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Men's and Women's Health EXAM 2
Men's and Women's Health EXAM 2 - Struemph
34
Pharmacology
Graduate
11/21/2011

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Term
definition of infertile
Definition
failure to achieve pregnancy during one year of frequent, unprotected sex
Term
definition of sterile
Definition
incapable of producing offspring
Term
definition of oligomenorrhea
Definition
interval between vaginal bleeding >/= 35 days

patient typically ovulates, but less often

weak predictor of infertility
Term
definition of amenorrhea
Definition
interval between vaginal bleeding > 6 months

patient may only rarely ovulate

strong predictor of infertility
Term
the burden of infertility upon patient well-being
Definition
emotional (depression, relationships), financial, and the susceptibility to questionable or fraudulent therapies

infertility often co-exists with secondary depression (15-54%)

infertility places extreme pressure on interpersonal relationships
often leads to marital difficulties and/or sexual dysfunction

financial burden of infertility treatments can be immense

women with infertility may be more susceptible to claims of questionable or fraudulent therapies
Term
signs and symptoms of clinical disease to screen for patients who require immediate physician attention to address "fertility issues"
Definition
WOMEN:

menstrual cycle:
regularity
catamenial symptoms

abdominal or vaginal pain

overweight, obesity, and physical inactivity are associated with decreased rates of conception

excessive caffeine may decrease fertility

MEN:

signs or symptoms of hypogonadism

lifestyle modifications that can increase testosterone levels, sprem count, and/or sperm motility:
avoid tobacco and marijuana
some pesticides are associated with low sperm count (especially with commercial use)
increasing weight bearing exercise can increase testosterone levels
Term
visual saliva fertility detection method
Definition
increased estradiol levels lead to increased NaCl concentration in saliva 3-4 days before ovulation and 2 days after ovulation

salt crystalizes into "fern pattern"

"traditional" method for detecting ovulation

15-20% of women do not "fern" during ovulation

must wait 2 hours after eating, drinking, or smoking

commercial visual saliva kits may offer no real advantage over less expensive visual methods
Term
urine LH fertility detection method
Definition
detects LH surge 14-48 hours prior to ovulation

cost ~ $50 for 2 kits

test strip kits and midstream kits:
both are reliable
patient preference

MORE ACCURATE THAN SALIVA METHOD; USUALLY USED FIRST LINE
Term
transdermal ovulation prediction
Definition
sensor worn on wrist detects increasing chloride ion levels in the sweat prior to ovulation

user begins device at night on 1st, 2nd, or 3rd day of menstrual cycle

MAY PROVIDE THE EARLIEST METHOD OF DETECTING OVULATION

very expensive: ~ $200 per 3 months of use

may be ineffective if too much or too little sweat
too much sweat or exposure to water may damage device
Term
basal body temperature charting fertility detection method
Definition
increase from 97F to 98F or higher

rise in temperature occurs 2 days after LH surge
Term
mid-luteal progesterone level fertility detection method
Definition
evaluates corpus luteal production of progesterone
Term
methods used in OTC sperm analysis kits and counseling for patients on their use
Definition
visual analysis of sperm count and motility

not the easiest thing for a novice to perform accurately

RECOMMEND PROFESSIONAL ANALYSIS
Term
WHO classifications of anovulation (based on laboratory findings and/or clinical presentation; average incidence of the 3 sub-groups)
Definition
WHO 1:
decreased FSH AND E2 levels
~5% of patients
hypothalamic/pituitary failure

WHO 2:
normal FSH AND E2 levels
~80-85% of patients
hypothalamic/pituitary dysfunction (PCOS)

WHO 3: increased FSH and decreased E2
~10% of patients
ovarian failure (menopause)
Term
step-wise treatment algorithm for WHO 2 patients: traditional
Definition
1. Clomiphene Citrate (CC)

2. Gonadotropins (FSH) +/- Clomiphene Citrate

3. in vitro fertilization (IVF) +/- Comiphene Citrate +/- FSH
Term
step-wise treatment algorithms for WHO 2 patients: optional revised version
Definition
1. Clomiphene Citrate

2. consider metformin for signs/symptoms of PCOS

3. gonadotropins (FSH) +/- Clomiphene Citrate

4. in vitro fertilization +/- Clomiphene Citrate +/- FSH
Term
clomiphene citrate:

singletone live birth rate
multiple live birth rate
average time to pregnancy
Definition
cumulative singleton live birth rate: 37%

multiple live birth rate: 2%

average time to pregnancy 11.4 months
Term
gonadotropins (FSH)

singleton live birth rate
average time to pregnancy
Definition
cumulative singleton live birth rate: 43%

average time to pregnancy: 11.4 months
Term
in vitro fertilization

singletone live birth rate
Definition
cumulative singleton live birth rate: 28%

MULTIPLE LIVE BIRTH RATE HIGHEST WITH IVF STRATEGIES USING MULTIPLE PRE-EMBRYOS
Term
combination clomiphene citrate and FSH

singletone live birth rate
multiple live birth rate
average time to pregnancy
Definition
cumulative singleton live birth rate: 71%

multiple live birth rate: 7%

average time to pregnancy: 11.4 months
Term
combination IVF, clomiphene citrate, and FSH

singleton live birth rate
Definition
cumulative singleton live birth rate: 77%
Term
clomiphene citration

typical timing and duration of doses
methods used for determining success
when to consider treatment failure
Definition
typical timing and duration of doses:

initiate on days 3-4 post spontaneous or MPA-induced withdrawal bleed
typically dose for 5 days
increase dose each cycle if ovulation does not occur

methods used for determining success:

CC has antiestrogenic effects on the hypothalmus which stimulates FSH and LH = follicular rupture
serum LH levels

when to consider treatment failure:

treatment duration ~1 year

predictors of failure with CC treatment alone:
obesity
amenorrhea prior to treatment
increased ovarian volume
hyperadrogenemia
older age (?)
(all similar to PCOS)
Term
gonadotropins: FSH

typical timing and duration of doses

methods used for determining success
Definition
typical timing and duration of doses:

low-dose, step-up protocol:
patient specific dosing beginning on DAY 6-7 OF CYCLE
dose increased if no response on ultrasonography or in serum estradiol

methods used for determining success:

ultrasounds every 2-3 days to visualize follicle development
human chorionic gonadotropin (hCG) given once one follicle is mature to induce ovulation
monitor serum estradiol (E2) levels to determine adequate response
Term
counseling points on clomiphene citrate
Definition
side effects:
headaches
hot flashes
breast tenderness
bloating
N/V
ocular effects
Term
counseling points on FSH therapy
Definition
contraception should be instituted in patients when >/= 3 dominant follicles develop to avoid multiple live births
Term
differentiate between available gonadotropin products (source, administration, and FSH and LH content)
Definition
urine sources:

typically IM adminstration

chorionic gonadotropin
mimics action of LH
from urine of pregnant women

menotropin (eqaal ratio of FSH and LH)
from urine of postmenopausal woemn

recombinant preparations (rFSH):

typically sub-Q adminstration

more pure and with less variability than urine sources

more expensive, but most widely used due to predictability

follitropin alpha and follitropin beta equally efficatious
Term
signs and symptoms of PCOS
Definition
cause is largely unknown

increased insulin levels decrease hepatic production of sex hormone binding globulin, resulting in higher concentration of free androgens in the blood

irregular menses

masculinization
relative functional hyperandrogenism
estrogen levels may not be decreased, but estrogen effects are decreased

obesity (cause vs. effect?)
fat represents a site of intense sex hormone metabolism resulting from steroidogenic enzymes, such as aromatase

infertility and 1st trimester spontaneous abortion are common with PCOS
Term
patients at risk for PCOS
Definition
risk factors: genetics, obesity, diabetes

PCOS is more prevalent in African American women
Term
treatment of PCOS
Definition
weight loss to near ideal body weight is the most effective therapy
caloric restriction
folic acid 1 mg per day
physical exercise: weight bearing and aerobic

metformin: first line drug therapy
metformin therapy has shown to improve both fertility and 1st trimester spontaneous abortion
normal menses resumes in 55-90% of women
no teratogenicity has been noted with use of metformin in pregnancy
use metformin regardless of diabetes co-incidence
indicated if patient has history of spontaneous abortion despite weight loss
addition of clomiphene citrate
Term
signs and symptoms of endometriosis
Definition
pelvic pain

dysmenorrhea

pain with intercourse

increase in menstruation

inferility
Term
definition of endometriosis
Definition
growth of estrogen-dependent endometrial tissue outside the uterus
Term
common sites of endometriosis
Definition
ovaries

fallopian tubes

outer surface of uterus

uterine ligaments
Term
drug therapies that treat the symptoms of endometriosis
Definition
NSAIDs

oral contraceptives - continuous

GnRH antagonists

gonadotropin inhibitor: danazol
MOA: blocks ovarian stimulating hormones to prevent menstruation
ADRs: acne, facial hair
Term
only effective therapy for treating endometriosis-induced inferility
Definition
surgery

NO DRUG THERAPY WILL TREAT ENDOMETRIOSIS-INDUCED INFERILITY
Term
what herbs are promoted to treat "female reproductive complaints"?
Definition
red clover blossom
licorice
chastetree berry
black cohosh
dong quai
wild yam
false unicorn root
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