Reproductive Endocrinology.doc


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Reproductive Endocrinology.doc

  1. 1. REI division EDUCATIONAL OBJECTIVES REPRODUCTIVE ENDOCRINOLOGY Basic Science/Mechanisms of Disease House Officers will understand and be able to apply to clinical problems: GENETICS 1. Disorders of mullerian development, including mullerian dysgenesis and mullerian agenesis 2. Disorders of androgen excess and abnormal hormone secretion 3. Disorders involving repetitive pregnancy wastage 4. Disorder resulting in ambiguous genitalia 5. Gamete fertilization and implantation biology PHYSIOLOGY 1. Hypothalamic physiology 2. Pituitary physiology 3. Ovarian sex steroid synthesis 4. Adrenal steroid synthesis 5. Physiology of the thyroid gland 6. Physiology of the mullerian tract, including endometrium and cervical mucus 7. Male reproductive physiology 8. Bone physiology EMBRYOLOGY and DEVELOPMENTAL BIOLOGY 1. Normal embryologic mullerian development 2. Disorders of embryologic mullerian development 3. Genetically related abnormalities in gonadal development Page 1 of 13 10/21/10
  2. 2. REI division 4. Phenotypic expression of disorders of sexual differentiation ANATOMY 1. Hypothalamic-pituitary-ovarian relationships 2. Tissue receptor physiology (e.g. skin, fat, endometrium) 3. Interpretation of reproductive anatomy as it relates to diagnostic imaging studies 4. Reproductive anatomy related to invasive endoscopic procedures 5. Surgical reproductive anatomy PHARMACOLOGY 1. Hormone production and maintenance 2. Pharmacologic intervention for patients with infertility disorders 3. Steroid biosynthesis, including biologic activity of steroid precursors, active compounds and measurements of end products 4. Prostaglandin metabolism and pharmacologic intervention in prostaglandin activity 5. Pharmacologic action of ovulation inhibition drugs 6. Pharmacologic action of sex steroid medications 7. Pharmacologic actions of insulin-sensitizing agents 8. Pharmacologic actions of bone anti-resorptive agents PATHOLOGY and NEOPLASIA 1. Histologic changes associated with the normal reproductive cycle 2. Changes in endometrial histology through the use of pharmacologic ovarian suppression 3. Gross and microscopic changes in specific pathologic or neoplastic conditions encountered in reproductive endocrinology 4. Histologic ovarian changes in cases of ovarian hyperstimulation 5. Gross and microscopic changes in cases of gonadal dysgenesis Page 2 of 13 10/21/10
  3. 3. REI division MICROBIOLOGY and IMMUNOLOGY 1. Maintenance of normal vaginal flora relative to the menstrual cycle 2. Alterations in vaginal flora in cases of gonadal failure or suppression 3. Alterations in cervical mucus composition by bacteriologic species 4. Alterations in endometrial and tubal histology resulting from abnormal bacterial proliferation or infection 5. Immunologic causes of infertility 6. Immunologic aspects of aging Clinical Reproductive Endocrinology House Officers will be able to outline the diagnostic and treatment strategies for: Pediatric and adolescent disorders A. Congenital reproductive tract abnormalities 1. Recognition and initial diagnosis 2. Treatment† B. Delayed development 1. Recognition and initial diagnosis 2. Treatment† C. Precocious development 1. Recognition and initial diagnosis 2.Treatment† D. Ambiguous genitalia 1. Recognition and initial diagnosis E. Adolescent gynecology (postmenarchal) MENSTRUAL and ENDOCRINE DISORDERS 1. Dysmenorrhea 2. Dysfunctional uterine bleeding 3. Amenorrhea 4. Premenstrual syndrome Page 3 of 13 10/21/10
  4. 4. REI division 5. Hirsutism 6. Polycystic ovary syndrome Hormonal contraception A. Mechanism of action B. Contraindications/side effects C. Risks/benefits Endometriosis 1. Etiology 2. Diagnosis 3. Clinical manifestations 4. Treatment (medical and surgical) Abnormal pregnancy Ectopic pregnancy 1. Diagnosis and treatment Recurrent abortion 1. Diagnosis and treatment MANAGEMENT OF THE CLIMACTERIC PERIOD 1. Physiology of menopause and the menopausal transition 2. Symptoms of menopause 3. Problems of menopause 4. Osteoporosis prevention and therapy INFERTILITY Evaluation 1. Male factor a. Interpretation of semen analysis b. Indications for referral c. Advanced sperm testing* Page 4 of 13 10/21/10
  5. 5. REI division 2. Cervical factor 3. Ovulatory factor 4. Uterine/tubal/peritoneal factors 5. Unexplained infertility B. Treatment 1. Ovulation induction a. Clomiphene citrate b. Dopamine agonist (bromocriptine/cabergoline) c. Glucocorticoids* d. Gonadotropins* e. GnRH* 2. Artificial insemination a. Husband insemination* b. Donor insemination* c. Intrauterine insemination* 3. Surgery a. Indication b. Patient selection c. Technique (see Table 4) d. Preoperative and postoperative care e. Management of complications 4. Assisted reproductive technologies a. Indications for referral b. Ability to counsel patients on success and techniques* 5. Prevention of infertility a. Adhesion prevention b. Sexually transmitted disease prevention and treatment Page 5 of 13 10/21/10
  6. 6. REI division III. Resident Roles and Responsibilities: Reproductive Endocrinology In addition to the basic science and clinical objectives, the following rotation- specific objectives are outlined below. SECOND YEAR (HO-II) OBJECTIVES At the end of the ten-week second-year rotation the resident will be able to: 1) Describe the development and maturation of the hypothalamic-pituitary- ovarian axis from conception through menopause. 2) Describe the normal development and disorders of mullerian, ovarian and genital development and their genetic basis. 3) Describe the physiology of the normal menstrual cycle, gamete transport in the female reproductive tract, fertilization and implantation. 4) Describe the biosyntheses, metabolism and mechanism of action, as well as the role of hypothalamic, pituitary, ovarian, adrenal and thyroid hormones. 5) Discuss the mechanisms of action, indications for, physiologic and anatomic changes resulting from and complications associated with the use of exogenous estrogens, progesterone/progestins, androgens, oral contraceptives, dopamine agonists, anti-resorptive agents, clomiphene and other SERMS ,gonadotropins, and GnRH-antagonists. 6. Discuss the basic causes, pathophysiology, evaluation and treatment of: o infertility o primary and secondary amenorrhea o hyperprolactinemia o chronic anovulation and oligo-ovulation o androgen excess disorders (hirsutism) o the menopausal transition and menopause o osteoporosis o premenstrual syndrome o endometriosis Page 6 of 13 10/21/10
  7. 7. REI division 7) Perform diagnostic laparoscopy and hysteroscopy and recognize pelvic anatomy as well as the common disorders detected by these techniques. 8) Perform and describe the indications for hysterosalpingography, postcoital testing, semen analysis and use of clomiphene citrate and gonadotropins in ovulation induction. 9. Perform transvaginal ultrasonography and be able to detect endometrial growth and follicular development during the menstrual cycle. 10. Perform and describe the indications for sonohysterograms. 11. Describe the indications, risks, evaluation, agents and procedures for conscious sedation. ROLES AND RESPONSIBILITIES To achieve these objectives the HO II will: 1. Read Clinical Gynecologic Endocrinology and Infertility, 5th ed., Speroff, L., Glass, R. and Kase, N. Williams and Wilkins, Baltimore. 2. Attend and perform sonohysterograms on Monday afternoons. 3. Attend the weekly Reproductive Endocrinology Conference at 12:00PM Wednesday. The resident will be expected to discuss case studies, interpret pelvic imaging studies and do library research to prepare for these conferences. 4. See patients with attendings. 5. Spend a half-day in the ART Laboratory observing semen analyses and semen preparation for insemination. 6. Spend a half-day with the Reproductive Endocrinology nurse Practioners observing post coital examinations and intrauterine inseminations. 7. Participate in scheduled surgery on Mondays and Fridays. 8. Attend all ART retrievals to administer conscious sedation. 9. Attend ART meetings on Mondays from 2:30PM-4:00PM and present all current and new ART patients. 10. Attend one-half of the weekend-scheduled clinics to perform ultrasounds, inseminations and ART preops. FOURTH YEAR (CHIEF - HO IV) OBJECTIVES Page 7 of 13 10/21/10
  8. 8. REI division At the end of the 10 week fourth year Ambulatory Gynecology and 10 week Impatient Gynecology rotations the resident will be able to fulfill the objectives of the second-year resident and: 1) Describe the evaluation and treatment of infertility due to endometriosis, tubal disease, mullerian anomalies, anovulation, endometrial disorders, and male factors. 2) Describe the indications for and interpretation of hysterosalpingography, pelvic ultrasonography, sonohysterography, computed tomography and magnetic resonance imaging when used to evaluate reproductive disorders. 3) Perform and describe the physiologic basis for hysterosalpingographies, sonohysterograms, post-coital examinations and intrauterine inseminations. 4) Perform and describe the indications for preoperative preparations of patients, instrumentation, techniques, complications, postoperative management and results of reproductive surgeries including: o diagnostic and operative laparoscopy, including management of tubal pregnancies o diagnostic and operative hysteroscopy o laparotomy o myomectomy o adhesiolysis o fimbrioplasty/salpingostomy o metroplasty o ovarian cystectomy o excision/ablation of endometriosis 5) Describe the physiology underlying, the indications for, and process of in vitro fertilization. 6) Describe the use of clomiphene citrate, bromocriptine, gonadotropins, GnRH, insulin-sensitizing agents, and corticosteroids for the induction of ovulation. 7) Describe the evaluation and management of developmental disorders of the urogenital tract. 8) Describe the evaluation and management of disorders of puberty. 9) Discuss the evaluation and management of disorders of menstruation including dysmenorrhea, amenorrhea, oligomenorrhea, hypermenorrhea, polymenorrhea, and premenstrual syndrome. Page 8 of 13 10/21/10
  9. 9. REI division 10) Describe the physiology, clinical manifestations, evaluation and management of the menopausal transition, early post-menopause and late post-menopause, including prevention and treatment of estrogen deficiency disorders. ROLES AND RESPONSIBILITIES To achieve these objectives the resident will: 1) Read Clinical Gynecologic Endocrinology and Infertility, 5th ed., Speroff, L., Glass, RH., and Kase, NG. Williams and Wilkins, Baltimore, as well as other assigned readings. 2) Attend and perform HSGs on Wednesday mornings, from 9:00AM-12:00 noon and on alternate Wednesdays from 1:00PM-3:00PM. 3) Attend the weekly Reproductive Endocrinology Conference at 12:00PM Wednesdays. The resident will be expected to discuss case studies, interpret pelvic imaging studies and do library research to prepare for these conferences. 4)See patients with faculty as indicated. 5) Participate in the immediate pre-operative evaluation, surgical procedures and post-operative care of all service patients, primarily on Mondays and Fridays. 6) Attend one-half of the weekend clinics to perform ultrasounds, inseminations and ART pre-ops. Page 9 of 13 10/21/10
  10. 10. REI division Page 10 of 13 10/21/10
  11. 11. REI division Therapeutics: Counseling Skills in the Psychosocial and Legal-Ethical Aspects of Reproduction 1. Contraception/sterilization 2. Premenstrual syndrome 3. Infertility 4. Assisted reproductive technologies& 5. Donor gametes* 6. Recurrent pregnancy loss* 7. Adoption* 8. Surrogacy† Medical: Counseling Skills in the Psychosocial and Legal-Ethical Aspects of Reproduction 1. Clomiphene citrate 2. Bromocriptine/Cabergoline 3. Estrogens 4. Progestins 5. GnRH analogs 6. Danocrine 7. Glucocorticoids* 8. GnRH* 9. Gonadotropins* 10. Anti-androgens (spironolactone)* 11. Progesterone antagonists† Page 11 of 13 10/21/10
  12. 12. REI division Surgical Procedures and Skills I. Surgical A. Hysteroscopy 1. Diagnostic 2. Operative* B. Laparoscopy 1. Diagnostic 2. Minor adhesiolysis (ovarian, tubal) 3. Conservative treatment of stage I and II endometriosis 4. Evaluation and drainage of simple cysts 5. Ovarian and peritoneal biopsy 6. Salpingostomy or partial salpingectomy for ectopic pregnancy 7. Adhesiolysis for moderate or severe adhesions, or adhesions involving bowel* 8. Salpingectomy/salpingo-oophorectomy* 9. Endoscopic management of endometrioma and ovarian Cystectomy* 10. Endoscopic surgery for stage III and IV endometriosis* C. Laparotomy 1. Ectopic pregnancy 2. Conservative surgery for ovarian cysts and neoplasms 3. Conservative surgery for endometriosis (stages I and II) 4. Myomectomy a. Simple b. Complex* 5. Microsurgical salpingolysis, salpingostomy* 6. Tubal anastomosis* 7. Conservative surgery for endometriosis (stages III and IV)* 8. Management of uterine anomalies* II. Other skills A. Endometrial biopsy B. Hysterosalpingogram C. Flexible hysteroscopy D. Vaginal ultrasound for early pregnancy detection E. Vaginal ultrasound for ovulation monitoring* F. Intrauterine insemination* All items are level one unless otherwise indicated. Level one: critical core curriculum; should be covered in depth by all residents. *Level two: Important; cover these items in depth after critical material is completed, assuming time and resources are available. †Level three: General knowledge only. Residents are expected to have a familiarity with these subjects. Page 12 of 13 10/21/10
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