Suppression of spermatogenesis may be achieved by interfering with:
• extragonadal endocrine control, i.e. the hypothalamic/pituitary/gonadal axis
• direct action on gonadal spermatogenesis
• vaccines to produce antibodies to sperm.
Approaches include androgen or combinations of androgen with danazol, or progestogen, or oestrogen, also gonadorelin.
In practice, the condom and vasectomy are the only commonly used forms of male contraception
Amenorrhoea, primary or secondary, requires specialist endocrinological diagnosis. Where the cause is failure of hormone production, cyclical replacement therapy is indicated.
Menorrhagia can be associated with both ovulatory and anovulatory ovarian cycles. It is important to distinguish the menstrual consequences of each cycle. Ovulatory ovarian cycles give rise to regular menstrual cycles whereas anovulatory cycles result in irregular menstruation or, extremely, amenorrhoea. This distinction is critical in management. Both ovulatory and anovulatory cycles can give rise to excessive menstrual loss in the absence of any other abnormality; so called dysfunctional uterine bleeding. Endocrine disorders do not cause excessive menstrual loss, with the exception of the endocrine consequences of anovulation. Equally, haemostatic disorders are rare causes of menorrhagia. One consequence of excessive menstrual loss is iron deficiency anaemia. In the western world menorrhagia is the commonest cause of iron deficiency anamea.
Medical treatment of menorrhagia is either nonhormonal or hormonal therapy. As there is no hormonal defect the use of hormonal therapy does not correct an underlying disorder but merely imposes an external control of the cycle. For many women, cycle control is as important an issue as the degree of menorrhagia.
The two main first-line treatments for menorrhagia associated with ovulatory cycles are nonhormonal namely, tranexamic acid (an antifibrinolytic) and a nonsteroidal anti-inflammatory drug e.g. mefenamic acid 500 mg when the blood loss becomes heavy, followed by 250 mg t.d.s. for 3 days. The effectiveness of these treatments has been shown in randomised trials and reported in systematic reviews of treatment. Tranexamic acid reduces menstrual loss by about a half and nonsteroidal anti-inflammatory drugs reduced it by about a third. Both have the advantage of only being taken during menstruation itself and are particularly useful in those women who either do not require contraception or do not wish to use a hormonal therapy They are also of value in treating excessive menstrual blood loss associated with the use of nonhormonal intrauterine contraceptive devices.
Hormonal therapy should be regarded as a third choice treatment only in women not requiring contraception as a parallel objective. Progestogens are effective only if given for 21 days in each cycle. Combined oral contraceptives are useful for anovulatory bleeding as they impose a cycle. The levonorgestrel releasing intrauterine system (Mirena) is advocated as an alternative to surgery.19
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