THE REPRODUCTIV E SYSTEM

Functional anatomy, physiology and investigations In the male, the testis subserves two principal functions: 1.synthesis of testosterone by the interstitial Leydig cells under the control of (LH) 2.Spermatogenesis by Sertoli cells under the control of (FSH) (but also requiring adequate testosterone)

The axis of pituitary- tests can be assessed easily by a random blood sample for testosterone, LH and FSH. Testicular function can be tested by a. random blood sample for testosterone, LH and FSH b. semen analysis.

In the female, physiology is complicated by variations in function during the normal menstrual cycle

Circulating levels of estrogen and progesterone in pre-menopausal women are critically dependent on the time of the cycle The most useful ‘test’ of ovarian function is a careful menstrual history. In addition, ovulation can be confirmed by: measuring plasma progesterone levels during the luteal phase (‘day 21 progesterone’) or by tracking changes in estrogen and progesterone metabolites in urine specimens collected at weekly intervals

In menopause estrogen and inhibin secretion falls and negative feedback results in increased pituitary secretion of LH and FSH (typically to levels > 30 U/L (3.3 mg/L)). What is climacteric? Mention its clinical implication(s)?

Presenting problems in reproductive disease Delayed puberty (full details in pediatrics) Amenorrhea (full details in ob/gyn) Male hypogonadism Infertility (female causes in ob/gyn) Gynaecomastia Hirsutism

Male hypogonadism It is classified into: a. hypo gonadotrophic hypogonadism b. hyper gonadotrophic hypogonadism

The features of both types of Male hypo gonadism include: loss of libido lethargy with muscle weakness decreased frequency of shaving gynaecomastia infertility delayed puberty anemia of chronic disease

Causes of hypogonadism

Investigations Male hypogonadism is confirmed by demonstrating a low serum testosterone level. The distinction between hypo- and hyper gonadotrophic hypogonadism is by measurement of random LH and FSH. Patients with Hypo gonadotrophic hypogonadism should be investigated as described for pituitary disease Patients with hyper gonadotrophic hypogonadism should have the testes examined for Cryptorchidism or atrophy and a karyotype performed (to identify Klinefelter’s syndrome).

Management Testosterone replacement is indicated in hypo gonadal men to: prevent osteoporosis restore muscle power and libido

infertility Infertility is defined as the failure of a couple to conceive after 12 months of unprotected sexual intercourse. If the female partner is 35 year of age or older, evaluation should be initiated after 6 months of unprotected intercourse.

Clinical assessment A history of previous pregnancies, relevant infections and surgery is important in both men and women. A sexual history Irregular and/or infrequent menstrual periods are an indicator of anovulatory cycles in the woman, in which case causes such as PCOS In men, the testes should be examined to confirm that both are in the scrotum and to identify any structural abnormality, such as small size, absent vas deferens or the presence of a varicocoele.

investigations Investigations are guided by the history and examination Semen analysis x 2 (sperm count, morphology, motility) Scrotal/testicular U/S (look for varicocele) Bloodwork: LH, FSH, testosterone, prolactin, thyroid function tests, DNA fragmentation of sperm, karyotype, Y chromosome deletion Test female partner (see lectures of gynecology)

Management See the pages 758 – 759 in Davidson's principles & practice of medicine 20 th edition

Gynaecomastia Gynaecomastia is the presence of glandular breast tissue in males. Gynaecomastia results from an imbalance between androgen and estrogen activity, which may reflect androgen deficiency or estrogen excess.

Clinical assessment Drugs history Differentiation from obesity Testicular examination for the evidence of cryptorchidism, atrophy or a tumor Features of hypogonadism should be sought

Investigations If a clinical distinction between gynaecomastia and adipose tissue cannot be made, then ultrasonography or mammography is required. A random blood sample should be taken for testosterone, LH, FSH, estradiol, prolactin and hCG. Elevated estrogen concentrations are found in testicular tumors and hCG producing neoplasms.

Management Reassurance in those having gynecomastia due to physiological causes, some times we need cosmetic surgery Androgen replacement will usually improve gynaecomastia in hypo gonadal males Any other identifiable underlying cause should be addressed if possible. The anti-estrogen tamoxifen may also be effective in reducing the size of the breast tissue.

Hirsutism Hirsutism refers to the excessive growth of thick terminal hair in an androgen-dependent distribution in women (upper lip, chin, chest, back, lower abdomen, thigh, forearm) It is one of the most common presentations of endocrine disease. It should be distinguished from hypertrichosis

Clinical assessment drug and menstrual history calculation of body mass index measurement of blood pressure examination for virilisation (clitoromegaly, deep voice, male-pattern balding, breast atrophy) associated features including acne vulgaris or Cushing’s syndrome Hirsutism of recent onset associated with virilisation is suggestive of an androgen- secreting tumor, but this is rare.

Investigations A random blood sample should be taken for testosterone, prolactin, LH and FSH. If there are clinical features of Cushing’s syndrome, an overnight 1 mg dexamethasone suppression test should be performed CT or MRI according to the result of hormones mentioned above.

Management It depends on the cause