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BRS Phase 1b > Reproductive treatments > Flashcards

Reproductive treatments Flashcards

1
Q

How would you carry out testosterone replacement in.a male not desiring fertility?

A

Treat Symptoms- loss of early morning erections, libido, decreased energy, shaving
At least 2 low measurements of serum testosterone before 11am.
Investigate the cause of low testosterone.

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2
Q

What are the options for testosterone replacement?

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 are the safety concerns associated with testosterone replacement?

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

How would you induce sperm production in someone with primary Hypogonadism?

A

Difficult to treat

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5
Q

How would you induce sperm production in somebody with Secondary hypogonadism?

A

(deficiency of gonadotrophins ie hypogonadotrophic hypogonadism):
Treat with Gonadotrophins (ie LH and FSH) to induce Spermatogenesis

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6
Q

How do LH and FSH help Sperm induction?

A

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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7
Q

What would the treatment be for someone who is desiring fertitlity and has Secondary hypogonadism?

A

Give hCG injections (which act on LH-receptors)
If no response after 6 months, then add FSH injections.
Simply giving testosterone would lower LH/Fsh and thus spermatogenesis.

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8
Q

What are the features of Hypothalamic Amenorrhea?

A 
Low body weight
Excessive exercise 
Stress
Irregular periods
Genetic susceptibility
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9
Q

What are the aims of Ovulation induction?

A

Develop one ovarian follicle

Aim to cause a small increase in FSH

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10
Q

What are the risks if you stimulate more than one follicle e?

A

Multiple pregnancies, risk for mother and baby during pregnancy

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11
Q

How would you carry out Ovulation stimulation in somebody with PCOS?

A
  1. Lifestyle / Weight Loss / Metformin
  2. Letrozole (Aromatase inhibitor)
  3. Clomiphene (Oestradiol receptor modulator)
  4. FSH stimulation
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12
Q

How does Letrozole work?

A

Aromatase inhibitor, aromatases converts testosterone to oestradial, so you limit oestradiol. Oestradiol feedbacks negatively on the hypothalamus, reducing LH/FSH. By lowering it you increase GnRH and LH/FSH.

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13
Q

How does Clomiphene work?

A

Oestradiol receptor antagonist. Reduces negative feedback of oestradiol on hypothalamus. increases GnRH & LH/FSH.

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14
Q

What are the basics of IVF?

A 
1 - Oocyte retrieval
2 - Fertilisation in vito
    - IVF, Intra-cytoplasmic sperm injection ICSI
3 - Embryo Incubation
4 - Embryo transfer
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15
Q

Describe how the first step of IVF?

A

Give FSH to develop multiple follicles, prevent LH surge to stop premature ovulation. Give LH exposure to mature eggs ( diploid to haploid).

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16
Q

How do you prevent a premature rise in FSH?

A

1 - GnRH Antagonist SHORT protocol, FSH on day 2 GnRH on day 6.
2 - GnRH Agonist LONG protocol, give agonist 7 days before the cycle starts. GnRH needs to be given in a pulsatile manner to stimulate LH, however continuously sly it causes desensitisation.

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17
Q

What is the most common hormone used to stimulate Oocyte maturation?

A

hCG, longer acting than simply LH.

18
Q

What is the timeline for IVF?

A 
Day 2 - FSH
Day 6 - GnRH antagonist
Day 11 - hCG to trigger LH
Day 13 - Oocyte retrieval + Fertilisation
Day 18 - Embryo transfer to endometrium
After 11 days do pregnancy blood test
19
Q

What are the main methods of contraception?

A

Barrier: male / female condom / diaphragm or cap with spermicide
Combined Oral Contraceptive Pill (OCP)
Progestogen-only Pill (POP)
Long Acting Reversible Contraception (LARC)
Emergency Contraception

20
Q

What are the permanent methods of contraception?

A

Vasectomy

Female sterilisation

21
Q

What are the positives of Condoms?

A

Protect against STI’s
Easy to obtain – free from clinics
/ No need to see a healthcare professional
No contra-indications as with some hormonal methods

22
Q

What are some of the negatives of Condoms?

A 
Can interrupt sex
 Can reduce sensation    
 Can interfere with erections 
 Some skill to use eg correct fit.
 Two are not better than one
23
Q

How does the Oral contraceptive pill work?

A

Contains oestrogen and progesterone, decrease GnRH, LH & FSH. Progesterone thickens cervical mucus & thinning of endometrial lining.

24
Q

What are the benefits of the OCP?

A 
Easy to take – 
  one pill a day (any time of day)
 Effective
 Doesn’t interrupt sex
 Can take several packets back to back and avoid withdrawal bleeds
 Reduce endometrial and ovarian cancer
 Weight Neutral in 80% 
  (10% gain, 10% lose
25
Q

What are the negatives of the OCP?

A

It can be difficult to remember
No protection against STIs
P450 Enzyme Inducers may reduce efficacy
Not the best choice during breast feeding

26
Q

What are possible side effects of the OCP?

A 
Spotting (bleeding in between periods)
 Nausea
 Sore breasts
 Changes in mood or libido 
 Feeling more hungry
(try different OCPs to see which suits best)
very rare - blood clots.
27
Q

What are some non-contraceptive uses of the OCP?

A

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

28
Q

What are the positives of the Progesterone only pill?

A

Works as OCP but less reliably inhibits ovulation
Often suitable if can’ttake oestrogen

 Easy to take – one pill a day, every day with no break
 It doesn’t interrupt sex
 Can help heavy or painful periods
 Periods may stop (temporarily)
 Can be usedwhen breastfeeding
29
Q

What are some negatives of the Progesterone only pill?

A

Can be difficult to remember
No protection against STIs
Shorter acting – needs to be taken at the same time each day

30
Q

What are possible side effects of the progesterone only pill?

A 
Irregular bleeding
 Headaches
 Sore breasts
 Changes in mood
 Changes in sex drive
31
Q

How does the Intra-Uterine Device IUD ie Copper coil work?

A

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

32
Q

How does the Intra-Uterine System eg Mirena coil work?

A

Secretes progesterone to thin lining of the womb and thicken cervical mucus (can be used to help with heavy bleeding). Last 3-5yrs.

33
Q

What are the options for 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.

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.

34
Q

What are the factors to take into consideration when choosing contraception?

A 
1. Risk of Venous Thromboembolism (VTE) / CVD / Stroke
Comorbidities- Avoid OCP if: 
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
  1. Other conditions that may benefit from OCP eg Menorrhagia / Endometriosis / Fibroids
  2. Need for prevention of Sexually Transmitted Infections (STI’s)
4. 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).
35
Q

What are the Risks for Venous thrombo-embolism associated with HRT

A

Oral oestrogens undergo first pass metabolism in liver
Oral&raquo_space; Increase SHBG, Triglycerides, CRP

Transdermal estrogens are safer for VTE risk than oral Avoid oral oestrogens in BMI > 30 kg/m2

36
Q

What are the cancer risks associated with HRT?

A

Breast Cancer
Slight increase 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

Ovarian cancer- Small increase in risk after long-term use. Endometrial Cancer-
Must prescribe Progestogens in all women with an endometrium !
Progestogens: synthetic progestins
and the natural hormone progesterone.

37
Q

When would you assess HRT efficacy?

A

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

38
Q

What are the cardiovascular risks associated with HRT?

A

No increased risk if started before age 60 yrs
Increased risk if started 10 years after menopause
Possible benefits of oestrogen supplementation in young women e.g. Premature Ovarian Insufficiency (POI)

  1. Risk of Stroke (cerebrovascular disease)
    Small increased risk
    Oral > transdermal oestrogens
    Combined > oestrogen only
39
Q

What are the benefits of HRT?

A

Relief of low oestrogen symptoms

Less osteoporosis related fractures

40
Q

What is the treatment for transgender transition?

A

Prepubertal Young people – GnRH agonist for pubertal suppression and then sex steroids.
Post-treatment regret 1-2%
Gender Reassignment surgery after 1-2 yrs of hormonal treatment

Masculinising Hormones for Transgender Men:
Testosterone (injections, gels)
(S/E: Polycythaemia, lower HDL, Obstructive Sleep Apnoea (OSA). No increase in CVD).

Progesterone to suppress menstrual bleeding if needed (endometrial hyperplasia 15%)

In 1 to 6 months:
Balding (depending on your age and family pattern)
Deeper voice / Acne / Increased and coarser facial and body hair
Change in the distribution of your body fat
Enlargement of the clitoris
Menstrual cycle stops
Increased muscle mass and strength

41
Q

What would be the feminising hormones for Transgender women?

A
  1. Estrogen (transdermal, oral, intramuscular)
    High dose oestrogen eg 4-5mg per day to aim for estradiol levels of 734 pmol/L.
    (Side Effects: VTE dose-related at 2.6%, high BP, Cardio-Vascular Disease, high Triglycerides,
    hormone sensitive cancers eg breast cancer, abnormal Liver Function tests 3%)
  2. Reduce Testosterone
    GnRH agonists (induce desensitisation of HPG axis)
    Ant-Androgen medications (eg Cyproterone acetate, Spironolactone)
  • Height, voice and Adam’s apple will not change.
  • Consider Sperm Banking before starting hormone therapy.

1 TO 3 MONTHS: Decrease in sexual desire / function (including erections) / Baldness slows or may reverse
3 TO 6 MONTHS: Softer skin / Change in body fat distribution / Decrease in testicular size /
Breast development / tenderness
6 TO 12 MONTHS: Hair may become softer and finer

BRS Phase 1b (80 decks)

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