. lithium/warfarin)
    more effective contraception needed in these cases
21
Q

which methods of contraception are the most effective?

A

the ones which arent user dependant

implant, IUS, IUD

22
Q

what are the risks of Hormone replacement therapy?

A
  1. venous thrombo embolism
    DVT or PE (pulmonary embolism)
    oral oestrogens undergo first pass metabolism in the liver
    oral greatly increases SHBG, triglycerides and CRP. so increases clotting risk

transdermal oestrogens are safer for VTE risks (especially avoid oral in BMI >30)

2. hormone sensitive cancers
breast cancer - slight increase
only in women on combined HRT
risk related to duration of treatment, goes down when stopped 
continuous is worse than sequential

ovarian cancer - small increase in risk after long term use

endometrial cancer - MUST prescribe progestogens (synthetic progestins and progesterone) in all women with an endometrium

  1. possible increase in risk of CVD
    no increase if started before age 60
    increase if started 10 years after menopause

4.stroke risk
oral> transdermal oestrogens
combined >oestrogen only

safety and efficacy should be assessed at 3 months then annually

23
Q

what are the benefits of HRT?

A

relieves symptoms of low oestrogen (flushing, disturbed sleep, decreased libido, low mood)

fewer osteoporosis related fractures (decreased by 1/3)

24
Q

how are prepubertal young people helped to transgender?

A

GnRH agonist for pubertal suppression and then sex steroids (T or E2)

post treatment regret 1-2%

gender reassignment surgery after 1-2 yrs of hormonal treatment

25
Q

what masculinising hormones are used for transgender men?

A

Testosterone (side effects: polycythaemia, lower HDL, obstructive sleep apnoea)

progesterone to suppress menstrual bleeding if needed (may cause endometrial hyperplasia 15%)

in 1-6 months:
balding
deeper voice
acne
facial and body hair
change in body fat
enlargement of clitoris
menstrual cycle stops
increased muscle mass
26
Q

what feminising hormones are used for transgender women?

A

oestrogen:
high dose
(side effects - VTE, high BP, CVD, high triglycerides, hormonal sensitive cancers, abnormal LFts)

reduce testosterone:
GnRH agonists (induce desensitisation of HPG axis)
anti-androgen medications (eg. spironolactone)

1-3 months: decrease in sexual desire and function, slowing in balding

3-6: softer skin, change in body fat, decreased testicular size, breast development

6-12: hair may become softer and finer

yr2 Lily BRS Endo (12 decks)

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