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ENDOCRINOLOGY 2 > REPRODUCTIVE TREATMENTS > Flashcards

REPRODUCTIVE TREATMENTS Flashcards

1
Q

To which type of patients is testosterone replacement given to?

A

Men not desiring fertility
Wish to treat loss of early morning erections, libido, decreased energy and shaving

Must have had at least 2 low measurements of serum testosterone before 11am

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2
Q

How can testosterone replacement carried out?

A

Daily gel
3 weekly intramuscular injection
3 monthly intramuscular injection
Less common implants, orals

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3
Q

What do you monitor for the safety of a patient who is taking testosterone replacement?

A

Haematocrit

Prostate (prostate specific antigen (PSA) levels)

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4
Q

If a patient with hypogonadism wishes to be fertile and produce sperm, how do you treat?

A

Primary hypogonadism - difficult

Secondary hypogonadism - give gonadotrophins to induce spermatogenesis

  • LH stimulates Leydig cells to increase intratesticular testosterone
  • FSH stimulate seminiferous tubules development and spermatogenesis
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5
Q

What is the role of LH and FSH in spermatogenesis?

A

LH - stimulates Leydig cells to increase intratesticular testosterone

FSH - stimulates seminiferous tubule development and spermatogenesis

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6
Q

What is the aim for ovulation induction and why?

A

Aim to develop 1 ovarian follicle

If > 1 follicle develop risks multiple pregnancy (twin…) which has risks for mother and baby during pregnancy

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7
Q

How is ovulation induction carried out in e.g. PCOS?

A
  1. Lifestyle/weight loss/metformin
  2. Letrozole (aromatase inhibitor)
  3. Clomiphene (oestradiol receptor antagonist)
  4. FSH stimulation (low dose FSH)
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8
Q

Why is an aromatase inhibitor used in ovulation induction?

A

Prevents testosterone becoming oestradiol which decreases the negative feedback on hypothalamus and pituitary gland so increased LH and FSH

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9
Q

Why is an oestradiol receptor antagonist used in ovulation induction?

A

Decreases the negative feedback on hypothalamus and pituitary gland so increased LH and FSH

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10
Q

List the 4 main steps of IVF treatment

A
  1. Oocyte retrieval
  2. Fertilisation in vitro by IVF or intra-cytoplasmic sperm
    injection (ICSI)
  3. Embryo incubation
  4. Embryo transfer
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11
Q

List the steps of oocyte retrieval in IVF

A
  • FSH stimulation to induce growth of follicles
    (superovulation)
  • Prevent premature LH surge
  • LH exposure for egg maturation from diploid (metaphase
    1) to haploid (metaphase 2)
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12
Q

Why must a premature LH surge be prevented in IVF?

A

Stops premature ovulation so that there will be eggs in the ovary to collect

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13
Q

What are the 2 ways we use to prevent premature LH surge?

A

GnRH antagonist protocol (short protocol: day 6-9)

GnRH agonist protocol (long protocol: day -7-9)

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14
Q

Should you use pulsatile or non-pulsatile GnRH when trying to suppress LH?

A

Non-pulsatile as it causes desensitisation and after an initial flare LH is inhibited

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15
Q

List some methods of contraception?

A

Barrier (condoms, diaphragm/cap with spermicide)
Combined oral contraceptive pill (OCP)
Progestogen-only pill (POP)
Long acting reversible contraception (LARC)
Emergency contraception

Permanent methods:

  • Vasectomy
  • Female sterilisation
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16
Q

What are the positives of condoms?

A
  • Protect against STI
  • Easy to obtain
  • No contra-indications
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17
Q

What are the negatives of condoms?

A
  • Can interrupt sex
  • Can reduce sensation
  • Can interfere with erections
  • Some skill to use
  • Two are not better than one
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18
Q

How does the oral contraceptive pill (OCP) work?

A

Contains oestrogen and progesterone which:

  • More -ve feedback so less LH/FSH (anovulation)
  • Thickens cervical mucus (reduce sperm entering)
  • Thins endometrial lining (reduces implantation)
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19
Q

What are the positives of the OCP?

A
  • Easy to take (one a day)
  • Effective
  • Doesn’t interrupt sex
  • Can take several packets back to back and avoid
    withdrawal bleeds
  • Reduces endometrial and ovarian cancer
  • Weight neutral
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20
Q

What are the negatives of the OCP?

A
  • Difficult to remember to take
  • No protection against STI
  • Not best choice during breast feeding
  • P450 enzyme inducers may reduce efficacy
  • Adverse effects
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21
Q

What are the possible side effects of the OCP?

A
  • Spotting (bleeding in between periods)
  • Nausea
  • Sore breasts
  • Changes in mood/libido
  • More hungry
  • Blood clots in legs/lungs (extremely rare)
22
Q

What are the non-contraceptive uses of the OCP?

A
  • Makes periods lighter and less painful
  • Withdrawal bleeds usually very regular
  • Reduces LH and hyperandrogenism for PCOS
23
Q

What are the positives of the progesterone only pill (POP)/”Mini-pill”

A
  • Works like OCP but less reliable to inhibit ovulation
  • Suitable if you can’t take oestrogen
  • Easy to take
  • Doesn’t interrupt sex
  • Helps heavy/painful periods
  • Periods may stop temporarily
  • Can be used when breastfeeding
24
Q

What are the negatives of the progesterone only pill (POP)/”Mini-pill”

A
  • Difficult to remember
  • No protection against STIs
  • Shorter acting - needs to be taken at same time each
    day
  • Side effects
25
Q

What are the possible side effects of the progesterone only pill (POP)/”Mini-pill”

A 
Irregular bleeding
Headaches
Sore breasts
Changes in mood
Changes in sex drive
26
Q

List examples of long-acting reversible contraceptives (LARCs)

A

Intra-uterine device (IUD)
Intra-uterine systems (IUS)
Progesterone-only injectable contraceptives/sub-dermal implants

27
Q

Explain what an IUD is

A

ie copper coil which mechanically prevents implantation, decreases sperm egg survival. Lasts 5-10 years

Can cause heavy periods

28
Q

Explain what an IUS is

A

Secretes progesterone to thin lining of the womb and thicken cervical mucus (helps with heavy bleeding)

Lasts 3-5 years

29
Q

What is the most effective emergency contraception?

A

IUD can be fitted up to 5 days after unprotected sex

< 1% chance of pregnancy

30
Q

List some emergency contraceptive pills

A 
Ulipristal acetate (ellaOne)
Levonorgestrel (Levonelle) - least effective
31
Q

How does ulipristal acetate work?

A

Progesterone antagonist preventing ovulation
Must be taken within 5 days of unprotected sex
Emergency contraceptive pill

32
Q

How does levonorgestrel work?

A

Synthetic progesterone which prevents ovulation

Must be taken within 3 days of unprotected sex

33
Q

What are the possible side effects of emergency contraceptive pills?

A

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

34
Q

Patients with what medical history should avoid the OCP and why?

A 
Migraine with aura
Smoking + age > 35 years
Stroke/CVD history
Current breast cancer
Liver cirrhosis
Diabetes with complications e.g. retinopathy/nephropathy/neuropathy

Risk of venous thromboembolism (VTE)/ CVD/Stroke

35
Q

What should you consider when choosing a contraception for a patient?

A

Risk of venous thromboembolism (VTE)/ CVD/Stroke
Other conditions that may benefit
Need to prevent STI?
Other current medication

36
Q

What concurrent medications should cause you to reconsider to a more effective method of cotnraception?

A

P450 liver enzyme-inducing drugs e.g. anti-epileptics

Teratogenic drugs e.g. lithium, warfarin

37
Q

What are the risks of HRT?

A

Venous thrombo-embolism (DVT/PE)
Hormone sensitive cancers
Increased risk of CVD (if age > 60)
Small increased risk of stroke

38
Q

Why should patients with a BMI > 30 avoid oral oestrogens?

A

Oral oestrogens undergo first pass metabolism in liver causing increase in SHBG, triglycerides and CRP

Increases risk of venous thrombo-embolism
Use transdermal oestrogens instead

39
Q

How is breast cancer risk affected by HRT?

A

Slight increase only in women with combined HRT

Duration of treatment and continuity increases risk

40
Q

How is ovarian cancer risk affected by HRT?

A

Small increase in risk after long-term use

41
Q

How is endometrial cancer risk affected by HRT?

A

Must prescribe progestogens in all women with an endometrium

Assess HRT safety/efficacy at 3 months and then annually
Unscheduled bleeding common in first 3 months

42
Q

What type of bleeding could indicate endometrial cancer?

A

Post-menopausal bleeding

43
Q

What are the hormone sensitive cancers?

A

Breast cancer
Ovarian cancer
Endometrial cancer

44
Q

Which type of HRT (oral or transdermal) (combined/oestrogen only) has a greater risk of stroke?

A

Oral combined HRT

45
Q

What increases the risk of CVD when taking HRT?

A

If started 10 years after menopause

46
Q

What are the benefits of HRT?

A

Relief of symptoms of low oestrogen

Less osteoporosis related fractures

47
Q

How is gender reassignment carried out in prepubertal young people?

A

GnRH agonist for pubertal suppression and then sex steroids

Gender reassignment surgery after 1-2 years of hormonal treatment

48
Q

What are the masculinising hormones for transgender men?

A

Testosterone (injections/gels)

Progesterone to suppress menstrual bleeding if needed

49
Q

What are the feminising hormones for transgender women?

A

Oestrogen (transdermal, oral, intramuscular)

Hormones which reduce testosterone:

  • GnRH agonists (induce desensitisation of HPG axis)
  • Anti-androgen medications e.g. spironolactone
50
Q

What is the time frame of male to female gender reassignment?

A

1-3 months: decrease in libido/function, baldness slows/reverses

3-6 months: softer skin, change in body fat distribution, decrease in testicular size, breast development

6-12 months: hair becomes softer and finer

51
Q

What is the time frame of female to male gender reassignment?

A

1-6 months: balding, deeper voice, acne, change in distribution of body fat, enlargement of clitoris, menstrual cycle stops, increased muscle mass and strength

ENDOCRINOLOGY 2 (12 decks)

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