Term
| Describe the venous drainage of the gonads. |
|
Definition
Flow through left spermatic vein is less, since it enters renal vein at 90 degree angle (Varicocele occurs on left)
1) Left ovary-testis---left gonadal vein---left renal vein---IVC
2) Right ovarian/testis---right gonadal vein----IVC |
|
|
Term
| Describe the lymphatic drainage of the gonads. |
|
Definition
1) Ovaries/testes
- para-aortic lymph nodes (metastatic site for cancers)
2) Distal 1/3 of vigain/vulva/scrotum
- Superficial inguinal
3) Proximal 2/3 of vagina/uterus
- Opturator, external iliac and hypogastric |
|
|
Term
What lymphatics drain each of the following?
1) Distal 1/3 of vagina/vulva/scrotum
2) Testis/Ovary
3) Proximal 2/3 of vagina/uterus |
|
Definition
1) Superficial inguinal nodes
2) Para-aortic LN
3) Obturator, hypogastric and external iliac. |
|
|
Term
| Describe the anatomy of the female reproductive tract as if you were entering form the vagina. |
|
Definition
- Vaginal canal leads to cervical Os, which marks the beginning of the cervix
- Cervix continues into the uterus, which is supplied by the uterine artery and consists of endometrium and myometrium
- Body of cervix continues to become fundus, where uterine tubes enter
- Uterine tubes connect to ovaries at Fimbriae |
|
|
Term
What structures are connected by and contained within each of the following ligaments in the female reproductive tract?
1) Suspensory ligament
2) Cardinal ligament
3) Round ligament
4) Broad ligament
5) Ligament of the ovary |
|
Definition
1) Connects ovaries to lateral pelvic wall and contains ovarian vessels
2) Connects Cervix to side of the pelvis and contains the uterine vessels
3) Connects uterine fundus to labia majora
- Derivative of gubernaculum that travels through round canal and contains no structures.
4) Connects Uterus, fallopian tubes and ovaries to pelvic side wall, containing the fallopian tubes, ovaries and round ligaments of uterus
5) Connects ovary to lateral uterus |
|
|
Term
| What are the sub-divisions of the broad ligament? |
|
Definition
Broad ligament connects ovaries, fallopian tubes and cervix to pelvic side wall (also contains round ligament)
1) Mesosalpynx (tubes)
2) Mesometrium (uterus)
3) Mesovarium (ovary) |
|
|
Term
Ovariectomy and Hysterectomy both carry risk of ureter damage.
Which ligaments might be damaged during these procedures? |
|
Definition
1) Ovarian vessles contained within Suspensory ligament, which connects ovaries to lateral pelvic wall
2) Uterine vessels contained within cardinal ligament, which connects cervix to side of pelvic wall |
|
|
Term
| What ligaments secure the ovaries in place in the female reproductive tract? |
|
Definition
1) Suspensory- to lateral pelvic wall and contains ovarian vessels
2) Ligament of ovary- to Lateral uterus
3) Broad- To pelvic side wall |
|
|
Term
What is the histological subtype of epithelium in the following female reproductive structures?
1) Ovary
2) Fallopian tube
3) Uterus
4) Endocervix
5) Ectocervix
6) Vagina |
|
Definition
1) Simple cuboidal
2) Simple columnar, ciliated
3) Simple columnar, pseudostratified, tubular glands
4) Simple columnar
5) Stratified squamous
5) Stratified squamous, nonkeratinized |
|
|
Term
| What is the basic pathway of sperm during ejaculation? |
|
Definition
SEVEN UP
1) Seminiferous tubules
2) Epididymus
3) Vas deferens
4) Ejaculatory duct
5) (nothing)
6) Urethra
7) Penis |
|
|
Term
| Describe the anatomical organization of the testis as it relates to sperm production. |
|
Definition
1) Outer tunica albuginea, which forms septae that interdigitate with seminiferous tubules
2) Inner Seminferous tubules produce sperm (spermatogonia, spermocytes, spermatids and spermatozoa) that are carried to the Rete testes, and emptied into the tail of the Epididymus
3) Epididymus gives sperm to Vas deferens, which takes it to the ejaculatory duct. |
|
|
Term
What is the autonomic innervation of the male sexual response in terms of
1) Erection
2) Emission
3) Ejaculation |
|
Definition
Para, Symp and visceral/somatic
Pelvic, Hypogastric and Pudendal
1) Parasympathetic (Pelvic nerve, S2-S4)
- vessels dilate in ischiocavernous sinuses
- NO increases cGMP, which relaxes smooth muscle and causes vasodilation
- NE increases Ca, which contracts smooth muscle and leads to vasoconstriction (loss of erection)
2) Sympathetic nervous system (hypogastric nerve T12-L1)
3) Visceral and somatic nerves (pudendal, S2-S4)
- Rythmic contractions of bulbospongiosis and ischiocavernosis |
|
|
Term
| Describe the major steps of sperm production in the seminiferous tubules. |
|
Definition
Spermatogenesis begins at puberty with spermatogonia and takes 2 months to produce spermatids (which undergo spermiogenesis)
1) Spermatogonia (germ) cells are Diploid (2N 2C) and line S. tubules
2) Primary spermatocytes are diploid (2N 4C)
3) Secondary spermatocytes are haploid (2N 2C)
4) Spermatids are haploid (1N 1C)
- Undergo spermiogenesis with cytoplasmic rearrangements and formation of acrosomal cap
5) Spermatozoa are haploid (1N)
- Mature sperm that are collected at Rete testes |
|
|
Term
| What are the 3 major cell types found in the seminiferous tubules and what are they functions? |
|
Definition
1) Spermatogonia lining tubules
- Maintain germ pool and produce primary spermatocytes
2) Sertoli cells (non-germ)
- Line seminiferous tubules and support sperm synthesis
- Form BTB with tight junctions (isolate from autoimmune attack)
- Produce inhibin, AMH and androgen-binding protein
**temperature sensitive**
3) Interstitial Leydig cells (endocrine)
- Secrete testosterone (unaffected by temperature) |
|
|
Term
| Why does increased temperature in a Varicocele or Cryptochordism endanger male fertility? |
|
Definition
Serotoli cells in seminiferous tubules are temperature sensitive
As temperature increases, sperm production and inhibin production decreases (seminoma issue) |
|
|
Term
| How is spermatogenesis regulated by the pituitary and hypothalamus? |
|
Definition
1) Hypothalamus produces GnRH, which stimulates Pituitary production of LH and FSH
2) FSH activates Sertoli cells to produce ABP and Inhibin, and LH activates Leydig cells to produce tesosterone
3) Inhibin and Testosterone inhibit pituitary release and Testosterone inhibits Hypothalamic release of GnRH |
|
|
Term
| What are the major Androgens, where are they produced and what are their functions? |
|
Definition
1) Testosterone (Testis by Leydig cells)
- Differentiation of epididymis, vas deferens and seminal vesicles (internal genitalia except prostate)
- Growth spurt
- Voice deepening
- Closure of epiphyseal plates (via converted estrogen)
- Libido
2) DHT (Testis by 5-alpha reductase)
- Most potent
- Early (differentiation of penis, scrotum and prostate)
- Late (prostate growth, balding and sebaceous gland activity)
3) Androstenedione (Adrenal)
**Testosterone and Adrostenedione are converted to estrogen by aromatase in Leydig cells and Adipose** |
|
|
Term
| Why might testosterone injections cause azospermia? |
|
Definition
| Exogenous testosterone inhibits the HPG axis, decreasing intratesticular testosterone and reducing testicular size. |
|
|
Term
| Where is testosterone and androstenedione converted to estrogen? |
|
Definition
|
|
Term
| Why might a patient who is balding and suffers from BPH be placed on Finestride? |
|
Definition
5-alpha hydroxylase inhibitor which prevents testosterone conversion to DHT
Remember, early on DHT is responsible for differentiation of external genitalia, but later it leads to prostate hyperplasia, balding and sebaceous gland activity. |
|
|
Term
| Where is estrogen produced and what are its major functions? |
|
Definition
Pulsatile GnRH release stimulates FSH/LH release from anterior pituitary
1) Source
- Ovary (17b-estradiol), Placenta (estriol), Blood (aromatization)
- Potency: Estradiol > Estrone > Estriol
2)
- Development of genitalia and breast, female fat distribution
- Growth of follicle, endometrial proliferation and increased myometrial excitability
- Upregulation of estrogen, LH and progesterone receptors; feedback inhibition of FSH and LH, then LH surge
- Increased transport proteins (SHBG), increased HDL, decreased LDL |
|
|
Term
| How is estrogen produced in the ovaries and what type of receptor does it bind to? |
|
Definition
1) Production
- GnRH stimulation of pituitary causes FSH/LH release.
- LH stimulates Theca cells to produce androstenedione from cholesterol (Desmolase)
- FSH stimulates Aromatase production in granulosa cells, which converts androstenedione to Estrogen
2) ER
- Cystoplasmic receptors that migrate to nucleus and regulate transcription. |
|
|
Term
| What is the differential potency of different estrogens and what happens to their levels during pregnancy? |
|
Definition
1) Potency
- Estradiol (ovary)> Estrone> Estriol (placenta)
2) 50X estradial and estrone
1000X estriol (indicator of fetal well-being) |
|
|
Term
Which of the following is NOT a function of progesterone?
1) Stimulation of endometrial glandular secretions and spiral artery development
2) Maintenance of pregany
3) Increased myometrial contractility
4) Inceased body temperature
5) Thickening of cervical mucus to inhibit sperm entry
6) Decreased ER expressivity |
|
Definition
Produced by Corpus luteum, Placenta, Adrenal cortex and Testes
3- Progesterone (as opposed to estrogen), inhibits myometrial contractility and relaxes uterine smooth muscle to prevent contractions during early pregnancy. |
|
|
Term
What is an elevated progesterone level indicative of?
Where is it produced? |
|
Definition
1) Ovulation (36 h after estrogen surge, egg is released from follicle and corpus luteum forms and begins producing progesterone)
2) Produced by Corpus luteum, Placenta, Adrenal cortex and Testes |
|
|
Term
| What are the 5 Tanner stages of sexual development? |
|
Definition
1) Childhood
2) Pubic hair appears (adrenarche); breasts enlarge
3) Pubic hair darkens and becomes curly; penis size/length increases
4) Penis width increases, darker scrotal skin, development of glans, raised areolae
5) Adult; areolae are no longer raised. |
|
|
Term
| What are the major events of the proliferative (follicular) and secretory (luteal) phases of the menstrual cycle? |
|
Definition
Proliferative varies but Secretory is constant (14d)
1) Proliferative (estrogen)
- Primary follicles mature (FSH dependent) most rapidly in second week.
- Estrogen levels rise and initiate LH surge around day 12-14
2) Luteal (progesterone)
- 36h after estrogen surge, ovulation occurs and corpus luteum forms.
- Leutinization of corpus luteum cells is required for progesterone production, which maintains the endometrium for implantation |
|
|
Term
What do each of the following terms mean in reference to the menstrual cycle?
1) Oligomenorrhea
2) Polymenorrhea
3) Metrorrhagia
4) Menometrorrhagia |
|
Definition
1) >35d cycle
2) <21d cycle
3) Frequent but irregular menstruation
4) Heavy, irregular menstruation at irregular intervals |
|
|
Term
| How is ovulation induced during the menstrual cycle? |
|
Definition
1) Estrogen consistently rises during the proliferative phase and leads to increased GnRH receptors on the anterior pituitary.
2) Near the end of the 2nd week of the proliferative phase, Rising estrogen levels lead to LH surge, which induces follicular rupture.
3) Estrogen then declines and Progesterone rises marking the Luteal phase.
Body temperature increases due to progesterone |
|
|
Term
|
Definition
| When blood from ruptured follicle causes peritoneal irritation that can mimic appendicitis |
|
|
Term
| Describe the stages of Oogenesis. |
|
Definition
Primary oocytes begin meisosis I in fetal development but are arrested in prophase 1 until ovulation.
Secondary oocytes are arrested in metaphase II until fertilization
1) Oogonium (2N2C)
2) Primary Oocyte (2N4C)
Ovulation
3) Secondary Oocyte (1N2C) and Polar body
- Will degenerate without sperm
Fertilization
4) Ovum haploid (1N 1C) and second polar body
4) |
|
|
Term
| In which stage of development are primary and secondary oocytes arrested in before ovulation and after ovulation, but prior to fertilization? |
|
Definition
1) - Prophase 1 (2N4C)
- Diploid
2) > Ovulation and < Fertilization
- Metaphase II (1N2C)
- Haploid |
|
|
Term
| When and where do fertilization and implantation occur? |
|
Definition
hCG is produced 1 week after conception and 2 weeks after on home test (Trophoblasts)
1) Fertilization
- 1 day after ovulation in upper fallopian tube (ampula)
2) Implantation
- 6 days are fertilization in posterior wall of uterus |
|
|
Term
| When does lactation begin and how is it maintained? |
|
Definition
Lactation begins after labor, when decreased progesterone removes blockage on prolactin production
Suckling gives nervous stimulation to induce production of oxytocin and prolactin in hypothalamus
- Prolactin (induces and maintains lactation, while inhibiting reproductive function)
- Oxytocin- Milk let-out and possibly uterine contractions |
|
|
Term
| What are the functions of hCG and where is it made? |
|
Definition
1) Produced by Syncytiotrophoblast of placenta (arising from chorion that fuses with decidua basalis)
2) Functions
- Maintains corpus luteum (progesterone production) for 1st trimester, until placenta starts to synthesize its own estriol and progesterone and the CL degenerates. |
|
|
Term
| When does the corpus luteum degenerate during pregnancy and why does this happen? |
|
Definition
| 2nd/3rd trimester when placenta begins to produce its own estriol and progesterone, and the CL is no longer required (hCG support drops off). |
|
|
Term
| What does an elevated hCG level indicate during 2nd/3rd trimester? |
|
Definition
| Possible hydatidiform mole (complete or partial), choriocarcinoma and/or gestational trophoblastic tumor |
|
|
Term
| What are the physical signs/symptoms of menopause and why do they occur? |
|
Definition
Menopause causes HHAVOC with low estrogen, high FSH, high LH (no surge) and high GnRH
1) Hirsutism (peripheral conversion of androgens is only way to make estrone)
2) Hot flashes
3) Atrophy of Vagina
4) Osteoporis (loss of estrogen)
5) Coronary artery disease (estrogen drops and HDL drops) |
|
|
Term
True or False:
High FSH/LH levels and low estrogen levels in a 38 year old woman experiencing hot flashes could indicate premature ovarian failure. |
|
Definition
True: Early menopause due to premature ovarian failure or smoking
Premature ovarian failure is atresia of follicles in women of reproductive age (<40)
Average age is 51 |
|
|
Term
What is the best test to confirm menopause?
When might you see this in a smoker? |
|
Definition
FSH (very high due to loss of negative feedback by estrogen).
Early in smokers and those with premature ovarian failure |
|
|
Term
What are the pathological manifestations associated with each of the following karyotypes?
1) XXY male
2) XO female
3) XYY male |
|
Definition
1) Klinefelter's syndrome (1:850)
- Hypogonadism with dysgenesis of seminiferous tubules (low inhibin and high FSH) and abnormal Leydig cell function (Low testosterone, high LH and high Estrogen)
- Testicular atrophy, eunochoid obody shape, tall, long extremities, gynecomastia, female hair distribution
2) Turner's syndrome (1:1000)
- Menapause before menarche (low estrogen leads to increased FSH/LH)
Short stature with ovarian dysgenesis (stream ovary), bicuspid aortic valve, lymphatic defects (web neck) and lymphedema in feet and hands
3) Turner's syndrome
- Phenotypically normal, very tall, severe acne and antisocial behavior (seen in 1-2% of XYY males). Normal fertility with small % of ASD |
|
|
Term
A 17 year old female presents with short stature, shield chest and "webbing" of the neck.
She has never had her period.
What congenital defects are associated with this condition and what is they karyotype? |
|
Definition
Turner syndrome (XO)
- Menopause before menarche with low estrogen and high LH/FSH
1) Bicuspid aortic valve and pre-ductal coarctation
2) Horseshoe kidney (inferior mesenteric artery prevents ascent)
3) Lymphedema in hands/feet
4) Dysgerminoma most common cause of primary amenorrhea (analogue to seminoma in male) |
|
|
Term
20 year old male presents complaining of "large breasts." He is tall and has a eunuchoid body shape, long extremities and a feminine hair distribution.
What are the common complications of this condition? |
|
Definition
Klinefelter's syndrome [male]- XXY (1:850)- Hypogonadism
1) Dysgenesis of seminiferous tubules leads to decreased inhibit (sertoli cells) and increased FSH (no negative feedback)
2) Abnormal leydig cell function with low testosterone and high LH and estrogen.
- presence of inactivated X chromosome (Barr body) |
|
|
Term
A very tall male presents complaining of severe acne. You notice avoidance and anti-social behavior in your office.
What should you tell him about his fertility status while treating his acne? |
|
Definition
This is Turner's syndrome in a XYY male.
- They have NORMAL fertility
- This guy sounds like he has ASD, which occurs in a sub-group of patients |
|
|
Term
What diagnosis fits the following sex hormone levels?
1) High Testosterone and Low LH
2) High Testosterone and high LH
3) Low Testosterone and low LH
4) Low Testosterone and high LH |
|
Definition
1) Testosterone-secreting tumor or exogenous steroids
2) Defective androgen receptor
3) Hypogonadotropic hypogonadism
4) Primary hypogonadism |
|
|
Term
What is Pseudohermaphoditism?
How would a female pseudohermaphrodite differ from a male pseudohermaphrodite? |
|
Definition
Disagreement between phenotype (external genitalia) and gonadal (tests vs. ovaries) sex
1) Female (XX) would have ovaries, but external genitalia that are virilized or ambiguous.
- Excessive and inappropraite androgenic steroid exposure during early gestation (CAH or exogenous administration)
2) Male (XY) would have testes, but external genitalia that are female or ambiguous.
- Androgen insensitivity (testicular feminization) would cause this. |
|
|
Term
| How does Pseudohermaphoditism differ from "True" hermaphoditism? |
|
Definition
Pseudohermaphoditism involves appropriate internal gonads, but inappropriate external sex structures (CAH in females or Androgen insensitivity in males)
"True" hermaphroditics have both ovary and testicular tissue (ovotestis) and is VERY RARE> |
|
|
Term
| How might a patient with androgen insensitivity and XY karyotype present? |
|
Definition
High testosterone, estrogen and LH
- Defect in androgen receptor resulting in normal-appearing female; female external genitalia with rudimentary vagina
- Uterus and uterine tubes are absent and no sexual hair is present
- Patient develops testes because of Y chromosome (surgically removed) |
|
|
Term
| How might a genetic male with congenital 5-alpha-reducate deficiency present? |
|
Definition
"Penis at 12"- Autosomal recessive
Male has testosterone and Y chromosome, so internal gonads (testes) are normal (Y).
External genitalia are ambiguous until puberty, when increase in testosterone causes masculiziation/growth of external genitalia.
Normal testosterone/estrogen levels with normal/increased LH |
|
|
Term
| What is Kallman syndrome and how does it present? |
|
Definition
AD disease
- Defective development of GnRH cells (low FSH/LH, testosterone and sperm count) and and olfactory placode (anosmia)
- Lack of secondary sexual characteristics |
|
|
Term
What is a Hydatidiform mole?
What are the two forms and their associated genotypes?
Which type is a cancer risk? |
|
Definition
1) Cystic swelling of chorionic villi and proliferation of chorionic epithelium (trophoblast) that presents with abnormal vaginal bleeding
2) Types
- Complete (46, XX or XY): 2 sperm and empty egg
- Partial (69, XXX, XXY or XYY): 2 sperm and 1 egg
3) Complete is 2% risk of choriocarcinoma and 15-20% risk of malignant trophoblastic disease |
|
|
Term
| How does a complete hyatidiform mole present? |
|
Definition
2 sperm + empty egg with 15-20% malignant trophoblastic disease
- Increased beta-hCG with abnormally large, "honeycombed uterus," with a "cluster of grapes" appearance.
- Risk of uterine rupture
- Often see vaginal bleeding with no fetus during 1st sonogram ("snowstorm appearance") |
|
|
Term
| How would you treat a pregnant woman who presents with vaginal bleeding and has a uterus that looks like a "cluster of grapes," with a no evidence of a fetus on the 1st sonogram? |
|
Definition
Hyatidiform mole (complete or partial).
Dilation and Curettage with MTX (follow up by monitoring beta-hCG) |
|
|
Term
| What is the major difference between sex chromosome disorders and sex hormone deficiency/insensitivity syndromes? |
|
Definition
Chromosome disorders like Kleinfelter's (XXY) and Turner's (XO) will have absent/dysfigured gonads because of lacking X or Y chromosome.
Androgen deficiency/insensitivity tend to have normal gonads, but abnormal secondary sex characteristics and external structures |
|
|
Term
| How could you tell the difference between a male with Androgen insensitivity and 5-alpha-reducatse deficiency? |
|
Definition
1) Androgen insensitivity in a male involves normal gonads, but female external genitalia
- High testosterone, estrogen and LH
2) 5-alpha reductase deficiency may have ambiguous genitalia until puberty, but then will grow a normal penis as testosterone levels rise.
- Testosterone/estrogen levels are normal and LH is normal/increased. |
|
|
Term
| Describe the pathophysiological basis for the condition that affects women between 20 weeks gestation and 6 weeks post-partum, causing hypertension, proteinuria and edema. |
|
Definition
1) Pre-eclampsia (before 20 weeks suggests molar pregnancy)
- Placental ischemia due to impaired vasodilation of spiral arteries (superficial invasion by chorion is insufficient for vascular remodeling), resulting in increased vascular tone
2) Eclampsia- + seizures |
|
|
Term
| What are the major risk factors associated with pre-eclampsia and what is mortality generally due to? |
|
Definition
Associated with HELLP syndrome (Hemolysis, Elevated LFTs and Low platelets)
1) Diabetes, pre-existing hypertension, chronic renal disease, autoimmune diseases
2) Cerebral hemorrhage and ARDS |
|
|
Term
32 year old diabetic women who is 40 weeks gestation presents with headache, blurred vision and abdominal pain.
On PE, you note edema of face and extremities, with hyper-reflexia and altered mentation.
You order labs and detect thrombocytopenia.
What do you do? |
|
Definition
Evidence of pre-eclampsia with risk factor (diabetes) and correct timing during pregnancy.
Thrombocytopenia makes you worry about HELLP syndrome, so you should order LFTs and a CBC as well.
1) IV Mg sulfate and diazepam to prevent Eclampsia and seizures and treat HTN
2) Delivery is only true treatment |
|
|
Term
| Why should you be concerned if a pregnant women presents with blurry vision, headache, abdominal pain and facial edema at 10 weeks gestation? |
|
Definition
Signs of pre-eclampsia (placental ischemia) prior to 20 weeks gestation indicates molar pregnancy.
Treat with D & C and MTX (monitor beta-hCG and well) |
|
|
Term
Describe what happens in each of the following complications of pregnancy.
1) Painful bleeding in 3rd trimester
2) Massive bleeding after delivery
3) Painless bleeding in any trimester
4) Sudden lower abdominal pain with increased hCG and +/- bleeding
5) Retained placental tissue |
|
Definition
1) Abruptio placentae
- Premature detachment of placenta from implantation site leading to Fetal death
- Associated with DIC, smoking, HTN and cocaine use
2) Placenta accreta
- Defective decidual layer allows placenta to attach to myometrium, so it cannot separate at birth.
- Risk with prior C-section, inflammation and placenta privia
3) Placenta previa
- Attachment of placenta to lower uterine segment, potentially occluding internal os.
- Risk with multiparity and prior C-section
4) Ectopic pregnancy (most often in tubes)
- Confirm with US
- Risk with h/x of infertility, salpingitis (PID), ruptured appendix and prior tube surgery. |
|
|
Term
What complications of pregnancy are women with each of the following risk factors predisposed to?
1) DIC, smoking, HTN and/or cocaine
2) Multiparity
3) Prior C section
4) h/x of infertility and/or salpingitis (PID) |
|
Definition
1) Abruptio placentae
- Premature detachment of placenta from implantation site leading to Fetal death
2) Placenta previa (risk for accreta)
- Attachment of placenta to lower uterine segment, potentially occluding internal os.
3) Placenta accreta or privia
- Defective decidual layer allows placenta to attach to myometrium, so it cannot separate at birth.
4) Ectopic pregnancy (most often in tubes)
- Confirm with US |
|
|
Term
| Why is retained placental tissue after delivery of clinical concern? |
|
Definition
| Post-partum hemorrhage (sheehan's post-partum necrosis with hypopituitarism) |
|
|
Term
What are the risk factors for each of the following?
1) Attachment of placenta to lower uterine segment, occluding internal Os
2) Pregnancy in Fallopian tubes
3) Defective decidual layer of placenta that allows attachment to myometrium and prevents separation at birth
4) Premature detachment of placenta from implantation site |
|
Definition
1) Placenta previa
- Painless bleeding in any trimester
- Risk with multiparity and prior C-section)
2) Ectopic pregnancy
- Confirm with US and may look like appendicitis (high hCG though)
- Risk with h/x of infertility, salpingitis (PID), ruptured appendix and prior tube surgery.
3) Placenta accreta
- Massive bleeding after delivery
- Risk with prior C-section, inflammation and placenta privia
4) Abruptio placentae
- Painful vaginal bleeding in 3rd trimester
- Associated with DIC, smoking, HTN and cocaine use |
|
|
Term
| What defines Polyhydramnios vs. Oligohydramnios? |
|
Definition
Amniotic fluid abnormalities (Normal 0.6-1.4L)
1) Polyhydramnios
- >1.5 L of fluid; associated with esophageal/duodenal atresia, causing inability to swallow fluid with anencephaly
2) Oligohydramnios
- <0.5 L; associated with placental insufficiency, bilateral renal agenesis or posterior urethral valves (in males) and resultant inability to excrete urine
**Can give rise to Potter's syndrome** |
|
|
Term
| What is "Potter's sequence" and what is it related to? |
|
Definition
Triad of Clubbed feet, Pulmonary hypoplasia and Cranial anomalies related to the oligohydramnios.
Oligohydramnios (<0.5 L) comes from placental insufficiency, bilateral renal agenesis or posterior urethral valves, all of which impede urination. |
|
|
Term
| What is the most common cervical cancer and what are its classic features? |
|
Definition
Squamous cell carcinoma beginning at squamo-columnar junction: associated with HPV 16 and (E6 inhibits p53) and 18 (E7 inhibits Rb)
1) Preceded by dysplasia and carcinoma in-situ (CIN 1, 2 or 3)
- Pap smear often catches cervical dysplasia cells (Koilocytes) with raisinoid nuclei and perinuclear halo clearing, prior to invasion
2) Lateral invasion blocks ureters, causing renal failure |
|
|
Term
| What are the risk factors for developing cervical cancer? |
|
Definition
Usually squamous cell carcinoma related to HPV 16,18
**May progress slowly if left untreated, but Vaccine is available**
1) Multiple sexual partners (#1)
2) Smoking
3) Early sexual intercourse
4) HIV infection |
|
|
Term
Women who recently gave birth presents with abdominal pain, fever, uterine tenderness and menstrual abnormalities.
What are the major causes of Endometritis and how do you generally treat? |
|
Definition
1) Inflammation of endometrium associated with retained products of conception following delivery or foreign body (IUD).
- Retained material promotes bacterial infection by flora from vagina or intestinal tract
2) Treat with
- Cefoxitin (HEN PEcKs)
- Ticarcillin-clavulanate (Pseudomonas)
- Ampicillin-sulbactam (HELPSS enterococci) |
|
|
Term
Why might a women present with severe menstrual-related pain, pain with intercourse and cyclic bleeding episodes associated with dark, blood-filled cysts?
What would you do? |
|
Definition
Endometriosis (chocolate cysts of uterine tissue in ovary or peritoneum)
1) Non-neoplastic endometrial glands/stroma in abnormal location outside of uterus, often brought on by retrograde menstrual flow
2) Danazol
- inhibits ovarian steroidogenesis resulting in decreased secretion of estradiol |
|
|
Term
| How does Endometriosis differ from Adenomyosis in terms of pathology and clinical presentation? |
|
Definition
Endometriosis will have normal sized uterus, while Adenomyosis will have enlarged uterus
1) Endometriosis- Non-neoplsatic endometrial glands/stroma in abnormal locations outside of uterus
- Morrhagia, dysmenorrhea, dyspareunia, infertility and NORMAL-sized uterus
- Treat with Danazol
2) Adenomyosis- Endometrium within myometrium
- Menorrhagia, dysmenorrhea, pelvic pain and ENLARGED uterus
- Treat with hysterectomy |
|
|
Term
Women presents with postmenopausal vaginal bleeding.
What are the risk factors for developing endometrial hyperplasia and why is it of clinical concern? |
|
Definition
Abnormal gland proliferation due to excess estrogen.
1) Risk Factors
- Anovulatory cycling
- Hormone replacement
- PCOS
- Granulosa cell tumor
2) Endometrial adenocarcinoma
- Age 55-65
- increased myometrial invasion indicates worse prognosis |
|
|
Term
| What are the major risk factors for Enometrial cancer? What is the most common benign tumor and malignant tumor? |
|
Definition
1) Risk factors
- Endometrial hyperplasia
- Estrogen w/o progestin
- Obesity/diabetes/HTN
- Nulliparity
- Late menopause/early menarche
2) Most commons
- Leiomyoma (benign fibroids that present with multiple tumors with well-demarcated borders).
- Endometrial Adenocarcinoma (most common gynecological malignancy) |
|
|
Term
| What are Leiomyomas and what is their relation to Leiomyosarcoma? |
|
Definition
1) Leiomyomas are the most common benign tumors in females.
- Benign estrogen-sensitive fibroids composed of smooth muscle ("Whorled pattern of muscle bundles" that present as multiple tumors with well-demarcated borders
- Peak age 20-40 (more in blacks)
2) No progression to leiomyosarcoma and generally asymptomatic (unless present with abnormal uterine bleeding/miscarriage that can lead to iron deficiency)
- Leiomyosarcomas are bulky, irregular tumors with necrosis and hemorrhage that arise de novo and tend to invade cervix and bleed |
|
|
Term
| What are Leiomyosarcomas? |
|
Definition
Rare, bulky, irregular smooth muscle tumors of the uterus that typically arise de novo (e.g. not from leiomyoma) and protrude into cervix causing bleeding.
- Invasive with high recurrence risk
- Peak middle-aged
- Increased risks in blacks |
|
|
Term
| What are the more common gynecological cancers in the US and which have the best/worst prognosis |
|
Definition
1) Common: Endometrial> Ovarian> Cervical (cervical is most worldwide)
2) Severity: Ovarian> Cervical> Endometrial |
|
|
Term
| What are the most common causes of anovulation? |
|
Definition
1) PCOS (most common)
2) HPO axis abnormalities
3) Premature ovarian failure
4) Hyperprolactinemia
5) Thyroid disease
6) Eating disorders
7) Cushing's
8) Adrenal insufficiency |
|
|
Term
Which of the following would NOT cause anovulation?
1) PCOS
2) Thyroid disease
3) Growth hormone-secreting tumor
4) Hyperprolactinemia
5) Cushing syndrome |
|
Definition
| 3- This would cause acromegaly and fasting hyperglycemia, but not anovulation. |
|
|
Term
Why do you see anovulation in Polycystic ovarian syndrome?
What are the LH/FSH/testosterone/estrogen levels and why? |
|
Definition
High LH, testosterone and estrogen (aromatization) and Low FSH
1) Increased LH production leads to anovulation (prevents LH surge)
2) Hyperandrogenism is due to deranged steroid synthesis by theca cells |
|
|
Term
38 year old woman presents complaining of "man hair on her face and pimples." She has not had her period for 3 months and she has a BMI of 38.
What is the pathophysiology underlying this condition and why/how would you treat it? |
|
Definition
1) Hirsutism/acne, Obesity and Anovulation suggests PCOS.
High LH, low FSH, high estrogen/testosterone
- High LH causes anovulation/infertility
- Androgens from deranged theca cells produce hirsutism.
2) Associated with insulin resistance and risk of endometrial cancer (estrogens from aromatization of testosterone in fat)
- Treat with weight reduction, low-dose OCPs or medroxyprogesterone (decrease LH and androgenesis), spironolactone (treats acne and hirsutism), clomiphere (if they want to get pregnant) |
|
|
Term
Which of the following drugs would you NOT give to treat PCOS and why would you give the others?
1) Low-dose OCP
2) Spironolactone
3) Thiazide diuretic
4) MEdroxyprogesterone
5) Clomiphene |
|
Definition
3- If she has hypertension, this would work, but hypertension is not necessarily associated with PCOS
- OCP or Medroxyprogesterone will take down LH levels and androgenesis
- Spironolactone treats acne and hirsutism
- Clomiphene will start pumping the hypothalamus if they want to get pregnant (SERM) |
|
|
Term
| Why do patients with PCOS has enlarged, bilateral cystic ovaries? |
|
Definition
Patients present with amenorrhea, infertility, obesity and hirsutism.
Low FSH levels cause follicles to regress and die, leaving cystic spaces in ovaries that are large because of excess LH/androgens. |
|
|
Term
Which of the following ovarian cysts are dangerous/benign?
1) Follicular
2) Corpus luteum
3) Theca-lutein
4) Hemorrhagic
5) Dermoid
6) Endometrioid |
|
Definition
Theca-lutein (choriocarcinoma/mole) and Proliferative follicular (endometrial hyperplasia) can lead to cancer
1) Follicular (most common)
- distention of unruptured graafian follicle, often associated with hyperestrinism and endometrial hyperplasia (cancer risk)
2) Hemorrhage into peristent corpus luteum that commonly regresses spontaneously
3) Often bilateral/multiple and due to gonadotropin stimulation
- Association with choriocarcinoma and moles
4) Blood vessel rupture in cyst wall
- grows with blood retenion and self-resolves
5) Mature teratoma. Cystic growths filled with various tissues
6) Endometriosis within ovary with cyst formation
- Called "chocolate" when filled with dark, reddish-brown blood |
|
|
Term
What kind of ovarian cyst is described by each of the following?
1) Distention of unruptured graafian follicle, often associated with hyperestrinism and endometrial hyperplasia
2) Hemorrhage into peristent corpus luteum that commonly regresses spontaneously
3) Often bilateral/multiple and due to gonadotropin stimulation
- Association with choriocarcinoma and moles
4) Blood vessel rupture in cyst wall
- grows with blood retenion and self-resolves
5) Mature teratoma. Cystic growths filled with various tissues
6)"Chocolate" when filled with dark, reddish-brown blood |
|
Definition
1) Follicular (most common)
2) Corpus luteum
3) Theca-lutein
4) Hemorrhagic
5) Dermoid
6) Endometrioid |
|
|
Term
What population is most affected by ovarian germ cell tumors and which kind is described by each of the following?
1) Malignant equivalent of seminoma in males but rarer (1% vs. 30%), presenting as sheets of uniform cells
2) Rare, malignant trophoblastic tumor that can present in baby or mom during pregnancy, along with theca-lutein cysts, and spread hematogenously to the lung in early stages of disease.
3) Aggressive malignancy in ovaries and sacrococcygeal area of young children that presents as yellow, friable mass with structures that appear like glomeruli
4) Contains cells form 2-3 germ cell layers and can be mature (benign) or immature (malignant) |
|
Definition
Adolescents- Most common is Teratoma (vs. Superficial epithelial tumors like serous cystadenomas)
1) Dysgerminoma (hCG and LDH)
- Associated with Turner's syndrome
2) Choriocarcinoma (hCG)
- Along with moles, comprise spectrum of gestational trophoblastic neoplasia
3) Yolk sac (endodermal sinus with AFP)
- Schiller-Duval bodies (50%)
4) Teratoma
- Mature is "Dermoid cyst" and is most frequent benign ovarian tumor
- Immature is aggressive
- Struma ovarri contains functional thyroid tissue and can present with hyeprthyroidism. |
|
|
Term
| What is a "Struma ovarri"? |
|
Definition
| Teratoma-type ovarian germ cell tumor containing mature thyroid tissue that can cause hyperthyroidism. |
|
|
Term
Which ovarian germ cell tumor is a particular high risk for lung metastasis?
What is the tumor marker of this and how specific is it? |
|
Definition
1) Choriocarcinomas (trophoblastic) spread hematogenously to the lung early in disease
2) hCG (can also be seen in Dysgerminoma, but you would also see LDH and presentation would be completely different) |
|
|
Term
What is the utility of the following tumor markers in diagnosing ovarian cancer?
1) LDH
2) hCG
3) AFP
4) CA-125
5) BRCA-1/2 |
|
Definition
1) Dysgerminoma (with hCG)
2) Dysgerminoma or Choriocarcinoma
3) Yolk sac tumor
4) General ovarian cancer marker (monitoring progression, but NOT screening)
5) Risk factor for serous cystadenocarcinoma |
|
|
Term
| What is the most common variety of non-germ cell ovarian tumor (benign and malignant)? |
|
Definition
1) Serous cystadenomas are the most common benign
- Frequently bilateral and lined with fallopian tube-like epithelium
2) Cystadenocarcinomas are more common malignant
- frequently bilateral with Psammoma bodies |
|
|
Term
Which of the following benign non-germ cell masses of the ovary are described below?
1) Unilateral mass of bladder-like tissue that is pale yellow-tan and appears encapsulated, with "coffee bean" nuclei on H & E
2) Frequently bilateral, with fallopian tube-like epithelium (ciliated, columnar vs. cuboidal of ovary)
3) Multilocular cyst of "intestine-like tissue" lined by mucus-secreting epithelium
4) Bundles of spindle-shaped fibroblasts associated with ascites and hydrothorax |
|
Definition
1) Brenner tumor
- Benign and unilateral
2) Serous cystadenoma (Most common)
3) Mucinous cystadenoma
4) Fibromas
- Meigs' syndrome tria with "pulling sensation" in groin |
|
|
Term
Patient presents with "pulling" sensation in groin.
What is Meigs' syndrome and what ovarian abnormality is it associated with? |
|
Definition
Triad of Ovarian Fibroma, Ascites and Pleural effusion
Bundles of spindle-shaped fibroblasts |
|
|
Term
| What is a "Krukenberg" tumor? |
|
Definition
| GI malignancy that metastasizes to ovaries causing a mucin-secreting signet cell adenocarcinoma. |
|
|
Term
| What are Call-Exner bodies and where are they found? |
|
Definition
Patient with abnormal uterine bleeding and precocious puberty.
Granulosa cell tumor (secreting estrogen, so risk of endometrial cancer) of the ovary.
- Small follicles filled with eosinophilic secretions |
|
|
Term
| What is the most important risk factor for ovarian cancer? |
|
Definition
| Most common tumor is serous cystadenocarcinoma and most important risk factor is family h/x because of strong genetic predisposition (BRCA1/2, HNPCC) |
|
|
Term
| What is "Pseudomyxoma peritonei" and what ovarian abnormality is it associated with? |
|
Definition
Intraperitoneal accumulation of mucinous material from ovarian or appendiceal Tumor.
Mucinous cystadenocarcinoma is most common ovarian cause. |
|
|
Term
| What is on your ddx if you suspect ovarian cancer? |
|
Definition
1) Non-germ cell (most common)
- Serous cystadenocarcinoma
- Mucinous cystadenocarcinoma
- Granulosa cell tumor (Estrogen)
- Krugenberg (GI)
2) Germ-cell
- Dysgerminoma (hCG, LH, Turner's)
- Choriocarcinoma (hCG)
- Yolk sac (AFP)
- Teratoma (most common germ cell) |
|
|
Term
What is the most common type/cause of vaginal cancer?
What are the other causes? |
|
Definition
1) Squamous cell carcinoma secondary to cervical SSC
2) Clear cell adenocarcinoma
- women with DES exposure in utero
3) Sarcoma botryoides (rhabdomyosarcoma variant)
- affects girls < 4 years of age; spindle-shaped tumor cells that are desmin positive. |
|
|
Term
| What 3 populations of people can get vaginal cancer? |
|
Definition
1) Those with cervical cancer (secondary SCC)
2) Women who had exposure to DES in utero (Clear cell adenocarcinoma)
3) Girls <4 (Rhabdomyosarcoma variant- desmin +) |
|
|
Term
| Describe the basic structure of a breast tract. |
|
Definition
In to Out
1) Stroma (Fibroadenoma, Phyllodes)
2) Lobules (Lobular cancer, Sclerosing adenosis)
3) Terminal ducts (Tubular carcinoma)
4) Major ducts (FCC, ductal cancer)
5) Lactiferous sinus (Intraductal papilloma, breast abscess, mastitis)
6) Nipple (Paget's disease, breast abscess) |
|
|
Term
There are 3 major variants of benign breast tumors.
What are they? |
|
Definition
1) Fibroadenoma (most common <35)
- Small, mobile, firm masses with sharp edges found in stroma
- Increase size/sensitivity with estrogen levels, but no cancer risk
2) Intraductal papilloma
- Small tumor of lactiferous ducts beneath areola that causes serous/bloody nipple discharge
- 1.5-2X risk of cancer
3) Phyllodes tumor (most common 6th decade)
- Large bulky mass of connective tissue and cysts with "leaf-like" progjections in stroma
- Can become malignant |
|
|
Term
| What are the non-invasive malignant breast tumors? |
|
Definition
Common postmenopause, arising from duct epithelium or lobular glands.
1) Ductal carcinoma in situ (DCIS)
- Fills ductal lumen, arising from hyperplasia
- Early malignancy without BM penetration
2) Comedocarcinoma (ductal caseous necrosis)
- sub-type of DCIS |
|
|
Term
Which of the following is NOT a risk factor for malignant breast cancer? What are the others?
1) Estrogen exposure
2) Increased total number of menstrual cycles
3) Obesity
4) Diabetes
5) Older age at 1st pregnancy live birth |
|
Definition
4- Diabetes is a risk factor for endometrial cancer, but not breast cancer.
1) Hyperplasia/carcinoma
2) Total time of estrogen cycles
3) Androstenedione to estrone in fat
5) Unclear |
|
|
Term
What is the most important prognostic factor for breast cancer?
What genes are associated with malignancy in the breast that may guide therapy? |
|
Definition
Breast cancers are most commonly in the upper-outer quadrant.
Axillary LN involvement (assuming no distant metastasis)
1) Estrogren/progesterone receptor expression
2) erb-B2 (HER-2, and EGF receptor) |
|
|
Term
Which invasive breast cancer is described by each of the following?
1) Firm, fibrous, "rock hard" mass with sharp margins and small, glandular, duct-like cells
2) Orderly rows of cells
3) Fleshy, cellular, lymphocytic infiltrate
4) Dermal lymphatic invasion by breast carcinoma with "Peu d'orange" (orange peal) appearance
5) Eczematous patches on nipple with large cells in epidermis with clear halos. |
|
Definition
Worst is Ductal and Inflammatory is bad too.
Medullary and Lobular are better.
1) Invasive ductal cancer (most common)
- Worst and most invasive
- Look for "stellate" morphology
2) Invasive lobular cancer
- Often multiple, bilateral
3) Medullary
- Good prognosis
4) Inflammatory cancer
- Blockage of lymphatic drainage
- 50% survival at 5 years
5) Paget's disease with paget cells
- Suggests underlying carcinoma (ductal)
- Also seen on vulva |
|
|
Term
What are the histological sub-types of fibrocystic disease of the breast?
Which are associated with cancer? |
|
Definition
Most common cause of "lumps" from age 25-menopause- usually NOT cancer risk
"Premenstrual breast pain and multiple lesions, often bilaterally, with fluctuation in size and mass"
1) Fibrosis- hyperplasia of stroma
2) Cystic- fluid filled, blue dome with ductal dilation
3) Sclerosis adenosis- Increased acini and intralobular fibrosis (calcifications)
4) Epithelial hyperplasia
- terminal duct lobule with risk of carcinoma if cells are atypical (women > 30) |
|
|
Term
| Why is fat necrosis sometimes easy to miss diagnose? |
|
Definition
| Due to trauma to breast tissue that is not reported 50% of the time. |
|
|
Term
| Which drugs cause Gynecomastia? |
|
Definition
Results from hyperestrogenism
Some Drugs Create Awesome Knockers
1) Spironolactone (K+ sparing diuretic)
2) Digitalis (Contractile agent)
3) Cimetidine (H2 antagonist for stomach)
4) Alcohol
5) Ketoconazole (fungal)
**also from estrogen, marijuana, heroin and psychoactive drugs** |
|
|
Term
Which condition is NOT associated with Gynecomastia?
1) Klinefelter's
2) Old age
3) Testicular tumors
4) Cirrhosis
5) Small cell lung carcinoma |
|
Definition
5) SSLC don't generally produce estrogen.
They produce ACTH (Cushing's), ADH (SIADH)and Lambert Eaton syndrome |
|
|
Term
| Why do breast abscesses sometimes occur during breast feeding? |
|
Definition
Acute Mastitis because of bacteria that travel through cracks in nipple
- Most common is S. aureus |
|
|
Term
True or False:
BPH involves an increased size of prostatic cells due to DHT exposure in men >50 |
|
Definition
| False: It is hyperPLASIA- increased cell number, not size |
|
|
Term
| Which regions of the prostate undergo hyperplasia vs. carcinoma? |
|
Definition
1) BPH is nodular enlargement of periurethral (lateral and middle) lobes, which compress the urethra and vertical slit
- urgency, increased frequencey, dribbling and incomplete vaulting
2) Posterior/peripheral zone (this is why DRE works to diagnose) |
|
|
Term
| How is BPH treated and how do you diagnose it? |
|
Definition
1) Diagnosed symptomatically (dysuria, dribbling, urgency, incomplete vaulting) and PSA level (increased free PSA)
2) Treat
- Finestiride (5-alpha-reductase inhibitor)
- Terazosin, tamsulosin (a1-antagonist for smooth muscle relaxation) |
|
|
Term
| If PSA is high in both prostate cancer and BPH, how is it useful diagnostically? |
|
Definition
Free PSA is high in BPH, while total PSA is high in carcinoma (free fraction is actually decreased)
- PAP is also useful in prostate cancer |
|
|
Term
| What are the most common/dangerous complications of prostatic adenocarcinoma? |
|
Definition
Carcinoma diagnosed by DRE of posterior lobe and PAP/PSA levels.
Osteoblastic metastasis (vs. osteolytic for breast) presenting with back pain and an increase in serum ALP and PSA |
|
|
Term
Patient presents with difficulty urinating with pain, dribbling and incomplete vaulting.
What are the common complications associated with BPH? |
|
Definition
1) Distention and hypertophy of bladder
2) Hydronephrosis
3) UTI
NOT cancer necessarilly
Treat with alpha blocker (Terazosin, tamsulosin) and Finesteride (5-alpha hydroxylase inhibitor) |
|
|
Term
Why are patients with untreated Cryptochidism often infertile?
What are the dangerous complications? |
|
Definition
Undescended testis (one or both)
1) Impaired spermatogeneiss (since temp >37 degrees in abdomen)
2) Seminoma risk |
|
|
Term
| What are the risk factors for Cryptochidism and what are the diagnostic hormone changes? |
|
Definition
1) Prematurity
2) Low inhibin (sertoli cells), high FSH/LH and normal (unilateral) or decreased (bilateral) testosterone.
**Leydig cells are temperature insensitive** |
|
|
Term
| Why might a patient with Cryptochidism have normal/high LH levels, but low inhibin levels? |
|
Definition
Leydig cells are temperature-independent (LH is made), but Sertoli cells are not (Inhibin cannot be produced and FSH increases)
This is why these patients can be infertile if not treated early |
|
|
Term
| What is a varicocele and what are the important complications? How do you treat? |
|
Definition
Most common cause of scrotal enlargement in adult males- diagnosed by US ("bag of worms")
1) Dilated veins in pampiniform plexus due to increased venous pressure (left side)
2) Infertility because of high temperature
3) Varicocelectomy or Embolization by interventional radiologist |
|
|
Term
| What are the causes of male infertility due to increased testicular temperature? |
|
Definition
1) Cryptochidism
2) Varicocele (could be due to obstruction like a renal stone) |
|
|
Term
| What are the most common testicular tumors and how do they appear? |
|
Definition
Malignant Germ cell tumors that present has painless, homogenous testicular enlargement in males 15-35, with large cells in lobules with watery cytoplasm and "fried egg" appearance.
"If it does not trans-illuminate, its cancer."
1) Most common pure variety is Seminoma
- Radiosensitive with late metastasis and good prognosis
2) Most common overall is mixed |
|
|
Term
Patient presents with testicular mass that does not transilluminate. You place you bets on a germ cell tumor.
What would each of the following indicate in your diagnostic workup?
1) Painless, homogenous enlargement
2) Painful with glandular/papillary morphology
3) Yellow and mucinous on biopsy with elevated AFP levels
4) Increased hCG with lung met
5) Increased hCG and/or AFP with > 2 dermal lineages |
|
Definition
1) Seminoma (most common)
- Radiosensitive and good prognosis with late metastasis
2) Embryonal carcinoma
- worse prognosis and commonly mixed (rare to see pure tumor)
3) Yolk sac (endodermal sinus)
- Schiller-Duval bodies resemble glomeruli
4) Choriocarcinoma
- may show gynecomastia
5) Teratoma
- Most often malignant (unlike in females) |
|
|
Term
Most testicular cancers are germ cell tumors, but some tumors are non-germ cell tumors.
What are these and how do they present? |
|
Definition
1) Leydig cell
- Golden brown tumor with Reinke crystals
- Androgen producing with gynecomastia in men and precocious puberty in boys
2) Sertoli cell
- Androblastoma from sex cord stroma
3) Testicular lymphoma
- Most common cancer of older men (metastasis) |
|
|
Term
| What is the Tunica vaginalis and what are the common lesions? |
|
Definition
Serous covering of testis- Lesions present as testicular masses that can be transilluminated (vs. tumors)
1) Hydrocele- Increase in fluid secondary to incomplete fusion of processus vaginalis
2) Spermatocele- Dilated epididymal duct |
|
|
Term
| What are the common causes of a painful sustained erection that is not associated with sexual stimulation or desire? |
|
Definition
Priapism
1) Trauma
2) Sickle cells (RBC trapping)
3) Medications (anticoagulants, PDE5 inhibitors, anti-depressants, alpha blockers, cocain) |
|
|
Term
| What is Peyronie's diseae? |
|
Definition
| Bent penis due to acquired fibrous tissue formation. |
|
|
Term
| What is the most common type/cause of penile cancer and where does it occur? |
|
Definition
1) SSC in Asia, Africa and South America
2) Lack of circumcision WITH poor hygeine is most common
- HPV is also associated |
|
|
Term
Why might you prescribe Leuprolide?
How does it work and what are the side effects? |
|
Definition
1) Infertility (pulsatile), Prostate cancer (continuous with flutamide) and Uterine fibroids
2) GnRH analog
- agonist properties if pulsatile
- antagonist properties if continuous
3) Anti-androgen, nausea and vomitting |
|
|
Term
| Why can Leuprolide be given to treat both prostate cancer and infertility? |
|
Definition
Pulsatile administration has GnRH agonist effect (infertility), while continuous administration has antagonist effect (Prostate cancer).
Continuous administration down-regulates GnRH receptor in pituitary and decreases FSH/LH release |
|
|
Term
Why might you prescribe Methyltestosterone?
How does it work and what are the side effects? |
|
Definition
1) Use
- Hypogonadism, promoting development of secondary sex characteristics
- Burn/injury recovery
- ER-positive breast cancer (Exemestane)
2) Agonist at androgen receptors
3) Side effects
- Masculinization in females
- Reduces intratesticular testosterone (gonadal atrophy and infertility)
- Premature fusion of epipheseal plates
- Increase LDL, decrease HDL (CVD) |
|
|
Term
| Why might you be wary about giving a child with 5-alpha-reductase deficiency methyltestosterone? |
|
Definition
He will grow a penis at 12 anyways.
1) Reduces intratesticular testosterone (gonadal atrophy and infertility)
2) Premature fusion of epipheseal plates
3) Increase LDL, decrease HDL (CVD) |
|
|
Term
| What are the side effects of treating an ER-positive breast cancer with methytestosterone? |
|
Definition
1) Increase LDL and decrease HDL (CVD)
2) Hirsutism/Virilization |
|
|
Term
How do each of the following anti-androgen compounds work and how are they used?
1) Finesteride
2) Flutamide
3) Ketoconazole
4) Spironolactone |
|
Definition
Concerns of gynecomastia
1) 5-alpha-reductase inhibitor used to prevent male-pattern hair loss and BPH
2) Nonsteroidal competitive inhibitor of AR used in prostate cancer
3) Inhibits steroid synthesis (inhibits desmolase, which is made in theca cells to make androstenedione from cholesterol)
4) Inhibits steroid binding
Ketoconazole and Spironolactone treat PCOS and prevent hirsutism, and may cause gynecomastia and amenorrhea |
|
|
Term
What are the mechanisms and uses of Ethyinyl estradiol, DES and Mestranol?
What are the risks of use? |
|
Definition
1) Bind ER
2) Use
- Hypogonadism or ovarian failure
- Menstrual abnormalities
- HRT in postmenopausal women
- Androgen-dependent prostate cancer
3) Risks
- Endometrial cancer
- Bleeding in postmenopausal women
- Clear cell adenocarcinoma of vagina (DES in utero)
- Thrombotic risk |
|
|
Term
| Which patients should NOT receive estrogen therapy? |
|
Definition
1) Smokers over 35
2) ER-positive breast cancer
3) H/x of DVT |
|
|
Term
| Describe the synthesis of estrogens starting from the hypothalamus. |
|
Definition
1) Hypothalamus (Clomiphene) makes GnRH (Leuprolide)
2) GnRH binds receptors on Pituitary, which produces FSH and LH (OCP and danazol)
3) FSH binds granulosa cells in ovary and induce production of Aromatase, while LH binds theca cells and induces production of Desmolase, which produces androstenedione from cholesterol
4) Androstenediole is converted estrone by Aromatase in granulosa cells, which is converted to Estradiol (Fulvestrant and SERMS) |
|
|
Term
| Why might you prescribe a patient Clomiphere? What side effects should you watch out for? |
|
Definition
SERM that acts as agonist at ER in hypothalamus, driving GnRH production (removing normal negative feedback)
1) Used for infertility and PCOS (drives FSH production)
2) Causes hot flashes, ovarian enlargement, multiple simultaneous pregnancies and visual disturbances. |
|
|
Term
| Why prescribe Tamoxifen and/or Raloxifene? |
|
Definition
SERMS that antagonist ER in breast for ER-positive breast cancer (Tamoxifene) and agonize it in the bone for osteoporosis (Raloxifene)
**Tamoxifene has risk of Endometrial cancer, while Raloxifene does not** |
|
|
Term
| Who should receive hormone replacement therapy and what are the risks? |
|
Definition
1) Menopausal symptoms (hot flashes, vaginal atrophy) and Osteoporisis
2) Risk of endometrial cancer, so add progesterone
- CV risk (LDL: HDL ratio increases) |
|
|
Term
| What are Anastrozole and Exemestane and why are they prescribed? |
|
Definition
| Aromatase inhibitors used in post-menopausal women with breast cancer. |
|
|
Term
| How are Progestins used clinically? |
|
Definition
1) Bind PR to reduce growth and increase vascularization of endometrium (thickening cervical mucus like in luteal phase)
2) Used in OCPs and in treatment of Endometrial cancer and abnormal uterine bleeding |
|
|
Term
| What drugs are used to terminate a pregnancy pharmacologically? |
|
Definition
Mifepristone (RU-486) and Misoprostol (PGE1)
Mifepristone is a competitive inhibitor of progestins at progesterone receptors: causes heavy bleeding, GI effects and abdominal pain. |
|
|
Term
| How do mixed OCPs prevent pregnancy? |
|
Definition
Estrogen and progestins inhibit LH/FSH and prevent estrogen surge (no LH surge and no ovulation)
Progestins thicken cervical mucus (limiting sperm access) and Inhibit endometrial proliferation (implantation) |
|
|
Term
| Who should NOT be placed on OCPs? |
|
Definition
- Smokers > 35 (CV events)
- H/x TE and stroke
- H/x estrogen-dependent tumor |
|
|
Term
| What drugs can be used to prevent pre-mature uterine contractions and pre-term birth? |
|
Definition
Ritodrine (only FDA approved) and Terbutaline
B2 agonists that relax uterus. |
|
|
Term
| Why is Tamsulonsin prescribed by BPH? |
|
Definition
| Selective a1-antagonist that targets alpha-1a,d receptors (prostate) vs. vascular alpha-1b receptors |
|
|
Term
| What are the side effects of using Sildenafil for ED? Who should NOT receive them? |
|
Definition
"Hot and sweaty, but then Headache, Heartburn and Hypotension.
Inhibit cGMP phosphodiesterase, causing smooth muscle relaxation in corpus cavernosum, with increased BF and erection.
1) Headache, flushing, dyspepsia, impaired blue-green color vision
2) Life-threatening hypotension with nitrates |
|
|
Term
Patient with CHF who you recently saw for sexual performance complaint comes in on a stretcher in hypotensive crisis.
What happened? |
|
Definition
| He was on Nitrates, which with Sildenafil, can cause hypotensive collapse |
|
|
Term
|
Definition
Endometriosis and Hereditary angioedema
Synthetic androgen that acts as partial agonist at AR
**Weight gain, edema, acne, hirsutism, masculinization and low HDL levels complicate it** |
|
|
Term
| What is the greatest risk factor for penile cancer? |
|
Definition
Squamous cell carcinoma from lack of circumcision with poor hygeine.
Other risks include Bowen's disease and Erythroplasia of Queyrat |
|
|
Term
| What hormones are responsible for the 2 phases of testicular descent? |
|
Definition
Chrytochidism (most commonly inguinal) has risk of infertility and seminoma
1) Abdominal
- Mullenian inhibitory factor from Sertoli cells
2) Inguinoscrotal
- Androgen and hCG |
|
|
Term
| What are the common causes of Orchitis |
|
Definition
1) Mumps
2) Syphilis
3) HIV
4) Extension of acute epidimitis |
|
|
Term
| What are the most common causes of Epidimytis in those <35 and those >35? |
|
Definition
Unilateral scrotal pain which is releaved with elevation
1) Under 35
- N. gonorrhea and C. trachomatis
- Ceftriaxone + Doxi
2) Over 35
- E. coli and Pseudomonas
- Extended release Cipro |
|
|
Term
Male football player presents complaining of testicular pain and you notice an absent cremasteric reflex.
What is your next step in the workup and how will you treat? |
|
Definition
Testicular torsion
1) Ultrasound is diagnostic
2) 1/3 spontaneously remit, but surgery is imperative within 12h for those that don't |
|
|
Term
| What is a hydrocele and what condition is it commonly associated with? |
|
Definition
- Most common cause of scrotal enlargement due to failure of closure of the tunica vaginalis, with fluid accumulation.
- Risk of indirect inguinal hernia
Diagnose with US and treat surgically |
|
|
Term
| What is the most common malignancy of men between ages 15-35 and what are the risk factors? Where do these masses metastasize? |
|
Definition
1) Testicular cancer (95% germ cell)
- Seminoma (40%) or mixed (60%)
2) Cryptorchidism (intra-abdominal), Klinefelter's (XXY), Inguinal hernia, Mumps orchitis.
3) Para-aortic lymph nodes (where they came from) |
|
|
Term
What is the most comomon testicular tumor in the following age brackets?
1) <4
2) 30-35
3) > 60 |
|
Definition
1) Yolk sac tumor- AFP (Good prognosis)
2) Seminoma (excellent prognosis)
3) Malignant lymphoma (poor prognosis) |
|
|
Term
| What are the most important risk factors for prostate cancer and what is the most common type? How do you treat? |
|
Definition
Increased bound PSA (vs. free in BPH) with needle core biopsy to confirm.
1) Adenocarcinoma in peripheral zone that metastasizes late to bone (osteoblastic)
2) Advancing age (most)
- family, race, smoking, high saturated fats
3) Early disease- surgery or beam radiation
- Late, hormonal |
|
|
Term
| How does decreased testosterone decrease sexual ability? |
|
Definition
| Decreases libido (no direct effect on erection) |
|
|
Term
How can you distinguish between primary and secondary hypogonadism in males.
What are the most common causes of each? |
|
Definition
High LH and low Androgen= Primary
Low LH and low Androgen= Secondary
1) Primary
- Leydig cell dysfucntion from alcohol, renal failure, orchitis or radiation
2) Secondary
- Constitutional delay
- Kallman's (AD)
- Hypopituitarism |
|
|
Term
| What is the most common cause of male infertility? |
|
Definition
Seminiferous tubule dysfunction
Normal LH and testosterone, but high FSH (no sertoli cells)
1) Varicocele
2) Klinefelter's
3) Orchitis |
|
|
Term
| What is the most common cause of impotence in men > 50? |
|
Definition
| Vascular insufficiency (example is Leriche syndrome) |
|
|
Term
| What is the site of development of most cerivical cancers? |
|
Definition
| Squamous-Columnar junction of cervix where endo and ectocervix meet and ectocervical cells are undergoing squamous metaplasia |
|
|
Term
| Distinguish between the stages of cervical intraepithelial neoplasia that precede squamous cell cancer. |
|
Definition
Remember, HPV 16,18 are the concern here, producing Koilocytosis at the transition zone.
1) CIN1- Lower 1/3
2) CIN2- Lower 2/3
3) CIN3- Approaching CIS, with entire thickness affected
**CINIII takes 3 years to progress to Cervical cancer** |
|
|
Term
| What is the most common indication of cervical cancer and what are the most dangerous complications? |
|
Definition
HPV 16,18 association
**Rarest gynecological cancer
1) Abnormal vaginal bleeding
2) Renal failure is common cause of death |
|
|
Term
| What are the primary functions of FSH and LH in the menstrual cycle? |
|
Definition
1) FSH
- Prepares monthly follicle
- Increases aromatase synthesis in Granulosa cells
- Synthesis of LH receptors
2) LH
- Induces theca cells to make DHEA and androstenedione, which is converted to testosterone
- Testosterone enter granulosa cells and is aromatized to estradiol. |
|
|
Term
| What are the 3 sources of estrogen and when do they each dominate? |
|
Definition
1) Estradiol
- Non-pregnant women
- Derived from aromatiziation of testosterone in granulosa cells
2) Estrone
- Weak estrogen produced during menopause in adipose cells from androstenedione, which is synthesized in adrenal cortex.
3) Estriol
- End-product of estradiol metabolism that dominates Pregnancy
- Derived from fetal adrenal, placenta and maternal liver. |
|
|
Term
| What are the 3 sources of estrogen and when do they each dominate? |
|
Definition
1) Estradiol
- Non-pregnant women
- Derived from aromatiziation of testosterone in granulosa cells
2) Estrone
- Weak estrogen produced during menopause in adipose cells from androstenedione, which is synthesized in adrenal cortex.
3) Estriol
- End-product of estradiol metabolism that dominates Pregnancy
- Derived from fetal adrenal, placenta and maternal liver. |
|
|
Term
| What changes occur normally during pregnancy in terms of plasma volume, RBC mass, respiration and thyroid function? |
|
Definition
1) Plasma volume and RBC mass increase
- Drop is Hb concentration
- Increased GFR
2) Respiratory alkylosis
- Estrogen/progesterone stimulate respiratory center, decreasing PaCo2, corresponding to increase in PaO2
3) Increased serum T4 and cortisol
- Estrogen stimulates TBG and trasncortin |
|
|
Term
| What is the most common cause of female hirsutism and how do you treat it? |
|
Definition
1) PCOS- risk of endometrial cancer (high LH means high estrogen)
2) Low-dose OCPs or medroxyprogesterone |
|
|
Term
| What are the most common causes of primary and secondary dysmenorrhea? |
|
Definition
Primary= PGF2alpha (uterine contractions)
Secondary= Endometriosis |
|
|
Term
| Describe how FSH/LH and Estrogen levels can help you work-up a case of amenorrhea. |
|
Definition
1) High FSH/LH and low Estrogen indicates a primary ovarian disorder (e.g. Turner's)
2) Low FSH/LH and low estrogen suggest Hypothalamic/Pituitary issue
- Hypopituitarism, Prolactinoma, Anorexia
3) Normal levels of both indicate an end-organ defect (imperforate hymen or Asherman syndrome) or Constitutional delay (family h/x) |
|
|
Term
| What is the typical triad of symptoms seen in endometriosis? |
|
Definition
Blood may collect in rectal pouch of douglas!
1) Dysmenorrhea
2) Dyspareunia
3) Infertility |
|
|
Term
What is the most commonly diagnosed gynecologic tumor?
What about cancer? |
|
Definition
1) Leiomyoma (fibroids)
2) Endometrial adenocarcinoma |
|
|
Term
| What is the most common cause of female infertility and ectopic pregnancy and what are the risk factors? |
|
Definition
1) PID- fever, lower abdominal pain and cervical motion tenderness due to N. gonorrhea or C. trachomatis
- Give ceftriaxone + doxi
2) Multiple sexual partners, vaginal douching, previous episodes, unprotected sex |
|
|
Term
What is the most common cause of an ovarian mass.
What are the common cancers? |
|
Definition
1) Follicular cyst (non-neoplastic)
2) Most common is Surface-derived (CA-125)
(serous cystadenocarcinoma)
- Germ cell tumors (teratoma)
- Less common are sex chord and metastasis |
|
|
Term
| What are the effects of estrogen and progesterone on normal breast growth? |
|
Definition
1) Estrogen- Stimulates ductal and alveolar growth
2) Progesterone
- Alveolar differentiation |
|
|
Term
Why might a patient have the following nipple discharges?
1) Galactorhea
2) Bloody
3) Purulent
4) Greenish brown |
|
Definition
1) Prolactinoma, Nipple stimulation, Primary hypothryoidism (high TRH)
2) Intraductal papilloma or ductal cancer
3) Acute mastitis due to Staph aureus (during lactation or breast-feeding)
4) Mammary duct ectasia (plasma cell mastitis) |
|
|
Term
What is the most common cause of breast pain?
What about the most common breast tumor? |
|
Definition
1) FCC (most common breast mass <50)
Cysts and fibrosis with "lumpy bumpy" feeling on breast exam.
2) Fibroadenoma
- associated with cyclosporine use |
|
|
Term
| What are the stromal masses of the breast? |
|
Definition
1) Fibroadenoma (most common)
2) Phyllodes tumor (can be benign or malignant) |
|
|
Term
| What is the first step in management of a suspected breast cancer on mammography? |
|
Definition
| FNA biopsy (vs. core biopsy for Prostate cancer) |
|
|
Term
| What is the most common cause of breast cancer? Where do they metastasize? |
|
Definition
1) Ductal adenocarcinoma
2) Lungs and Bone (osteolytic vs. osteoblastic for prostate) |
|
|
Term
| What is the genetic basis for male breast cancer? |
|
Definition
1) Klinefelter's (XXY)
2) Inactivation of BRCA2 |
|
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