Women's & Men's Health

Reproductive Endocrinology

Clinical overview and exam mastery guide covering PCOS, menopause and HRT, contraceptive pharmacology, male hypogonadism, and erectile dysfunction.

PCOS Base
Insulin resistance + hyperandrogenism
HRT Rule
Add progestin if uterus present
Hypogonadism
Testosterone replacement
ED Trap
No PDE-5 with nitrates

Therapeutic Decision Themes

PCOS cycle control androgen control Menopause symptom relief risk screening Male health testosterone ED management Match treatment to contraindications and reproductive goals Safety screening often determines first-choice drug class

Therapy selection changes with fertility goals, thrombosis risk, and comorbidity profile.

1. Polycystic Ovary Syndrome (PCOS)

Pathophysiology and Features

  • Insulin resistance
  • Hyperandrogenism
  • Ovulatory dysfunction
  • Clinical: irregular menses, hirsutism, acne, obesity, infertility

Treatment Principle

  • Goal-directed care: cycle control vs fertility focus
Drug/Class MOA Dose Regimen Side Effects Contraindications
Combined oral contraceptives Suppress LH, reduce ovarian androgen production, regulate cycle Ethinyl estradiol 20-35 mcg plus progestin, one tablet daily (21-28 day cycle) Nausea, breast tenderness, VTE risk Prior DVT/PE, migraine with aura, uncontrolled hypertension, smoking over age 35
Metformin Improves insulin sensitivity and may improve ovulation Start 500 mg daily, titrate to 1000-2000 mg/day divided GI upset, rare lactic acidosis Severe renal impairment, acute metabolic acidosis
Spironolactone Androgen receptor blockade for hirsutism control 50-100 mg orally twice daily Hyperkalemia, menstrual irregularity Pregnancy (teratogenic) and significant hyperkalemia risk; use reliable contraception

2. Menopause and Hormone Replacement Therapy (HRT)

Indicated for severe vasomotor symptoms or genitourinary syndrome after risk assessment.

Therapy MOA Dose Regimen Side Effects Contraindications / Rules
Estradiol (oral or transdermal) Replaces declining estrogen Oral 0.5-2 mg daily; patch 0.025-0.1 mg/day Breast tenderness, VTE/stroke risk Contraindicated in breast cancer, prior DVT/PE, active liver disease
Medroxyprogesterone (if uterus intact) Progestin endometrial protection against unopposed estrogen effect 2.5-5 mg daily Mood change, bleeding pattern changes Required when uterus is present to reduce endometrial cancer risk

3. Hormonal Contraceptives

Method MOA Dose Regimen Key Notes
Combined oral contraceptive Suppresses ovulation, thickens cervical mucus, thins endometrium Ethinyl estradiol 20-35 mcg daily with progestin Use only when estrogen is safe
Progestin-only pill Mainly thickens cervical mucus and alters endometrium Norethindrone 0.35 mg daily Useful during breastfeeding or estrogen contraindication
Depot medroxyprogesterone (DMPA) Ovulation suppression and endometrial effect 150 mg IM every 3 months Weight gain and bone density reduction can occur
Levonorgestrel IUD Local progestin effect on endometrium/cervical mucus Device duration 3-8 years by product Long-acting reversible method

4. Male Hypogonadism

Testosterone Replacement

  • MOA: restores physiologic serum testosterone
  • IM cypionate: 50-100 mg weekly or 100-200 mg every 2 weeks
  • Transdermal gel: 50-100 mg daily
  • Side effects: polycythemia, acne, infertility, prostate enlargement
  • Contraindications: prostate or breast cancer

5. Erectile Dysfunction (ED)

Most common etiology is vascular dysfunction.

PDE-5 Inhibitors (Sildenafil, Tadalafil)

  • MOA: PDE-5 inhibition raises cGMP and augments nitric oxide-mediated vasodilation
  • Sildenafil dose: 50 mg about 1 hour pre-intercourse (range 25-100 mg)
  • Side effects: headache, flushing, hypotension
  • Contraindication: concurrent nitrate use (risk of severe hypotension)

Management Recap Drill

PCOS: COC first-line for cycle control, add spironolactone for hirsutism with contraception.
Menopause: estrogen with progestin when uterus is intact.
Contraception: choose COC when safe; progestin-only when estrogen unsafe.
Hypogonadism: testosterone replacement with safety monitoring.
ED: sildenafil class, never with nitrates.

Visual Algorithm Placeholder

[Insert Reproductive Endocrine Treatment Algorithm Here During UI Integration]

Guideline References (Management)

Endocrine Society Guidelines

https://www.endocrine.org

ACOG Guidance

https://www.acog.org
Core scope includes PCOS care, HRT risk-safety balance, testosterone therapy, and contraceptive eligibility.

6. Common Exam Traps

Do not use estrogen in migraine with aura.
Add progestin when uterus is intact during systemic estrogen therapy.
Exogenous testosterone suppresses fertility.
PDE-5 inhibitors are contraindicated with nitrates.
Spironolactone is teratogenic and requires contraception planning.

7. Quick Revision Summary

Must Remember

  • PCOS centers on insulin resistance and hyperandrogenism
  • COCs regulate cycle and reduce androgenic features
  • HRT must account for uterus status and thrombotic risk
  • Testosterone therapy requires adverse effect monitoring
  • Sildenafil-class drugs cannot be combined with nitrates

Practice Questions Placeholder

  • Topic: Reproductive Endocrinology
  • Subtopics: PCOS, HRT, contraception, hypogonadism, erectile dysfunction