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Y2 - BRS - Endo > Reproductive Treatments > Flashcards

Reproductive Treatments Flashcards

1
Q

What is primary hypogonadism?

How difficult is it to treat it?

A

Something directly affecting gonads

Hard to treat

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2
Q

What is the treatment aim for secondary hypogonadism? How do these improve fertility?

A

Treatments aim to stimulate spermatognesis - e.g. treat with gonadotrophins
LH = stimulates Leydig cells to increase intratesticular testosterone
FSH = stimulates spermatogenesis

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3
Q

35M - opiod abuse = suppress hypothalamus = hypogonadism

LH 3, FSH 5 iU/L
Low morning Testosterone 7 nmol/L (normal 9-30 nmol/L)
Fatigue and reduced shaving frequency.
Trying to conceive with his partner for 2 years with no success.
Sperm sample: Low sperm count i.e. ‘Male Factor’ Infertility

Should testosterone given? to improve fertility? What else could or should be given?

A

Testosterone should not be given because:
Testosterone = negative feedback = reduces LH and FSH = reduces spermatogenesis

Instead give hCG injections (act on LH receptors), then perhaps FSH injections = improve fertility

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4
Q

30M - anosmic, Kallmann’s Syndrome (XXY)

Presents seeking fertility and has been trying to conceive for 2 years.
Sperm Analysis- Low sperm count
LH 0.5, FSH 0.8, Low morning Testosterone 3 nmol/L

Is the prognosis of congenital or acquired secondary hypogonadism worse?

What is the appropriate treatment option to improve fertility?

A

Congenital = worse because no puberty, no mini puberty after birth (activation of HPG axis)

Treatment - 2-4mo of FSH to trigger mini puberty before other treatments (i.e. hCG injections)
Low testicular volume = less likely to respond to treatments

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5
Q

When is testosterone replacement given / required?

A

Not looking for fertility, just wants to improve symptoms (e.g. loss of early morning erections, libido, decreased energy, shaving)

At least 2 low measurements to serum testosterone before 11am, often fasting serum testosterone taken

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6
Q

How is testosterone replacement given?

What are some possible side effects?

A 
Daily Gel e.g. Tostran. Care not to contaminate partner.
3 weekly intramuscular injection (e.g. Sustanon)
3 monthly intramuscular injection (e.g. Nebido)
Less Common (implants, oral preparations)
Increased haematocrit (ratio of RBC vol to blood vol) - hyperviscosity and stroke
Overstimulation of the prostate
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7
Q

30F - copy off slide

Unsuccessfully trying to conceive for 3 years
Irregular periods (Oligomenorrhoea)
Hyperandrogenism (hirsutism and acne)
US Scan – Polycystic ovarian morphology
LH 8.0 iU/L, FSH 4.5 iU/L

What is her diagnosis?

A

PCOS - symptoms point to this

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8
Q

How can fertility in PCOS be improved?

A

PCOS = anovulation

Therefore try ovulation induction to increase fertility

Simulate growth of one of her ovarian follicle by:
Lifestyle / Weight Loss / Metformin, Letrozole (Aromatase inhibitor), Clomiphene (Oestradiol receptor antagonist), FSH stimulation

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9
Q

What is the purpose of the aromatase inhibitor? How does it work to increase fertility?

A

Aromatase = converts testosterone to oestrodial

So aromatase inhibitors reduce negative feedback from oestrodial on HPG axis, stimulate hypothalamus to produce more GnRH, and pituitary to release more FSH / LH which can stimulate egg release

FSH stimulates follicle growth

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10
Q

How does IVF treatment work? What are the steps of IVF?

A

High doses of FSH to stimulate follicle growth
Eggs collected outside of utero
Sperm and eggs mixed together
Or if male factor infertility, inject sperm into the egg
Incubate embryo for 3-5 days
Select 1-2 embryos, place into uterus
Hopefully results in pregnancy

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11
Q

How can egg release / ovarian stimulation be achieved through hormones?

A

FSH stimulation for superovulation

Make sure ovulation does not occur as the egg cannot be collected

Medicine prevents pre-mature LH surge, which prevents ovulation occurring too soon

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12
Q

What medication / hormone prevents premature LH surge in IVF patients?

A
  1. GnRH antagonist protocol (short protocol) = prevents ovulation happening too soon
  2. GnRH agonist protocol (long protocol) = given for much longer
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13
Q

How can both, GnRH antagonists and agonists work to prevent premature LH surge?

A

GnRH works in a pulsatile manner

Prolonged. high dose GnRH agonist = desensitisation = LH inhibition

Low dose GnRH antagonist for short time = GnRH actions suppressed

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14
Q

How can the eggs be matured in IVF treatments?

A

Prevent LH surge to allow follicles to get to the right size

But once follicles are right size, just before egg maturation (metaphase 1), give LH to make the immature egg mature (becomes haploid)

Give hCG as it acts on the LH receptors

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15
Q

What are some side effects of IVF treatment and hCG?

A

OHSS (Ovarian Hyper-Stimulation Syndrome) - exaggerated response to excess hormones

Pleural effusion
Ascites - swelling of the abdomen
Insufficient fluid in the blood = renal failure
Ovarian Torsion

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16
Q

Summarise the IVF process:

A 
FSH - stimulate follicle growth 
GnRH antagonist / agonist - prevents premature egg release
Give LH / hCG for egg maturation 
Eggs collected
Combined with sperm
1-2 embryos planted back into uterus
17
Q

What are common methods of contraception?

What are permanent 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

Vasectomy
Female sterilisation

18
Q

What are common barrier contraceptions?

What are the adv. and disadv. of barrier contraception?

A

E.g. condoms

Adv - easy to obtain, protects against STI

Disadv - higher failure rated (due to incorrect usage)

19
Q

What is the oral contraceptive pill?

How does it work by acting on the HPG axis?

A

Oral contraceptive pill (OCP) - contains oestrogen and progesterone, results in anovulation

Oestrogen - anovulation due to negative feedback on GnRH and gonadotrophins

Progesterone - thickening of the cervical mucus and thinning of endometrial lining

20
Q

What are the adv. and disadv. of the OCP?

What are some possible side effects?

A

Adv - easy to take, effective, reduces endometrial and ovarian cancer, weight neutral

Disadv - Difficult to remember, not good during breastfeeding, no protection again STIs, certain enzymes / medications may reduce efficacy

Side effects - progesterone = may increase hunger, therefore switch pills until one works
Enzyme inducers = may increase metabolism of the pill
Spotting
Nausea
Changes to mood / libido / breast tenderness
VTE (venous thromboembolism) - v. rare

21
Q

What other conditions can the oral contraceptive pill help?

A

Heavy bleeding - can help make periods lighter / less painful
PCOS - help reduce LH and hyperandrogenism

22
Q

What is the progesterone only pill (POP)?

What are the adv. and disadv. of the POP?

What are some possible side effects?

A

POP - like OCP, but only progesterone (no oestrogen)

Adv - works like the OCP, suitable if patient cannot take oestrogen, easy to take, can help heavy periods, can be used when breastfeeding

Disadv - less reliable than OCP, difficult to remember, no protection against STIs, short acting = taken same time each day

Side effects - irregular bleeding, headaches, sore breasts, changes in mood / libido

23
Q

What are some examples of long acting reversible contraceptives (LARCs)?

A

IUDs - copper coil, mechanically prevents implantation, decreases sperm egg survival, lasts 5-10 years

IUS - acts as the coil but also secretes progesterone, thickens cervical mucus (Can be helpful for women with heavy bleeding). Lasts 3-5 years

Progestogen-only injectable contraceptives or subdermal implants

24
Q

What are the advantages of LARCs?

A

Suitable for most women including those with no previous children
Can be used as emergency contraception
Long lasting
Exclude STI’s and cervical screening up to date before insertion

25
Q

What are some examples of emergency contraceptions?

What are some possible side effects?

A

IUD - most effective (less than 1% chance of pregnancy) - fitted up to 5 days after unprotected sex

Emergency contraceptive pill, ulipristal acetate - 30mg, taken within 5 days of unprotected sex

Emergency contraceptive pill, levonorgestrel - synthetic progesterone, 1.5mg, taken within 3 days of unprotected sex

Side effects: Does not cause an abortion, just prevents pregnancy
Nausea within 2-3 hours = require another dose
Heaches, abdominal pain
Liver P450 enzyme inducer = reduces efficacy

26
Q

What should be taken into account for the choice of contraception?

A 
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 retinopathy/nephropathy/neuropathy

Other conditions that may benefit from a contraception

Need to prevent STIs

Concurrent medication

27
Q

What is the issue with user dependent contraceptions?

A

Worse chance of failure due to incorrect use

28
Q 
53F - presents with post-menopausal symptoms
Presenting Complaint (PC) – 
Hot flushes, sweating, disturbed sleep, 
Low libido, vaginal dryness, low mood.
Joint and muscle aches
Absent periods for 10 months

What is the diagnosis and treatment?

A

Menopause

Hormone replacement therapy (HRT) to ease symptoms

29
Q

What are the risks of HRT (hormone replacement therapy)?

HINT: first pass metabolism, cancers, CVD, strokes

A

VTEs (venous thrombo-embolisms)

Oral oestrogens - go through liver to undergo first pass metabolism (more risky) VS transdermal = straight into the bloodstream

Breast cancers = slight increased risk with combined HRT (oest and prog)
Ovarian cancer - increased risk after long term use
Endometrial cancers = must prescribe progestogens to minimise risk (post-menopausal bleed may indicate endometrial cancer)

No increased risk of CVD if started before aged 60
Risk of stroke - small increase, most increase with oral combined pill (least = transdermal oestrogen only)

30
Q

What are the benefits of HRT?

A

Relieves symptoms caused by low oestrogen

Reduce post-menopausal fractures (osteoporosis)

31
Q

Define:

Gender
Sex
Cis
Non-comforming
Dysphoria
Non-binary 
Transgender
A

Gender = social construct, how you see yourself as male, female, or non-binary.

Sex = biologically defined e.g. male, female, or intersex.

Cisgender = same sex and gender

Gender non-conforming = gender does not match assigned sex

Gender Dysphoria = when that causes depression

Non-binary = gender does not match to traditional binary gender understanding,
includes agender, bigender, pangender, gender fluid

Transgender = transitioning or planning to transition physical appearance from one to another.

32
Q

What are some HRTs for transgender and gender non-binary individuals?

A

GnRH agonist - high dose continuously pre-puberty = delays prepubertal effects to make the decision

Masculising hormones = testosterone
Progesterone to suppress menstrual bleed (if needed)

Feminising hormones = oestrogen
GnRH angonists = reduce testosterone levels

Y2 - BRS - Endo (22 decks)

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