Reproductive Treatments Flashcards
How to diagnose low testosterone?
At least 2 low measurements of testosterone before 11am
When is testosterone replacement done?
- when fertility is not desired
- used to treat the symptoms of low testosterone
What are the symptoms of low testosterone?
- loss of early morning erections
- low libido
- decreased energy
- reduced frequency of shaving
What are the options for testosterone replacement?
- Daily (gel - contact awareness)
- 3 x week IM injection
- 3 x monthly IM injection
LESS COMMON: - implants
- oral preparations
What needs to be monitored when on testosterone replacement therapy?
- Increased haematocrit (increased risk of hyperviscosity and stroke)
- Prostate (Prostate Specific Antigen/PSA) levels
How to induce spermatogenesis in primary hypogonadism?
Difficult to treat
How to induce spermatogenesis in secondary hypogonadism?
treat with Gonadotropins (LH and FSH)
How does LH induce spermatogenesis?
stimulates Leydig cells to increase intratesticular testosterone to much higher levels than circulation (100x)
How does FSH induce spermatogenesis?
FSH stimulates seminiferous tubule development and spermatogenesis
What to avoid when treating low testosterone in those desiring fertility?
testosterone
Why should you avoid using testosterone to treat those low in testosterone and desiring fertility?
- additional testosterone will further lower LH/FSH
- also will reduce spermatogenesis
What is the treatment for men low in testosterone desiring fertility?
- hCG injections (act on LH receptors)
- if no response after 6 months, add FSH injections
What are the physiological features of PCOS?
- hyperandrogenism (hirstuism or acne)
- PCO morphology on Ultrasounds
- irregular periods
What can cause hypothalamic amenorrhoea?
- low body weight
- excessive exercise
- stress
- genetic susceptibility
What is the aim of ovulation induction?
develop one ovarian follicle (more risks multiple pregnancy) by causing a small increase in FSH
How to restore ovulation in Anovulatory PCOS?
- lifestyle/weight loss/metformin
- letrozole (aromatase inhibitor)
- clomiphene (oestradiol receptor modulator)
- FSH stimulation
What is the basic mechanism of action of letrozole and clomiphene?
- lowers oestradiol
- decreased negative feedback for the hypothalamus and pituitary gland
- therefore, increase FSH and LH
- high FSH stimulates follicle growth
What is the process of IVF?
- oocyte retrival
- fertilisation in vitro
- embryo incubation
- embryo transfer
What are the two main things involved in hormone therapy for transgender women?
- Oestrogen
- reduce testosterone
How is Oestrogen administered for transgender women?
- transdermal, oral and IM
- high dose (4-5mg/day)
What are the side effects of administering Oestrogen for transgender women?
- VTE
- hypertension
- CVD
- high triglycerides
- hormone sensitive cancers (breast)
- abnormal liver function tests (3%)
How is testosterone reduced in transgender women?
- GnRH agonists (induces desensitisation of HPG axis)
- Anti-Androgen medications
What is given to transgender individuals pre puberty?
GnRH agonist to supress puberty, and then sex steroids
What is the rate of regret post hormone therapy?
1-2%
When is gender reassignment surgery an option?
after 1-2 years of hormonal therapy
What masculinising hormones are given to transgender men?
testosterone (injections or gels)
What are the side-effects of giving testosterone to trans men?
- polycythaemia
- lower HDL
- Obstructive sleep apnoea (OSA)
What can be given to suppress menstrual bleeding in trans men?
- progesterone
What is the risk of taking progesterone to stop menstrual bleeding in trans men?
endometrial hyperplasia (15%)
What is gender?
- social construct
- male, female or non-binary
What is sex?
- biological sex
- male, female or intersex
What is cisgender?
same sex and gender
What is gender non-conforming?
gender and assigned sex do NOT match
What is gender dysphoria?
When gender and sex are mismatched and causes distress
What is non-binary?
- gender doesn’t match traditional binary gender
- includes: agender, bigender, pangender and gender fluid
What is transgender?
transitioning or planning to transition physical appearance from one gender to another
What is the general prevalence of transgender individuals?
- trans women 3 x more common than trans men
What are the benefits of HRT?
- relief of low oestrogen symptoms
(flushing, disturbed sleep, low libido, low mood) - less osteoporosis related fractures
(reduced by a third)
What are the risks of HRT?
- VTE (DVT or PE)
- Hormone-sensitive cancers
- Increased risk (if started 10 years post menopause)
- Risk of stroke (CVD)
What MUST be an adjunct prescription during HRT if an endometrium is present?
- progestogens
What are progestogens?
synthetic progestins and the natural hormone progesterone
How to assess HRT safety and efficacy?
- at 3 months, then annually
- unscheduled bleeding is common in first 3 months
- post-menopausal bleeding could indicate endometrial cancer
Who does the increased risk of CVD in HRT apply to?
- if started 10 years post menopause
- NO increased risk if started pre-60yo
- possible benefits of oestrogen supplementation in young women (POI)
What is the increased risk of stroke in HRT associated with?
- small increased risk
- risk higher in oral than transdermal oestrogens
- risk higher in combined than oestrogen only
What proportion of pregnancies are unplanned?
19-30%
What are the temporary methods of birth control?
- barrier (condom, diaphragm/cap with spermacide)
- combined oral contraceptive pill (OCP)
- progestogen-only pill (POP)
- long acting reversible contraception (LARC)
- emergency contraception
What are the permanent methods of birth control?
- vasectomy
- female sterilisation
What are the positives of condoms?
- STI protection
- easy to obtain
- no contraindications
What are the negatives of condoms?
- interrupts sex
- reduced sensation
- interferes with erections
- requires skill to use
- two are not better than one
What is the impact of the Combined Oral Contraceptive pill (OCP) on the HPG axis?
- negative feedback on hypothalamus and pituitary gland by progesterone and oestrogen
- decreased GnRH
- decreased LH and FSH
- anovulation
- thickening of cervical mucus
- thinning of endometrial lining to reduce implantation
What are the positives of the OCP?
- easy to take (1 x daily, any time)
- effective
- can take several packets back to back, avoid withdrawal bleeds
- reduce ovarian and endometrial cancer
- weight neutral in 80% (10% gain, 10% lose)
What are the negatives of the OCP?
- difficult to remember
- no STI protection
- P450 enzyme inducers may reduce efficacy
- not great while breastfeeding
What are the possible side effects of taking the OCP?
- spotting (in between periods)
- nausea
- sore breasts
- changes in mood and libido
- increased hunger
EXTREMELY RARE - blood clots in legs or lungs (2/10,000)
What are the non-contraceptive uses of the OCP?
- lighter and less painful periods (endometriosis, period pain or menorhagia) - regular withdrawal bleeds PCOS - reduce LH and hyperandrogenism
What are the positives of the Progesterone Only pill (POP)?
- easy to take (1 x daily)
- help heavy/painful periods
- possibly stop periods
- can be used while breastfeeding
- suitable when you can’t take oestrogens
What are the negatives of taking the POP?
- difficult to remember
- no STI protection
- short acting, needs to be taken at the same time everyday
- less reliably inhibits ovulation
What are the possible side effects of the POP?
- irregular bleeding
- headaches
- sore breasts
- mood changes
- sex drive changes
What does Nulliparous mean?
no previous children
When are Coils suitable?
- for most women
- emergency contraception
Why are coils not preferred in some religions?
prevents the implantation of the conceptus
What is the main risk involved in coils?
can cause ectopic pregnancy
How do IUDs work?
- mechanically prevent implantation
- decreases sperm-egg survival
- lasts 5-10 years
What are the negatives of IUDs?
- can cause heavy periods
- 5% come out, particularly during the first 3 months
What are Intra-uterine systems (IUS)?
- coils that secrete progesterone (mirena coil)
How do IUSs work?
progesterone secretion thins the lining of the womb and thickens cervical mucus
What are the benefits of using an IUS?
- help with heavy bleeding
- lasts 3-5 years
What are the 3 main types of Long-Acting Reversible Contraceptives (LARC)?
- IUD
- IUS
- progestogen-only injectable contraceptives or subdermal implants
What is the most effective emergency contraceptive?
- copper IUD
- can be fitted 5 days after unprotected sex
- < 1% chance of pregnancy
What are the 2 types of emergency contraceptive pill?
MOST EFFECTIVE: - Ulipristal Acetate 30mg (ellaOne) LEAST EFFECTIVE (BMI>27) - Levonogestrel 1.5mg (Levonelle)
How does Ulipristal Acetate work?
- stops progesterone working, prevents ovulation
- must be taken within 5 days (the earlier the better)
How does Levonogestrel work?
- synthetic progesterone prevents ovulation (no abortion)
- must be taken within 3 days
What are the side-effects of the morning-after pill?
- liver P450 enzyme inducer medications makes it less effective
- if vomit within 2-3 hours of taking it, need to take another one
- headache
- abdominal pain
- nausea
What needs to be considered when choosing a contraceptive?
- Risk of VTE/CVD/stroke
- Other conditions that will benefit from OCP
(menorrhagia/endometriosis/fibroids) - Need for STI protection
- Concurrent medication
- ease of use
How to assess the risk of VTE/CVD/stroke when choosing a contraceptive?
AVOID OCP IF:
- Migraine with aura (stroke)
- Smoking (>15/day) + age (>35yo)
- Stroke or CVD history
- Current breast cancer
- Liver Cirrhosis
- Diabetes with complications
What concurrent medication should you be aware of when choosing a contraceptive?
- P450 liver enzyme-inducing drugs (anti-epileptics, antibiotics)
- Teratogenic drugs (lithium, warfarin)
Consider LARCs NOT the PILL
What are the benefits of HRT?
- relief of low oestrogen symptoms
- (flushing, disturbed sleep, low libido, low mood)
- less osteoporosis related fractures (reduced by a third)
What are the risks of HRT?
- VTE (DVT or PE)
- Hormone-sensitive cancers
- Increased risk (if started 10 years post menopause)
- Risk of stroke (CVD)
Why is there an increased risk of VTE with HRT?
Oral oestrogens undergo first pass metabolism in liver and increase clotting factors
What can reduce the risk of VTE in HRT?
- Transdermal estrogens are safer for VTE
- Avoid oral oestrogens in BMI > 30 kg/m2
Which cancers have an increased risk in HRT?
Breast, ovarian and endometrial
When is breast cancer risk increased in HRT?
- Slight increase 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
When is ovarian cancer risk increased in HRT?
Small Increase in risk after long-term use.
When is endometrial cancer risk increased in HRT?
- when progestogens aren’t prescribed to women with their womb still intact
What can post-menopausal bleeding indicate?
endometrial cancer
What is ICSI and when is it done?
- intra-cytoplasmic sperm injection
- direct injection of a single sperm into the egg
- done when there is male factor failure/insufficiency
