Female Physiology Flashcards
What hormones are responsible for regulating the menstrual cycle?
Gonadotropic releasing hormone (GnRH) Follicle stimulating hormone (FSH) Luteinizing hormone (LH) Estrogen Progesterone
What is GnRH secreted by? When is it secreted?
By the hypothalamus
When serum estradiol levels fall below a given concentration
GnRH signals the _______ _______ _______ to secrete _______ _______ _______ and _______ _______.
anterior pituitary gland
follicle stimulating hormone (FSH) luteinizing hormone (LH)
What does FSH stimulate?
The growth and development of ovarian follicles
What does LH stimulate? What does this then cause?
The maturation of follicle and is responsible for Graafian follicular rupture causing ovulation
Which organ in the reproductive system secretes estrogen and progesterone? Specify what secretes these in this organ.
Ovary
Estrogen = secreted by developing follicles (and in lesser amounts the corpus luteum)
Progesterone = secreted by the corpus luteum
What are the pituitary gonadotropins?
FSH and LH
Any “-tropic” hormone signals what?
Another organ to function or secrete
What cells within the follicles produce estrogen? What does this then stimulate?
Theca cells
Stimulates endometrial growth
What stimulates progesterone production? When does progesterone peak?
Rupture of the Graafian follicle which causes ovulation
Peaks after ovulation in secretory phase
When the fertilized ovum implants into the endometrium, _____ signals _______ _______ to continue secreting _______ to prevent shedding of the endometrial lining.
hCG
corpus luteum
progesterone
What happens to progesterone and the endometrium if implantation does not occur?
Levels decrease and the uterine lining sheds
Define menarche.
The onset of menses, usually occurring between 11-14 years of age
When does menopause usually occur? What age is considered premature menopause?
44-55 years of age = menopause
prior to age 40 = premature menopause
When do FSH and LH peak?
Mid-cycle, ovulation
When does estrogen peak?
Proliferative phase, before ovulation
Sonographic findings of a dominant follicle:
- any follicle measuring >11mm will most likely ovulate
- grows linearly (approximately 2-3mm/day)
- maximum diameter varies between 15 and 30mm
- line of decreased reflectivity around follicle suggests ovulation will occur within 24 hours
- presence of cumulus oophorus (mural nodule within follicle) suggests ovulation will occur within 36 hours
Describe the follicular phase: what days does it occur? What is it stimulated by? When does the dominant follicle appear and what will it measure?
Days 1-14
Stimulate by FSH
Several follicles develop, but the dominant follicle may be identified by about day 8 when it measures 10mm
Define Mittelschmerz.
Unilateral pelvic pain occurring mid-cycle, associated with ovulation.
When does ovulation occur?
MID-CYCLE (~day 14)
Describe ovulation and the sonographic findings.
A surge of LH secretion causes rupture of follicular membrane (usually within 24-36 hours after surge)
Sonographic findings:
- sudden decrease in follicular size
- free fluid in posterior cul-de-sac
Describe the luteal phase: what days does this occur? What is secreting progesterone and for what reason? What happens if there is no pregnancy?
Days 15-28
The corpus luteum is secreting progesterone to prepare and maintain the endometrium for implantation
If there is no pregnancy:
- absence of hCG
- corpus luteum regresses and atrophies and becomes corpus albicans
What are the sonographic findings during the luteal phase?
- replacement of dominant cystic follicle with an echogenic structure representing thrombus (corpus albicans)
- small irregular cystic mass with irregular thick borders and low-level echoes
- Doppler findings of a hyper vascular corpus luteum with low resistance flow (ring of fire - CL is performing a vital to life function)
Describe the menstrual phase: include what days.
Days 1-5
Sloughing of the superficial layer of endometrial tissue and blood cells (menses)
Describe the sonographic findings of beginning and end of menstrual phase.
Beginning of menses:
- endometrium thickened
- might see fluid in endo
- complex appearance
End of menses:
- endometrium thinned, slightly irregular
- endo max diameter of 2mm
Describe the proliferative phase: include what days/how long does it last/when does it end?
Days 6-14
- Regeneration/proliferation of endometrium is stimulated by estrogen and secreted by the developing follicles
- lasts about 10 days and ends at ovulation
Sonographic findings of the proliferative phase
Early proliferative:
- endometrium = hypoechoic area around prominent midline echo
Late proliferative (peri-ovulatory): - tri-layered endometrium (3 line sign) with a hyper echoic basalis, hyperechoic functionalis and a hyperechoic line indicating the cavity
When you see the three line sign, about what day in the phase are they at?
About day 14
Describe the secretory phase: what days/what happens to the endometrium/what happens in the absence of fertilization?
Days 15-28
Endometrium becomes edematous and spongy due to progesterone
In absence of fertilization/implantation:
- no hCG production so the endometrial glands fragment and undergo autolysis to start the cycle again
Describe the sonographic findings of the secretory phase.
Endometrium appearance:
- homogeneous
- hyperechoic
- obscured midline echo
- may have posterior acoustic enhancement
- max diameter 14-16mm
Define hypermenorrhea. What is another name for it?
Excessive volume during cyclic menstrual bleeding
AKA menorrhagia
Define hypomenorrhea.
An abnormally small amount of menstrual bleeding
Define polymenorrhea.
Frequent menstrual bleeding occurring less than 21 days apart
Define oligomenorrhea.
Menstrual bleeding occurring more than 35 days apart
Define metrorrhagia. What population does this most frequently occur with?
Irregular, frequent bleeding
Especially in patients near menopause
Define menometrorrhagia.
Bleeding that is irregular in both frequency and volume
Define intermenstrual bleeding.
Bleeding that occurs between normal cycles
Define breakthrough bleeding.
Intermenstrual bleeding in OCP or HRT
Define postcoital bleeding.
Bleeding after vaginal intercourse
Define dysmenorrhea
Painful bleeding
Define amenorrhea and the two types.
Absence of menstrual flow
Primary: patient has never had a period
Seconday: patient had periods but they stopped
Define post-menopausal bleeding.
Bleeding occurring 1 year after menopause or at unanticipated times in HRT
Define dysfunctional uterine bleeding (DUB).
Abnormal bleeding from an essentially normal uterus
Causes may be functional or organic, and may include endocrine disorders and many others
What is the endometrial thickness in each phase: menses, proliferative, secretory.
menses = 1-4mm proliferative = 4-8mm secretory = 8-16mm
Name the dominant hormones of each phase: menses, proliferative, secretory.
menses = FSH, estrogen proliferative = FSH, estrogen --- LH at ovulation secretory = progesterone
What do OCP’s prevent? What is the most common regimen in the US?
Prevent conception by inhibiting ovulation
Pills with a combination of estrogen and progesterone
What will be different sonographically with patients who are on OCP’s?
- Won’t develop a dominant follicle (bc they don’t ovulate)
- May have smaller follicles (5-19mm)
- Endometrial growth suppressed - can’t go by normal measurements
What is the general lifespan of an IUD? What are the most common types?
5-10 years
Copper-coated (Paraguard, Copper-T)
Lippes Loop
Hormonal (Mirena, Progestasert, Skyla, Liletta, Kyleena)
What commonly happens with the uterus during insertion of an IUD?
Uterine perforation
Describe the sonographic appearance of an IUD.
- hyperechoic to the endometrium (could appear isoechoic)
- posterior acoustic shadow or other artifact
- positioned in fundus or mid portion of uterine body
How is sonography used with the placement of IUD’s?
Sonography is used to confirm IUD position in the uterus or evaluate for myometrial perforation. 3D is useful in determining exact location.
Define infertility.
The inability of a man and woman to achieve pregnancy after at least a year of having regular intercourse without any type of birth control.
How many couples does infertility affect? Approximately how many are due to female factors, male factors, both partners and how many are unexplained?
1 in 7 couples
Female factors = 40%
Male factors = 40%
Both = 5-10%
Unexplained = 5-10%
What do the female factors for infertility include?
- an ovulation and abnormal ovulation
- tubal and transport factors (ie adhesions, hydrosalpinx)
- endometriosis
- uterine factors (ie myoma, congenital anomalies)
- polycystic ovarian syndrome
- cervical factors
How is sonography used in in-vitro fertilization programs?
- Establishes normal uterine anatomy and evaluates endocrine indicators (ie: thickness, texture of endo and presence of intracavitary lesions or fluid)
- Monitors the development of growing follicles and determine the timing of injection of hCG to trigger ovulation
- Confirms ovarian response to various drugs (ie Clomid, Pergonal), or identify hyperstimulated ovaries
- Guide oocyte retrieval from ovaries
What are the ovulation induction medications?
- Clomiphene Citrate
- Gonadotropins
- Glucophage (metformin)
- hCG
- Parlodel and dostinex
What does clomiphene citrate used for?
Tablet used for women who have infrequent periods for long menstrual cycles
What are gonadotropins(med) used for?
Injectible medication used to induce the release of the egg once the follicles are developed and the eggs are mature
What is glucophage used for? What population is it typically given to and what are the effects of that?
Given to patients as an insulin lowering medication, commonly used in PCOS patients
Will reverse PCOS endocrine abnormalities in 2-3 months
What is hCG(med) used for?
Used with other drugs to trigger ovulation
What are parlodel and dostinex used for?
Used to lower prolactin levels and will reduce pituitary tumor size, should one be present
How big are follicles when they are typically aspirated for IVF?
18-24mm
What is the IVF sonographic protocol?
- baseline TA sonogram
- preliminary TV evaluation of follicles
- daily TV to monitor dominant follicles
Describe in vitro fertilization (IVF).
Consists of:
- ovarian stimulation
- needle aspiration of oocytes
- incubation of oocytes with sperm
- catheter delivery of typically 2-4 embryos into the uterus
Describe zygote intrafallopian tube transfer (ZIFT).
Embryo (or zygote) is placed into the fallopian tube (rather than the uterus, as with IVF)
Describe gamete intrafallopian tube transfer (GIFT).
Sperm and ova are placed into the Fallopian tube
Describe intrauterine insemination (IUI). In what cases is this used?
Catheter placement of a sperm preparation into the uterine fundus
Used in cases of male factor infertility
What is ovarian hyperstimulation syndrome (OHSS)?
A condition resulting from excessive stimulation of the ovaries in women taking fertility drugs
What are the sonographic findings of OHSS?
- large simple cysts with an ovarian diameter of >5cm
- bilateral
- resemble theca lutein cysts
- may have ascites and pleural effusion
When/how does OHSS usually resolve?
Mild cases usually resolve spontaneously following the next menstrual cycle
More severe cases are associated with a high mortality rate (50%) and may require hospitalization to correct fluid and electrolyte imbalances
- more severe in patients who conceive
The incidence of ______ ______ increased with successful fertility treatment.
multiple gestations
