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Endocrinology > Reproductive Treatments > Flashcards

Reproductive Treatments Flashcards

1
Q

If not desiring fertility - male

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.

Testosterone Replacement: 
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)

Safety Monitoring:
Increased Haematocrit (risk of hyperviscosity and stroke)
Prostate (Prostate Specific Antigen (PSA) levels)

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2
Q

Desiring fertility - male

A

Primary Hypogonadism- difficult to treat

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

Give hCG injections (which act on LH-receptors)
If no response after 6 months, then add FSH injections.

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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3
Q

Polycystic Ovary Syndrome (PCOS) and Hypothalamic Amenorrhoea

A

PCOS - hyperandrogenism and PCO morphology

HA - low body weight, stress, genetic, excessive exercise

Both have irregular periods

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4
Q

Ovulation induction

A

Aim to develop one ovarian follicle

If >1 follicle develops, this risks multiple pregnancy (ie Twin / Triplet)

Multiple pregnancy has risks for mother and baby during pregnancy

Ovulation induction methods aim to cause small increase in FSH

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5
Q

Restore Ovulation

A
  1. Lifestyle / Weight Loss / Metformin
  2. Letrozole (Aromatase inhibitor)
  3. Clomiphene (Oestradiol receptor modulator)
  4. FSH stimulation
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6
Q

Letrozole

A

Aromatase inhibitor

Blocks conversion of testosterone to oestradiol

Oestradiol normally causes negative feedback on Hypothalamus and Pituitary Gland

Decreases negative feedback, thus increasing GnRH and increased FSH

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7
Q

Clomiphene

A

Oestradiol Receptor Antagonist

Decreased negative feedback to hypothalamus and anterior pituitary, thus increased FSH

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8
Q

IVF

A

Inject FSH to stimulate multiple follicles produced

Fertilisation in vitro naturally by putting sperm with eggs in dish or intracytoplasmic sperm injection where sperm is injected into egg (when male factor is also included)

Embryo incubation

Embryo transfer into uterus

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9
Q

Prevent premature ovulation

A

Suppress LH surge

Short protocol - GnRH antagonist started day 6, FSH started day 2 of menstruation cycle

Long protocol - GnRH agonist started day -7, FSH started day 2

GnRH is pulsatile, if given continuously there is an initial LH flare but then LH level flattens and inhibition

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10
Q

Induce egg maturation

A

Expose to LH

From diploid in metaphase I to haploid in metaphase II

Use hCG
Second commonest is GnRH agonist

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11
Q

Contraception methods

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

Vasectomy
Female sterilisation

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12
Q

Condoms (Barrier Contraception)

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

Can interrupt sex
Can reduce sensation    
Can interfere with erections 
Some skill to use eg correct fit.
Two are not better than one
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13
Q

Oral contraceptive pill mechanism

A

Oestrogen and progesterone negatively feedback to hypothalamus and pituitary - decreasing FSH and LH - anovulation

Progesterone also thicken cervical mucus and thin endometrial lining - reduce implantation

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14
Q

Combined Oral Contraceptive Pill (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)

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

Possible side effects:
Spotting (bleeding in between periods)
Nausea
Sore breasts
Changes in mood or libido 
Feeling more hungry (try different OCPs to see which suits best)

Extremely rare side effects:
Blood clots in the legs or lungs (2 in 10,000)

Non-contraceptive uses:
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

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15
Q

Progesterone Only Pill (POP)

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

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

Possible side effects
 Irregular bleeding
 Headaches
 Sore breasts
 Changes in mood
 Changes in sex drive
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16
Q

Long-Acting Reversible Contraceptives (LARC)

A

Coils are suitable for most women incl Nulliparous (no previous children).
Exclude STI’s and cervical screening up to date before insertion
Prevent implantation of conceptus – important for some religions
Rarely can cause ectopic pregnancy
Can be used as emergency contraception

  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
17
Q

Emergency Contraception

A

Morning After Pill & IUD

  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.

18
Q

Considerations for Choice of 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).
19
Q

Risks of HRT

A
  1. Venous Thrombo-embolism: Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)
    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
  2. Hormone Sensitive Cancers:
    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.

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

  1. Concern about increased risk of Cardiovascular disease
    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)
  2. Risk of Stroke (cerebrovascular disease)
    Small increased risk
    Oral > transdermal oestrogens
    Combined > oestrogen only
20
Q

Benefits of HRT

A

Relief of symptoms of low oestrogen eg Flushing, disturbed sleep, decreased libido, low mood

Less osteoporosis related fractures - decreased by one third

21
Q

Masculinising Hormones for Transgender Men

A

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

22
Q

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.
  2. Reduce Testosterone
    GnRH agonists (induce desensitisation of HPG axis)
    Anti-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

23
Q

Gender does not match assigned sex

A

Gender non-conforming

24
Q

when gender non-conforming causes distress

A

Gender Dysphoria

25
Q

Gender does not match to traditional binary gender understanding, includes agender, bigender, pangender, gender fluid

A

Non-binary

26
Q

POC differential

A

Hypothalamic amenorrhoea

Endocrinology (13 decks)

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