Curriculum standards

Knowledge guides

LG 24: Female reproductive endocrinology

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Less common or more complex presentations and conditions

Advanced Trainees will understand these presentations and conditions.

Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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Investigations, procedures, and clinical assessment tools

Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.

Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management, and integrate these into care.

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Presentations

Altered mood
Delayed or incomplete puberty
Depression
Fatigue
Genito-urinary symptoms
Hirsutism
Infertility
Loss of libido
Menstrual disturbance
Sexual dysfunction
Vasomotor symptoms
Virilisation

Conditions

Hyperandrogenism:
- adrenal
- ovarian
Menopause:
- premature menopause
Polycystic ovarian syndrome (PCOS)
Premenstrual syndrome:
- premenstrual dysphoric disorder
Primary amenorrhea:
- cancer survivorship
- central:
  - isolated GnRH deficiency
  - Kallman syndrome
  - pituitary dysfunction
- functional
- outflow tract disorders
Secondary amenorrhea:
- functional hypothalamic amenorrhoea
  - eating disorders
  - exercise
  - weight fluctuations
- ovarian dysfunction:
  - autoimmune polyendocrinopathy
  - chemotherapy
  - ovarian tumours
  - premature ovarian insufficiency:
    - fragile X
    - gonadal dysgenesis
    - Turners syndrome
  - radiation
- pituitary dysfunction:
  - hyperprolactinaemia
  - immunotherapy-related hypophysis
  - infiltrative disease:
    - histiocytosis
    - Langerhans
    - lymphoma
    - malignancy
    - sarcoidosis
  - other endocrinopathies
  - other tumours

For each presentation and condition, Advanced Trainees will know how to:

Synthesise

recognise the clinical presentation
identify relevant epidemiology, prevalence, pathophysiology, and clinical science
take a comprehensive clinical history
conduct an appropriate examination
establish a differential diagnosis
plan and arrange appropriate investigations
consider the impact of illness and disease on patients and their quality of life when developing a management plan

Manage

provide evidence-based management
prescribe therapies tailored to patients' needs and conditions
recognise potential complications of disease and its management, and initiate preventative strategies
involve multidisciplinary teams

Consider other factors

identify individual and social factors and the impact of these on diagnosis and management

Conditions

Congenital adrenal hyperplasia (non-classic)
Infertility
Malignancy:
- germ cell tumours
- ovarian tumours

For each presentation and condition, Advanced Trainees will know how to:

Synthesise

recognise the clinical presentation
identify relevant epidemiology, prevalence, pathophysiology, and clinical science
take a comprehensive clinical history
conduct an appropriate examination
establish a differential diagnosis
plan and arrange appropriate investigations
consider the impact of illness and disease on patients and their quality of life when developing a management plan

Manage

provide evidence-based management
prescribe therapies tailored to patients' needs and conditions
recognise potential complications of disease and its management, and initiate preventative strategies
involve multidisciplinary teams

Consider other factors

identify individual and social factors and the impact of these on diagnosis and management

Pathophysiology

Normal stages of pubertal development
Regulation of the hypothalamic-pituitary-gonadal axis and hormonal variations in the menstrual cycle and menopause

Diagnostic work up

Aetiology, pathology, and clinical manifestations of hypogonadism:
- evaluation of oestrogen-dependent and oestrogen-independent amenorrhoea
Evaluation of delayed puberty, constitutional and pathological
Evaluation of menopausal symptoms
Impact of environmental, psychological, and comorbid conditions on the HPG axis:
- determine when hormonal replacement is and when it is not indicated
Principles of assessing ovarian reserve and fertility preservation in elective and oncology cases
Thorough history, physical examination and diagnostic work up of patient presenting with disorders of sexual development (e.g., delayed puberty), anovulation and/or infertility

Treatment

Consideration of contraceptive needs
Hormone deprivation therapy (often treatment of breast or ovarian cancer):
- bone preservation
- cardiovascular risk mitigation
- endocrine disruptors of the reproductive axis
- symptom management
Hormone replacement therapy, including menopausal hormonal therapy (MHT) and monitoring
Indications, contraindications and appropriate prescribing of hormone replacement therapy for patients in different life stages including, knowledge of pubertal induction
Monitoring of hormone replacement therapy and its potential complications with dose and route of administration adjustment as needed
Non-hormonal management of menopause
Preventative screening as needed:
- bone health
- breast
- cardiovascular
Treatment options for PCOS including ovulation induction and basic principles of artificial reproduction therapies (ART)

Investigations

Knowledge of timed measurement of reproductive hormones in relation to the menstrual cycle
Karyotype and genetic testing as applicable
Laboratory biochemistry:
- dynamic testing (e.g., short Synacthen in non-classic-CAH)
- specific understanding of the timing, patient preparation and assay platforms suited for sex steroid analysis and interfering factors
Radiology:
- bone mineral density
- MRI
- ultrasound

Procedures

When indicated, facilitate referrals for:
- assisted reproduction services
- fertility preservation services
- peri-implantation genetic testing

Evidence-based practice

Remain abreast of evidence for best practice and apply this using clinical judgement and individual circumstances in partnership with patients

General management considerations

Impact of sexual dysfunction, infertility and/or genetic diagnoses on the patient, their partner and, where applicable, their family and carers:
- consider the sociocultural impact of infertility
Impact of socioeconomic factors on equitable access to fertility preservation and treatment services
Incorporate environmentally sustainable practices in clinical care
Menopause management in the complex patient:
- premature ovarian insufficiency
- previous breast cancer
- prothrombotic comorbidities:
  - deep vein thrombosis
  - pulmonary embolism
Referrals and access to genetic, sexual, and relationship counselling
Referral for oocyte preservation prior to planned treatment potentially resulting in premature ovarian insufficiency (POI) or at diagnosis of POI with low AMH with residual oocytes

Health needs of specific patient groups

Care of hormone deprivation therapy recipients
Endocrine care of women with pituitary or adrenal dysfunction through pregnancy, labour, and postpartum
Ethical considerations in discussing fertility preservation procedures with adolescents and their family
Longitudinal and multidisciplinary care needs of women with genetic conditions such as Turner syndrome, such as:
- cardiovascular risk screening and mitigation
- collaboration with:
  - counselling services
  - education services
  - primary care providers
Screening in cancer survivorship