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Phase 1b - Endocrinology > Reproductive Treatments > Flashcards

Reproductive Treatments Flashcards

1
Q

What is the treatment of a testosterone deficiency in a male not desiring fertility?

A

Testosterone replacement:
* Daily Gel. Care not to contaminate partner.
* 3 weekly intramuscular injection
* 3 monthly intramuscular injection
* Less Common (Implants, oral preparations)

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2
Q

When is testosterone replacement recommended?

A

To treat men with low testosterone (Hypogonadism)
* Investigate the cause of low testosterone

Treat Symptoms:
* Loss of early morning erections
* Libido
* Decreased energy
* Shaving

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3
Q

How can one confirm male hypogonadism?

A

Confirm at least 2 low fasting measurements of serum testosterone in morning

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4
Q

What are the associated risks with testosterone replacement therapy?

A
  • Increased haematocrit (risk of hypervicsosity and stroke) due to stimulation of erythropoietin (EPO) receptors
  • Measure prostate specific antigen (PSA) levels
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5
Q

What is the treatment of a testosterone deficiency in a male desiring fertility?

A
  • Gonadotrophins (i.e. LH and FSH) needed to induce spermatogenesis
    • hCG injections (which act on LH-receptors)
    • If no response after 6 months, then add FSH injections

Secondary Hypogonadism: deficiency of gonadotrophins (LH/FSH)

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6
Q

What is the use of a LH treatment in a male desiring fertility?

A

LH stimulates Leydig cells to increases intratesticular testosterone levels much higher than in circulation (x100)

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7
Q

Which receptors do HCG injections stimulate?

A
  • LH receptors on Leydig cells
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8
Q

What is the use of an FSH treatment in a male desiring fertility?

A

FSH stimulates seminiferous tubule development & spermatogenesis

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9
Q

How is ovulation restored in patients living with Polycystic Ovary Syndrome (PCOS) (5)?

A
  • Lifestyle / Weight Loss 5%
  • Metformin
  • Letrozole (Aromatase inhibitor)
  • Clomiphene (Oestradiol receptor modulator)
  • FSH stimulation
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10
Q

How is ovulation restored in patients living with hypothalamic amenorrhoea (5)?

A
  • Lifestyle / Weight gain / reduce exercise
  • Pulsatile GnRH pump
  • FSH stimulation
  • Letrozole (Aromatase inhibitor)
  • Clomiphene (Oestradiol receptor modulator)
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11
Q

Why should one avoid giving testosterone treatment to men desiring fertility?

A

Giving testosterone treatment could further reduce LH / FSH via negative feedbackand worsen spermatogenesis

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12
Q

What are the steps of invitro fertilisation (IVF) (6)?

A
  1. FSH stimulation (superovulation)
    • Egg retrieval
  2. Prevent premature ovulation, by preventing a premature LH surge
    • Use GnRH antagonist
  3. Exposure of cell to LH, leading to maturation of egg
  4. Fertilisation in vitro
  5. Egg maturation
  6. Implantation
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13
Q

What is the aim of ovulation induction?

A

Aim to develop one ovarian follicle, to increase FSH by a small amount

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14
Q

Upon egg retrieval which hormone is exposed to the eggs for maturation?

A
  • LH
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15
Q

Which hormone is used to trigger egg maturation?

A

hCG

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16
Q

If there is a male factor of infertility how does IVF take place?

A
  • Intra-cytoplasmic injection of sperm (ICSI)
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17
Q

What are the common forms of contraception (Male 2 / Female 6)?

A
  • Male:
    • Barrier:
      • Condom
    • Permanent:
      • Vasectomy
  • Female:
    • Barrier:
      • Diaphragm or cap with spermicide
    • Medication:
      • Combined oral contraceptive pill (OCP)
      • Progesterone-only (Pill)
    • Long acting reversible contraception (LARC)
    • Emergency contraception
    • Permanent: Hysterectomy / Salpinectomy
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18
Q

What are the advantages of condoms (3)?

A
  • Protection against STIs
  • Easy to obtain - free from clinics / No need to see a healthcare professional
  • No contra-indications
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19
Q

What are the disadvantages of condoms (4)?

A
  • Can interrupt sex
  • Can reduce sensation
  • Can interfere with erections
  • Some skill to use
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20
Q

What hormones are within the oral contraceptive pill?

A
  • Oestrogen and progesterone
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21
Q

How do combined oral contraceptive pills work?

A
  • Anovulation
    • Progesterone causes the thickening of the cervical mucous, prevent sperm penetration, and thinning of the endometrial lining to reduce implantation
    • Oestrogen exerts negative feedback on GnRH hypothalamic neurones and gonadotrophs within the pituitary gland, this reduced LH and FSH secretion leading to anovulation
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22
Q

What are the contraceptive benefits of using OCPs (6)?

A
  • Easy to take - one pill a day (any time of the day)
  • Effective
  • Can take several packets back-to-back and avoid withdrawl bleeds
  • Doesn’t interrupt sex
  • Reduce endometrial and ovarian cancer
  • Weight neutral in 80%
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23
Q

What are the disadvantages of using OCPs (5)?

A
  • 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
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24
Q

What are the possible side effects of using OCPs (6)?

A
  • Spotting (bleeding between periods)
  • Nausea
  • Sore breasts
  • Changes in mood or libido
  • Feeling more hungry
  • Extremely rare: Blood clots in the legs or lungs
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25
In what comorbidities should OCP be avoided because of risk of venous thromboembolism (VTE) / CVD / Stroke (6)?
* **Migraine with aura** (Risk of stroke) * **Smoking** (\> 15 / day) + **age** \> 35 years * Stroke or **CVD** history * Current breast **cancer** * **Liver cirrhosis** * **Diabetes** with retinopathy / nephropathy / neuropathy
26
What are the non-contraceptive benefits of using OCPs (3)?
* Help **reduce LH and hyperandrogenism** * PCOS * Helps makes **periods lighter and less painful** * Endometriosis / Fibroids * Menorrhagia / Dysmenorrhoea * Regular Withdrawal Bleeds / or no Bleeds
27
Which enzymes reduce the efficacy of oral contraceptive piill?
P450
28
What are the advantages of progesterone only pill (POP) (7)?
* Works as OCP but **less reliably inhibits ovulation** * Often **suitable** if one cannot take oestrogen * **Easy to tak****e** - one pill a day * It **doesn't interrupt sex** * Can **help** heavy & painful periods * Periods may **stop** temporarily * Can be used during **breastfeeding**
29
What are the disadvantages of progesterone only pill (POP) (4)?
* Can be **difficult to remember** * **No protection** against STIs * **Short acting** - needs to be taken at the same time every day * **Possible side effects**
30
What are the possible side effects of progesterone only pill (POP) (5)?
* **Irregular bleeding** * **Headaches** * Changes in **mood** * Changes in **libido** * **Sore breasts**
31
Which contraceptive pill can be used by breastfeeding women?
* Progesterone only pill
32
What are the 3 forms of long-acting reversible contraceptives (LARCs) for women?
* **Intra-uterine device (IUD)** (copper coil) * **Intra-uterine system (IUS)** which secretes progesterone (Mirena coil) * **Progesterone-only** injectable contraceptives or subdermal implants
33
What are the benefits with using a coil (IUD / IUS)?
* Coils are **suitable for most women** including Nulliparous (no previous children) * **Exclude STIs 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**
34
What are IUDs?
Copper coils that mechanically prevent implantation and decrease sperm egg survival (lasts 5-10 years)
35
What are the advantages of IUD (3)?
* Mechanically prevent implantation * Decreases sperm / egg survival * Lasts 5-10 years
36
What are the disadvantages of IUD (2)?
* Can cause heavy periods * 5% can come out especially during first 3 months with period
37
What is the main risk with using an IUD?
* Can cause **heavy periods** and **5% come out during the first 3 months**
38
What is an IUS?
* An **intra-uterine system** which secretes **progesterone** (Mirena coil), thinning the lining of the womb and thickens cervical mucous
39
What are the advantages of IUS (3)?
* Thinning lining of the womb * Thicken cervical mucus * Lasts 3-5 years
40
What are the three forms of emergency contraception?
* **IUD** * Pill - **Ulipristal acetate** * **Levonorgestrel**
41
What is the most effective emergency contraception?
* Copper intrauterine device **(IUD)**
42
Which emergency contraception is least effective?
* Levonorgestrel, least effective especially if the BMI \> 27
43
How can copper coils be used as emergency contraception?
Can be fitted up to 5 days after unprotected sex (\<1% chance of pregnancy)
44
What is within an emergency contraceptive pill?
* **Ulipristal acetate 30mg**
45
What are the side effects with using the morning after pill (4)?
* **Headache** * **Abdominal pain** * **Nausea** * Can **vomit** within 2-3 hours of taking it - may need to take another
46
How does the emergency contraceptive pill work?
Delays ovulation
47
Which types of medications makes taking the emergency contraceptive pill ineffective (2)?
* Liver **p450 enzyme inducer** * **Tetrogenic** (lithium or warfarin) **drugs**
48
Until how many days after unprotected intercourse, does the morning after pill become ineffective?
5 days
49
What is levonorgestrel?
* **Synthetic progesterone** prevents ovulation * Taken within 3 days of unprotected intercourse for emergency contraception
50
What is levonelle, emergency contraceptive pill?
* **Synthetic progesterone prevents ovulation**, must be taken within 3 days of unprotected intercourse
51
What are the benefits of HRT (5)?
* **Relief of symptoms of low oestrogen** * **​**Flushing * Disturbed sleep * Decreased libido * Low mood * **Less osteoporosis** (decreased by one third)
52
What are the risks with hormone replacement therapy (3)?
* **Venous thrombo-embolism (VTE)** - **​**Deep vein thrombosis / Pulmonary embolism 1. Oral oestrogens undergo first pass metabolism in liver 2. Oral can increase SHBG, triglycerides and CRP * **Hormone sensitive cancers** * **​**Breast cancer * Ovarian cancer * Endometrial cancer * **CVD** * **Risk of Stroke**
53
Which is the most preferable form of HRT?
* **Transdermal oestrogens** ## Footnote Transdermal estrogens are safer for VTE risk than oral Avoid oral oestrogens in BMI > 30 kg/m2
54
Above what BMI range are oral oestrogen not recommended?
* **\> 30kg/m2**
55
In what age group is the risk of cardiovascular disease greater with the use of HRT?
* Above the age of 60 * Increased risk if HRT is started 10 years after menopause
56
Which is the highest risk associated with oestrogen only HRT?
* **Endometrial cancer**
57
What supplement reduces the risk of endometrial cancer in HRT?
* Prescribe **progestogens** in all women with an endometrium
58
Which type of HRT increases the risk of breast cancer?
* **Continuous combined HRT** (oestrogen and progesterone) * Risk is related to duration of treatment
59
Which is the highest risk associated with combined oral HRT?
* **Breast cancer**
60
What is gender?
Social Construct, how you see yourself as male, female, or non-binary
61
What is non-binary?
* Gender does not match to traditional binary gender understanding. Includes agender, bigender, pangender, and gender fluid
62
What is cisgender?
* Same sex and gender
63
What is gender non-confirming?
* Gender does not match assigned sex
64
What is gender dysphoria?
* When gender causes depression
65
What is the management for prepubertal young people undergoing gender transformation?
* **GnRH agonist** for pubertal suppression and then **sex steroids** * **Gender reassignment surgery**
66
What hormones are given to transgender men?
* **Testosterone** (injections, gels) * **Progesterone** to suppress menstrual bleeding if needed (endometrial hyperplasia 15%)
67
Within 1 to 6 months what are the effects of hormonal therapy in transgender men (8)?
* **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**
68
What are the side effects with testosterone supplements in transgender men (3)?
* **Polycythaemia** * **Lower HDL** * **Obstructive Sleep Apnoea (OSA)** * No increase in CVD
69
What should be prescribed to transgender males to suppress menstrual bleeding?
* Progesterone
70
What hormones are given for transgender women?
* To Reduce Testosterone: * **GnRH agonists** (induce desensitisation of HPG axis) * **Anti-Androgen medications** * **Oestrogen** (transdermal, oral, intramuscular) * High dose oestrogen eg 4-5mg per day (side-effects: higher risk of VTE 2.6%)
71
How is testosterone reduced in transgender women?
* **GnRH agonists** (induce desensitisation of HPG axis) * **Anti-androgen medications** (crypterone acetate, spirnolactone)
72
What happens to transgender women during the first 3 months (2)?
* **Decrease** in **sexual** **desire / function** (erections) * **Baldness slows**
73
What happens in 3-6 months for transgender women (4)?
* **Soft skin** * Change in **body fat distribution** * **Decrease** in **testicular size** * **Breast development / tenderness**
74
What will not change in transgender women undergoing hormonal therapy (3)?
* **Height** * **Voice** * **Adam's apple**
75
How long does it take for hair to become softer and finer in transgender women?
* 6 to 12 months

Phase 1b - Endocrinology (19 decks)

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