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BRS YR2 > Reproductive Treatments > Flashcards

Reproductive Treatments Flashcards

1
Q

How to diagnose low testosterone?

A

At least 2 low measurements of testosterone before 11am

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2
Q

When is testosterone replacement done?

A
  • when fertility is not desired
  • used to treat the symptoms of low testosterone
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3
Q

What are the symptoms of low testosterone?

A
  • loss of early morning erections
  • low libido
  • decreased energy
  • reduced frequency of shaving
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4
Q

What are the options for testosterone replacement?

A
  • Daily (gel - contact awareness)
  • 3 x week IM injection
  • 3 x monthly IM injection
    LESS COMMON:
  • implants
  • oral preparations
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5
Q

What needs to be monitored when on testosterone replacement therapy?

A
  • Increased haematocrit (increased risk of hyperviscosity and stroke)
  • Prostate (Prostate Specific Antigen/PSA) levels
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6
Q

How to induce spermatogenesis in primary hypogonadism?

A

Difficult to treat

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7
Q

How to induce spermatogenesis in secondary hypogonadism?

A

treat with Gonadotropins (LH and FSH)

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8
Q

How does LH induce spermatogenesis?

A

stimulates Leydig cells to increase intratesticular testosterone to much higher levels than circulation (100x)

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9
Q

How does FSH induce spermatogenesis?

A

FSH stimulates seminiferous tubule development and spermatogenesis

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10
Q

What to avoid when treating low testosterone in those desiring fertility?

A

testosterone

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11
Q

Why should you avoid using testosterone to treat those low in testosterone and desiring fertility?

A
  • additional testosterone will further lower LH/FSH
  • also will reduce spermatogenesis
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12
Q

What is the treatment for men low in testosterone desiring fertility?

A
  • hCG injections (act on LH receptors)
  • if no response after 6 months, add FSH injections
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13
Q

What are the physiological features of PCOS?

A
  • hyperandrogenism (hirstuism or acne)
  • PCO morphology on Ultrasounds
  • irregular periods
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14
Q

What can cause hypothalamic amenorrhoea?

A
  • low body weight
  • excessive exercise
  • stress
  • genetic susceptibility
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15
Q

What is the aim of ovulation induction?

A

develop one ovarian follicle (more risks multiple pregnancy) by causing a small increase in FSH

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16
Q

How to restore ovulation in Anovulatory PCOS?

A
  • lifestyle/weight loss/metformin
  • letrozole (aromatase inhibitor)
  • clomiphene (oestradiol receptor modulator)
  • FSH stimulation
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17
Q

What is the basic mechanism of action of letrozole and clomiphene?

A
  • lowers oestradiol
  • decreased negative feedback for the hypothalamus and pituitary gland
  • therefore, increase FSH and LH
  • high FSH stimulates follicle growth
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18
Q

What is the process of IVF?

A
  1. oocyte retrival
  2. fertilisation in vitro
  3. embryo incubation
  4. embryo transfer
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19
Q

What are the two main things involved in hormone therapy for transgender women?

A
  • Oestrogen
  • reduce testosterone
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20
Q

How is Oestrogen administered for transgender women?

A
  • transdermal, oral and IM
  • high dose (4-5mg/day)
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21
Q

What are the side effects of administering Oestrogen for transgender women?

A
  • VTE
  • hypertension
  • CVD
  • high triglycerides
  • hormone sensitive cancers (breast)
  • abnormal liver function tests (3%)
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22
Q

How is testosterone reduced in transgender women?

A
  • GnRH agonists (induces desensitisation of HPG axis)
  • Anti-Androgen medications
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23
Q

What is given to transgender individuals pre puberty?

A

GnRH agonist to supress puberty, and then sex steroids

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24
Q

What is the rate of regret post hormone therapy?

A

1-2%

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25
Q

When is gender reassignment surgery an option?

A

after 1-2 years of hormonal therapy

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26
Q

What masculinising hormones are given to transgender men?

A

testosterone (injections or gels)

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27
Q

What are the side-effects of giving testosterone to trans men?

A
  • polycythaemia
  • lower HDL
  • Obstructive sleep apnoea (OSA)
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28
Q

What can be given to suppress menstrual bleeding in trans men?

A
  • progesterone
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29
Q

What is the risk of taking progesterone to stop menstrual bleeding in trans men?

A

endometrial hyperplasia (15%)

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30
Q

What is gender?

A
  • social construct
  • male, female or non-binary
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31
Q

What is sex?

A
  • biological sex
  • male, female or intersex
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32
Q

What is cisgender?

A

same sex and gender

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33
Q

What is gender non-conforming?

A

gender and assigned sex do NOT match

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34
Q

What is gender dysphoria?

A

When gender and sex are mismatched and causes distress

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35
Q

What is non-binary?

A
  • gender doesn’t match traditional binary gender

- includes: agender, bigender, pangender and gender fluid

36
Q

What is transgender?

A

transitioning or planning to transition physical appearance from one gender to another

37
Q

What is the general prevalence of transgender individuals?

A
  • trans women 3 x more common than trans men
38
Q

What are the benefits of HRT?

A
  • relief of low oestrogen symptoms
    (flushing, disturbed sleep, low libido, low mood)
  • less osteoporosis related fractures
    (reduced by a third)
39
Q

What are the risks of HRT?

A
  • VTE (DVT or PE)
  • Hormone-sensitive cancers
  • Increased risk (if started 10 years post menopause)
  • Risk of stroke (CVD)
40
Q

What MUST be an adjunct prescription during HRT if an endometrium is present?

A
  • progestogens
41
Q

What are progestogens?

A

synthetic progestins and the natural hormone progesterone

42
Q

How to assess HRT safety and efficacy?

A
  • at 3 months, then annually
  • unscheduled bleeding is common in first 3 months
  • post-menopausal bleeding could indicate endometrial cancer
43
Q

Who does the increased risk of CVD in HRT apply to?

A
  • if started 10 years post menopause
  • NO increased risk if started pre-60yo
  • possible benefits of oestrogen supplementation in young women (POI)
44
Q

What is the increased risk of stroke in HRT associated with?

A
  • small increased risk
  • risk higher in oral than transdermal oestrogens
  • risk higher in combined than oestrogen only
45
Q

What proportion of pregnancies are unplanned?

A

19-30%

46
Q

What are the temporary methods of birth control?

A
  • barrier (condom, diaphragm/cap with spermacide)
  • combined oral contraceptive pill (OCP)
  • progestogen-only pill (POP)
  • long acting reversible contraception (LARC)
  • emergency contraception
47
Q

What are the permanent methods of birth control?

A
  • vasectomy
  • female sterilisation
48
Q

What are the positives of condoms?

A
  • STI protection
  • easy to obtain
  • no contraindications
49
Q

What are the negatives of condoms?

A
  • interrupts sex
  • reduced sensation
  • interferes with erections
  • requires skill to use
  • two are not better than one
50
Q

What is the impact of the Combined Oral Contraceptive pill (OCP) on the HPG axis?

A
  • 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
51
Q

What are the positives of the OCP?

A
  • 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)
52
Q

What are the negatives of the OCP?

A
  • difficult to remember
  • no STI protection
  • P450 enzyme inducers may reduce efficacy
  • not great while breastfeeding
53
Q

What are the possible side effects of taking the OCP?

A
  • 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)
54
Q

What are the non-contraceptive uses of the OCP?

A 
- lighter and less painful periods 
(endometriosis, period pain or menorhagia)
- regular withdrawal bleeds
PCOS
- reduce LH and hyperandrogenism
55
Q

What are the positives of the Progesterone Only pill (POP)?

A
  • 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
56
Q

What are the negatives of taking the POP?

A
  • difficult to remember
  • no STI protection
  • short acting, needs to be taken at the same time everyday
  • less reliably inhibits ovulation
57
Q

What are the possible side effects of the POP?

A
  • irregular bleeding
  • headaches
  • sore breasts
  • mood changes
  • sex drive changes
58
Q

What does Nulliparous mean?

A

no previous children

59
Q

When are Coils suitable?

A
  • for most women
  • emergency contraception
60
Q

Why are coils not preferred in some religions?

A

prevents the implantation of the conceptus

61
Q

What is the main risk involved in coils?

A

can cause ectopic pregnancy

62
Q

How do IUDs work?

A
  • mechanically prevent implantation
  • decreases sperm-egg survival
  • lasts 5-10 years
63
Q

What are the negatives of IUDs?

A
  • can cause heavy periods
  • 5% come out, particularly during the first 3 months
64
Q

What are Intra-uterine systems (IUS)?

A
  • coils that secrete progesterone (mirena coil)
65
Q

How do IUSs work?

A

progesterone secretion thins the lining of the womb and thickens cervical mucus

66
Q

What are the benefits of using an IUS?

A
  • help with heavy bleeding
  • lasts 3-5 years
67
Q

What are the 3 main types of Long-Acting Reversible Contraceptives (LARC)?

A
  • IUD
  • IUS
  • progestogen-only injectable contraceptives or subdermal implants
68
Q

What is the most effective emergency contraceptive?

A
  • copper IUD
  • can be fitted 5 days after unprotected sex
  • < 1% chance of pregnancy
69
Q

What are the 2 types of emergency contraceptive pill?

A 
MOST EFFECTIVE:
- Ulipristal Acetate 30mg (ellaOne)
LEAST EFFECTIVE
(BMI>27)
- Levonogestrel 1.5mg (Levonelle)
70
Q

How does Ulipristal Acetate work?

A
  • stops progesterone working, prevents ovulation
  • must be taken within 5 days (the earlier the better)
71
Q

How does Levonogestrel work?

A
  • synthetic progesterone prevents ovulation (no abortion)
  • must be taken within 3 days
72
Q

What are the side-effects of the morning-after pill?

A
  • 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
73
Q

What needs to be considered when choosing a contraceptive?

A
  • Risk of VTE/CVD/stroke
  • Other conditions that will benefit from OCP
    (menorrhagia/endometriosis/fibroids)
  • Need for STI protection
  • Concurrent medication
  • ease of use
74
Q

How to assess the risk of VTE/CVD/stroke when choosing a contraceptive?

A

AVOID OCP IF:

  • Migraine with aura (stroke)
  • Smoking (>15/day) + age (>35yo)
  • Stroke or CVD history
  • Current breast cancer
  • Liver Cirrhosis
  • Diabetes with complications
75
Q

What concurrent medication should you be aware of when choosing a contraceptive?

A
  • P450 liver enzyme-inducing drugs (anti-epileptics, antibiotics)
  • Teratogenic drugs (lithium, warfarin)
    Consider LARCs NOT the PILL
76
Q

What are the benefits of HRT?

A
  • relief of low oestrogen symptoms
  • (flushing, disturbed sleep, low libido, low mood)
  • less osteoporosis related fractures (reduced by a third)
77
Q

What are the risks of HRT?

A
  • VTE (DVT or PE)
  • Hormone-sensitive cancers
  • Increased risk (if started 10 years post menopause)
  • Risk of stroke (CVD)
78
Q

Why is there an increased risk of VTE with HRT?

A

Oral oestrogens undergo first pass metabolism in liver and increase clotting factors

79
Q

What can reduce the risk of VTE in HRT?

A
  • Transdermal estrogens are safer for VTE
  • Avoid oral oestrogens in BMI > 30 kg/m2
80
Q

Which cancers have an increased risk in HRT?

A

Breast, ovarian and endometrial

81
Q

When is breast cancer risk increased in HRT?

A
  • 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
82
Q

When is ovarian cancer risk increased in HRT?

A

Small Increase in risk after long-term use.

83
Q

When is endometrial cancer risk increased in HRT?

A
  • when progestogens aren’t prescribed to women with their womb still intact
84
Q

What can post-menopausal bleeding indicate?

A

endometrial cancer

85
Q

What is ICSI and when is it done?

A
  • intra-cytoplasmic sperm injection
  • direct injection of a single sperm into the egg
  • done when there is male factor failure/insufficiency

BRS YR2 (67 decks)

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