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HY Female Repro FA

Day 10

What is the drainage pathway for the L ovary/testis to the IVC? What is the drainage pathway for the R ovary/testis to the IVC? L: L gonadal v--> L renal v--> IVC R: R gonadal v--> IVC (Right goes Right to the IVC)
Why are varicoceles more common on the L side of the testicles? B/c the L renal v passes btwn the aorta and SMA and enlargement or hardening of the SMA may cause compression of the L renal v and pooling of blood in the L testicle. "bag of worms"
To which nodes will ovaries/testes drain? Para-aortic lymph nodes
To which nodes will the distal 1/3 of vagina/vulva/scrotum drain? Supf inguinal (palpable externally)
To which nodes will the proximal 2/3 of the vagina/uterus drain? Obturator, external iliac, and hypogastric nodes (not palpable externally; this is where the cervix drains)
Which ligament connects the ovaries to the lateral pelvic wall? What structures does it contain? Suspensory ligament of the ovaries. Ovarian vessels (take it SLO= Suspensory Ligament=Ovarian vessels)
Which ligament connects the cervix to the side wall of the pelvis? What structures does it contain? Cardinal ligament (C for Cervix!). Uterine vessels. (CU later= Cardinal ligament Uterine vessels)
Which ligament connects the uterine fundus to the labia majora? What structures does it contain? Round ligament. Contains 0 structures. Round like the number 0.
From what structure is the round ligament derived? What does it travel through? Derived from gubernaculum. Travels thru round inguinal canal.
Which ligament connects the uterus, fallopian tubes, and ovaries to the pelvic sidewall? What structures does it contain? Broad ligament (has broad coverage of all the organs in the pelvis). Also B for Blanket (looks like a blanket covering everything). Contains ovaries, fallopian tubes, and round ligaments of the uterus.
Which ligament connects the ovary to the lateral uterus? Ligament of the ovary (don't confuse with suspensory ligament of the ovaries which connects ovaries to lateral pelvic wall).
What is the difference in the type of tissue is found in the ovaries and that found in the fallopian tubes? Ovaries have simple cuboidal epithelium, but fallopian tubes have ciliated simple columnar epithelium to move egg along.
What is the difference in the type of tissue found in the endocervix and ectocervix? Endocervix is stratified columnar epithelium and ectocervix is stratified squamous epithelium (like the vagina).
Would you find keratin pearls in vaginal tissue? No! Vagina has NON-KERATINIZED stratified squamous epithelium.
Where is estradiol made? In ovaries.
Where is estrone made? In fat (aromatized peripherally)
Where is estriol made? In placenta
What is the potency of estrogens from greatest to least? Estradiol > Estrone > Estriol (estraDIol is to DI for b/c it's the strongest stuff. Estriol comes from the little baby placenta so it is little and weak)
Which estrogen is greatly increased in pregnancy (x1000) and is an indicator of fetal well-being? Estriol
Where are estrogen receptors expressed? Where to they translocate to when bound by ligand? Expressed in cytoplasm. Move to nucleus when bound to ligand.
Which H stimulates prolactin secretion but inhibits its action at the breast? Estrogen (this is why we don't give OCPs to nursing moms; makes it hard to breastfeed)
Which hormone increases transport of proteins and SHBG, increases HDL, and decreases LDL? Estrogen
Which antimicrobial agent inhibits the key enzyme for andostrenedione production in the theca cells? What disease can it be used to treat? Ketoconazole (inhibits desmolase/17-alpha-hydroxylase/CYP17). Can be used to treat polycystic ovarian syndrome.
The thecal cells are missing which enzyme that is necessary for estrogen production? Aromatase (must send androstenedione to granulosa cells to be aromatized)
The granulosal cells are missing which enzyme that is necessary for androstenedione production? Desmolase (must receive androstenedione from the theca cells to make estrogen via aromatase)
In which cell is cholesterol converted to androstenedione? Which enzyme accomplishes this? Which pituitary H stimulates the process? In theca cells; desmolase is enzyme. LH stimulates desmolase.
In which cell is androstenedione converted to estrogen? Which enzyme accomplishes this? Which pituitary H stimulates the process? In granulosal cells; aromatase is enzyme; stimulated by FSH.
Which hormone stimulates endometrial gland secretions and spiral a development? Progesterone (pro gestation; gets uterus ready to support a pregnancy)
Which H inhibits gonadotropins? Progesterone (don't want a cycle when you're pregnant!)
Which H decreases E receptor expressivity? Progesterone (who else?)
Stimulates endometrial proliferation E (queen of the proliferative/follicular phase)
Maintains endometrium to support implantation P (pro gestation)
Decreased levels are linked to infertility and frequent miscarriages P
Which phase of the menstrual cycle is exactly 14 days in all women? Luteal phase (ovulation day +14 days= menstruation)
Really long cycle (>35 days) oliGOmenorrhea (like the energizer bunny-- it keeps GOing, and GOing, and GOing)
Short cycles (<21 days) Polymenorrhea (if you have short cycles, you'll have "many" of them. Poly means many.)
Frequent but irregular menstruation Metrorrhagia (metro bus comes frequently, but irregularly)
Heavy, irregular menstruation at irregular intervals Menometrorrhagia (double stuff)
Which hormone trigger ovulation? LH (LH surge)
When does progesterone start to increase in the menstrual cycle? What physiological change is accompanied by this increase? 24 hours after ovulation. Accompanies an increase in body temperature.
What stimulates the LH surge? High levels of E near the end of the proliferative/follicular phase (ovulation marks the beginning of the secretory/luteal phase)
What structure produces P during the cycle? The corpus luteum (aka the ruptured follicle)
What is Mittelschmerz? Blood from ruptured follicle causes peritoneal irritation that can mimic appendicitis
What change in GnRH receptors on the anterior pituitary occurs during ovulation? Receptors increase
The primary oocyte is arrested in what phase until ovulation first occurs? The primary (I) Oocyte gets stopped at meiosis I in prOphase until Ovulation
The secondary oocyte is arrested at which stage until fertilization occurs? The secondary (II) oocyte gets stopped at meiosis II in METaphase until it has MET a sperm (fertilization).
What happens to the secondary oocyte if fertilization does not occur? It degenerates
Why is the end product of oogenesis about the same size as the beginning egg? Have uneven division of cytoplasm so end up with one big ovum and a bunch of empty little polar bodies.
Where is the MC location for fertilization to occur? In the ampulla (upper part of fallopian tube).
How soon is beta hCG detectable in serum? How soon is it detectable in urine (home pregnancy tests)? Serum: 1 week after conception Blood: 2 weeks after conception
When does implantation occur? 6 days after after fertilization (about 3 weeks after last menstrual period)
What induces lactation post-labor? Decrease in progesterone (lose the placenta!)
How does suckling maintain milk production? Nerve stimulation increases oxytocin and prolactin
Which H can cause uterine contractions during breast feeding? Oxytocin
What is the source of beta hCG? Syncytiotrophoblast of the placenta
What structure provides progesterone (and eventually estriol) during each trimester? 1st: corpus luteum provides P (bHCG acts as LH to stimulate this) 2nd and 3rd: placenta takes over and synthesizes its own estriol and P (corpus luteum degenerates)
In which pathologic states is bHCG elevated? Hyatidiform moles, choriocarcinoma, and gestational trophoblastic tumors (testicular choriocarcinoma)
What are the hormonal changes seen in menopause? Decreased estrogen, and greatly increased LH and FSH (no neg feedback from E)
What are the symptoms of menopause? Hirsuitism, Hot flashes, Atrophy of the Vagina, Osteoporosis, and Coronary a disease (HHAVOC)
What is the best test to confirm menopause? Greatly increased FSH
How does smoking affect menopause? Causes earlier onset
What is the source of estrogen (estrone) after menopause? Peripheral conversion of androgens (increased androgens can cause hirsuitism)
Greatly increased levels of beta-hCG, diploid karyotype (e.g., 46, XX), uterine size large for gestational age, and vaginal bleeding Complete mole
What are the components of a complete mole? Does it have any fetal parts? 2 sperm + an empty egg. No fetal parts. Complete mole is Completely empty.
Increased levels of beta-hCG with triploid or tetraploid karyotype (e.g., 69, XXY), normal uterine size Partial mole
What are the components of a partial mole? Does it have any fetal parts? 2 sperm + 1 egg (PARTy inside the uterus with all those ppl). PARTial mole has fetal PARTs.
Which type of mole carries an increased risk of malignant conversion to choriocarcinoma? Complete mole (C for Choriocarcinoma Conversion)
Increased beta hCG, honeycombed uterus, cluster of grapes appearance, bleeding, snowstorm appearance with no fetus on first sonogram. Molar pregnancy (hyatidiform mole)
What causes a bicornate uterus (one of causes of miscarriages in the second trimester)? Incomplete fusion of paramesonephric ducts
What is the treatment for a hyatidiform mole? D+C and methotrexate (if beta-hCG levels do not go down on their own); (for a choriocarcinoma, tx with MTX, vincristine, and vinblastine)
HTN, proteinuria, and edema (although edema is no longer a requirement) in pregnancy Pre-eclampsia
HTN, proteinuria, edema, and seizures Eclampsia
Symptoms of eclampsia/pre-eclampsia prior to 20 weeks gestation suggests which obstetric abnormality? Molar pregnancy
What is the HELLP syndrome? What is mortality due to? HELLP= Hemolysis, Elevated Lft's, and Low Platelets. Mortality is due to cerebral hemorrhage and ARDS (respiratory distress)
Woman at 34 weeks gestation develops headaches, blurred vision, abdominal pain, edema of face and extremities, altered mentation, and hyperreflexia. After being admitted, she develops seizures. What does she have? What is the treatment? Eclampsia. Deliver fetus ASAP. Also give IV magnesium sulfate and diazepam (anti-seizant) to prevent and treat seizures.
Pregnant patient with increased BP, severe anemia, bruising or bleeding from gums, and jaundice. HELLP syndrome
Painful bleeding in 3rd trimester with detachment of placenta leading to fetal death. What are the risk factors? Abruptio placenta. Increased risk with smoking, HTN, and cocaine use.
Placenta attaches to myometrium and cannot detach during birth. Massive bleeding after delivery. What is the underlying cause? What are the predisposing factors. Placenta accreta. Underlying cause is defective decidual layer. Multiple pregnancies, inflammation, and prior C-sections predispose.
Painless bleeding during pregancy assoc'd with attachment of placenta to lower uterine segment (may occlude internal cervical os). What are the predisposing factors? Placenta previa. Multiparity and previous C sections predispose.
What is the MC site for an ectopic pregnancy? What is the treatment? Fallopian tubes. Treat with MTX.
What complication can retained placental tissue cause? Postpartum hemorrhage
What are the risk factors for an ectopic pregnancy (5)? 1. History of infertility 2. Salpingitis (PID) 3. Ruptured appendix 4. Prior tubal surgery 5. Current IUD
Which fetal abnormalities are assoc'd with polyhydramnios (>1.5L)? Esophageal/duodenal atresia (inability to swallow), anencephaly (loss of swallowing center b/c no brain)
Which fetal abnormalities are assoc'd with oligohydramnios (<0.5L)? Placental insufficiency, bilateral renal agenesis, or posterior urethral valves in males (inability to excrete urine)
Infant with flattened nose, recessed chin, epicanthal folds, low set ears, limb defects, and CV abnormalities. Also has plumonary hypoplasia. Potter's syndrome (oligohydramnios= not enough amniotic fluid)
What is the progression to cervical cancer? Dysplasia--> carcinoma in situ--> invasive carcinoma
Squamous cell CA with koilocytes assoc'd with multiple sex partners, smoking, early sexual intercourse, and HIV infection Invasive carcinoma of the cervix
Cyclic bleeding from locations outside the uterus; assoc'd with chocolate cysts Endometriosis
Severe pain that begins near or at the beginning of the menstrual cycle and ends when menstruation ends. Pathology is usually in ovary or peritoneum. Endometriosis
What is an endometrioma? Enlargment of ectopic endometriosis tissue during pregnancy.
Post-menopausal vaginal bleeding requires a work up for which diseases? Endometrial hyperplasia (precursor lesion) and endometrial CA
What happens to leiomyomas (fibroids) in the presence of estrogen? Increase in size with increased estrogen (e.g., in pregnancy) and decrease in size with decreased estrogen (e.g., during menopause )
Patient presents with signs of menopause after puberty but before the age of 40. What does she have and what will her labs show? Premature ovarian failure. Decreased estrogen, increased LH, and increased FSH.
What is the underlying problem in polycystic ovarian syndrome (PCOS)? Increased LH production (leads to anovulation, hyperandrogenism)
Give the 3 diagnostic criteria for PCOS. 1. Androgen excess (acne, hirsuitism) 2. Ovulatory dysfunction (amenorrhea, infertility) 3. Polycystic ovaries on ultrasound
30yo, obese woman complaining of amenorrhea and infertility presents with facial hair and insulin resistance. What test would you do to confirm your clinical suspicion? What is she at an increased risk for? Ultrasound. She probably has PCOS which increases her risk for developing endometrial cancer (high E levels w/out ovulation, so no P protection).
What drug should you offer a PCOS patient who wants to get pregnant? Clomiphene or metformin.
What drugs are used to treat PCOS? What is the reasoning behind each? Clomiphene and metformin treat infertility. OCPs provide E opposition by supplying P. Spironolactone opposes androgens. Also may suggest weight loss (helps with insulin resistance) or surgery.
Ovarian cyst: Often multiple/bilateral. Due to gonadotropin stimulation. Assoc'd with choriocarcinoma and moles. Theca-lutein cyst
E secreting primary ovarian tumor that predisposes to endometrial adenocarcinoma. Presents with abnormal bleeding and an adnexal mass on physical exam. Granulosa cell tumor
Blood containing cyst from ovarian endometriosis. Chocolate cyst
What are the tumor markers for a dysgerminoma? hCG and LDH (lactate dehydrogenase)
What are the tumor markers for a choriocarcionma? hCG
What is the tumor marker assoc'd with aggressive malignancy in ovaries (or testes in boys). Yellow friable, solid mass that may have Schiller-Duval bodies. What is the tumor marker? Yolk sac (endodermal sinus) tumor. Marker is AFP (America's Favorite Pancakes go great with eggs/yolk)
What are Schiller-Duval bodies? Blood vessels enveloped by germ cells; may be seen in yolk sac tumors
Which teratoma contains functional thyroid tissue. How can it present? Struma ovarii. Hyperthyroidism.
What is the most frequent benign ovarian tumor? Mature teratoma (dermoid cyst)
Painful mass in labia majora that requires draining and treatment with antibiotics. Bartholin gland cyst.
What are the genetic risk factors for serous cystadenocarcinoma? BRCA-1 and HNPCC
Bundles of spindle-shaped fibroblasts with pulling sensation in groin Fibromas
Vaginal carcinoma affecting women exposed to DES in utero. Clear cell adenocarcionma
Spindle shaped tumor cells of the vagina that affect girls <4 years of age. This tumor is a variant of what cancer? What does the tumor stain with? Sarcoma botryoides. Stains with desmin. Rhabdomyosarcoma variant.
Small tumor beneath the areola that presents with straw colored discharge. Intraductal papilloma. Increased risk for carcinoma.
Galactorrhea, amneorrhea, and bitemporal hemianopia. Prolactinoma (most common pituitary adenoma)
Central acinar compression and distortion (by surrounding fibrotic tissue) and peripheral ductal dilation. Common finding in fibrocystic change. Sclerosing adenosis
Adnexal mass in an elderly female. Most likely diagnosis? What levels should be checked? Ovarian cancer. Check CA-125 levels.
Ductal dilation, ispissated (dried up) breast secretions, and chronic granulomatous inflammation in the periductal or interstitial areas. Mammary duct ectasia (ectasia= dilation, like bronchiECTASIs)
Precursor lesion for invasive (infiltrating) ductal carcinoma of the breast. DCIS (Ductal carcinoma in situ)
Breast cancer that tends to metastasize to peritoneum. What is the mechanism of metastasis? Invasive lobular CA; mechanism of via loss of E cadherins
Dimpling of breast suggests what underlying pathology? Suspensory ligament involvement in breast CA.
New nipple retraction suggests what underlying pathology? Lactiferus duct involvement in breast CA.
What is the most common pathogen in breast feeding mastitis? What is the treatment? S aureus. Keep breastfeeding to drain and clear infection (not harmful to infant)
Which drugs cause gynecomastia? Spironolactone, Digitalis, Cimetidine, Alcohol, Ketoconazole (Some Drugs Create Awesome Knockers); also estrogen, marijuana, and neuroleptics
How is leuprolide different when given in a pulsatile fashion and when given in a continuous fashion? Pulsatile: GnRH agonist; treats infertility Continuous: GnRH antagonist; treats prostate cancer (w/flutamide) and uterine fibroids
What are the contraindications for estrogen therapy? ER positive breast cancer or history of DVTs
Estrogen therapy can be used to treat which male cancer? Androgen-dependent prostate cancer
How does clomiphene work? Partial agonist at estrogen receptors in hypothalamus; prevents normal feedback inhibition and increases LH and FSH from pituitary to stimulate ovulation; treats infertility and PCOS
Woman comes in with visual disturbances, hot flashes, adnexal mass, and six fetuses on ultrasound. What drug was she probably taking? Clomiphene
Which SERM is a bone and endometrial agonist? Tamoxifen (increased risk of endometrial CA)
Which SERM is a bone agonist only? Raloxifene (use to treat osteoporosis; no increased risk of endometrial CA)
What are anastrazole and exemestane? What is their clinical use? Aromatase inhibitors (aromatase converts androstenedione to estrogen in the granulosa cells). Used in post-menopausal women with breast cancer.
Competitive inhibitor of progestins at progesterone receptors. What agent is it administered with? Why? Mifepristone (RU-486); induces abortion. Administered with misoprostol, a PGE1, b/c it causes the uterus to contract.
How do OCPs work? No LH surge so no ovulation
Which has a lower dose of E- HRT or OCPs? HRT (this is why we give HRT to treat symptoms of menopause, rather than OCP which carries higher risk for endometrial CA)
Which PGE2 analog causes cervical dilation and uterine contraction, inducing labor? Dinoprostone
Name 2 Beta 2 agonists that relax the uterus and reduce premature uterine contractions. Ritodrine and terbutaline (Ritrodrine allows fetus to REturn TO DREAMS by preventing early delivery and Terbutaline keeps those early contractions from TEaRing your BUTt up!)
Name 2 contraindications for OCP use. What risk are these contraindications assoc'd with? Smoker over 35yo and migraines with aura. Assoc'd with increased risk of thromboembolic event (DVT).
Primary amenorrhea in a patient with fully developed secondary sex characteristics. Suggests presence of an anatomic defect in the genital tract such as an imperforate hymen or Mullerian duct abnormalities.
What hormone levels would you expect to see in a Turner's patient with primary amenorrhea? Elevated LH and FSH
What is the primary MOA of OCPs? Suppression of gonadotropins FSH and LH in anterior pituitary--> inhibition of ovulation
Created by: sarah3148



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