Female Reproductive Tract- Witwer Flashcards
1
Q
Menstrual Cycle is required for:
- production of ______
- Preparation of the ______
A
- **ovocytes
- uterus for pregnancy
2
Q
Menarche=
A
first period
3
Q
avrg period=
A
28 days
4
Q
Sx associated with Menstrual cycle:
A
-Premenstrual symptoms are common, acne, tender breasts, bloating, malaise, iritability, mood changes.
- **If these interfere with normal activities = Premenstrual Syndrome
- -Severe in 3-8%
5
Q
Menopause: women ____ yo
A
45-55 yo
6
Q
Menstrual cycle: Three Components (list)
A
- Hypothalamus/Pituitary Cycle
- Ovarian cycle
- Uterine cycle
7
Q
Describe the Hypothalamus/Pituitary Cycle (hormones)
A
- Hypothalamic Gonadotropin Releasing Hormone
- Follicle Stimulating Hormone
- Luteinizing Hormone
8
Q
Describe the Ovarian Cycle:
A
Follicular Phase
Ovulation
Luteal Phase
9
Q
Describe the uterine cycle
A
Menstruation
Proliferative Phase
Secretory Phase
10
Q
Hypothalamus-Pituitary-Ovarian Axis
A
- Precise signalling b/w hypothalamus and ovary.
- Primary Signal is Hypothalamic GnRH (stimulating the release of FSH and LH from the anterior pituitary) feedback loop with ovarian androgen and estrogen steroids regulating the GnRH.
- FSH and LH act in concert to stimulate gamete (ovum) maturation and hormone production
11
Q
Gametes are _____ cells
A
- *haploid
- -ovum or sperm cells
12
Q
Slide 8
A
draw out
13
Q
Menstrual cycle:
Three Ovarian phases–>
Follicular=
Ovulatory=
Luteal=
A
Follicular–> Granulosa cells proliferate in response to Follicle Stimulating Hormone (FSH) and produce estradiol
-Luteinizing Hormone (LH) stimulates Theca
cells to produce androgens > estradiol in
granulosa cells
-Estradiol and progestins stimulate Gonadotropin Releasing Hormone (GnRH) which stimulates FSH and LH and induces ovulation
-Ovulatory –
Luteal–> after ovulation, follicular cells transform into Corpus Luteum in response to Luteinizing Hormone and produce progesterone and estrodiol and these along with Inhibin produced by granulosa cells suppresses LH and FSH.
Without fertilization, corpus luteum regresses
and cycle starts again.
14
Q
Hormonal Regulation of Menstrual Cycle
A
GnRH = Gonadotropin Releasing Hormone
Granulosa cells = follicle cells – produce sex hormones in ovary.
15
Q
Fertilization= ____ hours
A
12-24
16
Q
Zygote (2-cell stage) approx. ____ hrs
A
30
17
Q
Four cell stage=
A
40 hrs
18
Q
**Early Morada= ____ hrs
A
80 hrs**
19
Q
Blastocyst approx __ days
A
5 days
20
Q
Early implantation approx. __ days
A
6
21
Q
Vaginal Developmental Variants (list ex’s)
A
- Double Vagina
- Absence of Vagina
- Rudimentary second vagina without external opening forming a cyst
(these are rare)
22
Q
Uterine Developmental Variants (ex’s)
A
Uterus Didelphys= 2 uteruses
Uterus Duplex bicornis= this means a horned uterus (not uncommon)
23
Q
Normal Variations of the uterus:
A
retroverted, anteverted, retroflexed, anteflexed
Retrocession= whole uterus moves posteriorly
24
Q
Vulvar Disease - Benign
-list Ex’s
A
varicose veins, Angioneurotic edema, Bartholin cyst, Sebaceous cyst, Lipoma, fibroma
25
Vulvar Disease – “Inflammatory”
| -list Ex's
Furunculosis= inflammatory infxn of the hair follicle (common w shaving)
Herpes genitalis (HSV)
Intertrigo= inflame. Condition in folds of tissue
Tinea cruris= fungal infxn
Psoriasis
Diabetic vulvitis, Tichomoniasis, Candidiasis, Acute urethritis, Bartholin abscess
26
Vulvar Disease - Malignancies
| -list ex's
carcinoma of the clitoris, Carcinoma on leukoplakia, Sarcoma of the labium, metaplastic hypernephroma (=kidney cancer, rare)
Leukoplakia tends to be pre cancerous condition**
27
Sexually Transmitted Disease:
- Chancroid
- bubo=
Chancroid= there will be a bubo (= inflamed lymph node, that can break down and form an abscess)
28
Sexually Transmitted Disease:
| -list ex's
- Chancre with inguinal adenopathy
| - Condylomata lata or acuminata
29
____ is the MCC of female infertility and ectopic pregnancy
**PID
30
PID:
| -risk factors
- Multiple partners
- Vaginal douching
- Previous episodes of PID
- Unprotected sex
31
Most, but not all cases of PID are ____
STDs
32
PID: causes?
* **Most often Neisseria gonorrhea or Chlamydia trachomatis
- Coexisting infection in 45%
- Without treatment, 40% with gonorrhea and 10% with Chlamydia will get PID
33
PID:
| -other non-STD pathogens ?
- Bacteroides fragilis
- Streptococci
- Clostridium perfringens (gas gangrene)
- Mycobacterium tuberculosis
- Cytomegalovirus
34
PID:
| -findings?
- Fallopian tubes filled with pus
- MCC of hydrosalpinx, the result of pus resorption
- Tuboovarian Abscess - TOA
35
PID:
| -clinical Sx?
- Fever
- Lower abd pain
- Pain with cervical motion, palpation of adnexa and uterus
- Abnormal uterine bleeding
- Vaginal discharge
- Mucopurulent cervical os discharge
- RUQ pain in 5% > FitzHugh-Curtis Syndrome, inflammatory adhesions around liver secondary to Chlamydia or GC infection
36
PID: dx
**Pelvic Ultrasound
| MRI
37
Cul-de-sac abscess-->
In Pt with PID, Culposcopy= scope in there and draining the abscess
38
tuboOvarian abscess can develop in Pts with ____
PID
39
If the patient’s beta-HCG level is >1000 IU/mL (2IS Standard) or >2000 IU/mL (IRP Standard), an _____ _____ _____should be identifiable on a Transvaginal Sonogram.
**intrauterine gestational sac
40
**An intrauterine gestational sac should be present by __ weeks and also show embryonic cardiac activity by ___ weeks on a Transvaginal Sonogram when the sac is at least 16mm long or embryonic crown rump length is at least 5mm.
- **5 weeks
| - 5+
41
If none of the above are evident (ie gestational sac at 5 weeks), strongly suspect an Ectopic Pregnancy. Additional criteria for ectopic pregnancy:
If no intrauterine gestational sac is seen at all
If a live, extrauterine embryo is identified
There is free fluid in the pelvis or peritoneum
There is an adnexal mass
There is a hematosalpinx
42
Ectopic pregnancy:
___% of pregnancies
-___% of maternal deaths, MCC of death in early pregnancy
- 1-2%
| - 13%
43
Ectopic Pregnancy:
| -risk factors=
```
Scarring from previous PID
Endometriosis
Altered tubal motility
Progestin only pill
Previous tubal ligation
```
44
Ectopic Pregnancy:
| -MC location?**
fallopian tubes*
45
Ectopic Pregnancy:
clinical Sx ?
-complications?
```
Pain 95%
About six (6) weeks from LMP
Adnexal tenderness 90+%
-Peritoneal signs 70+%
-Abnormal uterine bleeding 75%
```
-Complications:
Rupture with intra-abdominal bleeding
46
Ectopic pregnancy:
| -dx?
Beta HCG with Ultrasound
-Positive Pregnancy Test
No Intrauterine Pregnancy
(also note fluid in the adnexa)
47
Vaginal conditions:
| -ex's
- foreign body
- Chemical vaginitis
- Adhesions after severe chemical erosion
- irritation from prolonged use of pessary and poor hygeine
48
Vaginal Cancer (ex's)
- sarcoma
- melanoma
- Squamous cell carcinoma
49
Simple Ovarian Cysts:
- how common
- 2 types=
- Common, majority of no clinical significance, can be large.
- Related to ovulation
-2 Types:
Follicular cysts
Corpus Luteum cysts
50
Simple Ovarian Cysts:
-Clinical sx=
Dx=
```
Bloating, lower abdominal pain, lower back pain
May rupture > pain, usually self limiting
May volve (twist, torsion) > pain
```
Dx: Ultrasound, CT, or MRI
51
REMEMBER: Endometriosis, dermoid cysts, polycystic ovarian syndrome, cystadenomas and cystadenocarcinoma can form cysts. These are NOT _____ cysts
simple
52
"blue" mass in ovary=
= cyst
53
Ovarian Torsion
- large ovary w large follicles
| - large ovary w/out doppler flow
54
Polycystic Ovary Disease=
**PCOD - Enlarged ovaries with thick sclerotic capsules and an abnormally high number of follicles
55
Stein-Levanthal Syndrome=
| -4 things**
amenorrhea, infertility, hirsutism and enlarged polycystic ovaries
56
Ovarian Epithelial-Stromal Tumors
| - benign or malignant?
- May be benign: MC forms are Cystadenomas, Serous and Mucinous tumors
- May be malignant, Cystadenocarcinoma
57
Ovarian Germ Cell tumors – about 30%:
are benign, occur in young females
58
Ovary - Serous Cystadenoma:
- demographic?
- benign or malignant
Tumors <45 yrs tend to be benign
75% of serous tumors benign, 25% malignant
-Ovarian tumors may be bilateral in significant percent, especially
malignant tumors 66%
59
Ovary Cystadenoma - Mucinous tumors ___% are ovarian tumors
25%
-**Very large masses can occur.
60
Ovary: Teratoma/Dermoid Cyst
- describe
- benign or malignant
- teratoma=
- Germ Cell tumors 20% -tend to be **Benign
- Note hair and teeth and skin
- Teratoma= can be benign or malignant ,tumors of germ cell origin, and often has differentiated structures within it
These can be nasty and are benign
61
Carcinoma of the Ovary:
- risk of malignancy increases with ____
- majority derived from _____
- *age
- -Median age 61 yrs
- Peaks in late 70s
- 60% present with advanced disease
- Majority derived from surface cells – Epithelial-stromal tumors
62
Carcinoma of the Ovary:
| -risk factors?
Nulliparity – greater menstrual cycles increases risk, oral contraceptives
* *and pregnancy decreases risk
- **Genetic factors: BRCA 1 and 2
- Lynch Syndrome: Hereditary Non-Polyposis Colorectal Cancer
- History of Breast Cancer
- Postmenopausal estrogen therapy
- Obesity
63
Carcinoma of the Ovary:
| Serous Cystadenocarcinoma – ___% carcinomas
40%
64
Carcinoma of the Ovary:
-Metastases seed omentum and ________
-Other malignancies may metastasize to
the ovaries, from uterus, breast, ___
peritoneum
| -and GIT
65
Carcinoma of the Ovary:
| -Clinical Sx: (hint: which sign, and which tumor marker**)
- Malignant ascites common
- Palpable ovarian mass in postmenopausal
- Malignant pleural effusion
- **Sister Mary Joseph Sign
-***Tumor markers: CA125
66
Abnormal Uterine Bleeding:
menorrhagia=
Metorrhagia=
=heavy or prolonged flow
=spotting or between menstrual flow
67
AUB:
| Think-->
```
Uterus and Cervix:
Menstruation disorders
Pregnancy Disorders
Tumors
Infection
```
-Ovary or Adnexa:
Tumors
Endometriosis
PID
Hormonal Disorders: Pituitary, Ovarian, Exogenous
Systemic conditions
1 thing to be careful about= POST menopausal woman w uterine bleeding MUST R/O malignancy
68
Carcinoma of the Cervix:
- how common?
- majority are ____ cell carcinoma
* Least common Gynecologic cancer
- Higher incidence in developing countries
- **Squamous Cell Carcinoma
69
Carcinoma of the Cervix:
| -risk factors for Types 16 and 18=
**-HPV--> Types 16 and 18 have high risk
70
Carcinoma of the Cervix:
other risk factors?
-clinical sx?
Early onset of sexual intercourse
- Multiple, high risk partners
- Smoking, OCP, immunodeficiency
- *Abnormal vaginal bleeding MC
- Malodorous discharge
- Obstructs ureters leading to renal failure and death
71
Leiomyoma -Uterine Fibroids = _____ ____ _____ tumor
**Benign smooth muscle tumor
72
Leiomyoma - Uterine Fibroids:
| -how common?
- Most frequently diagnosed gynecologic tumor
- Occurs in 20-50% women over 30 yrs
- Blacks > whites
- Estrogen sensitive – larger in pregnancy
-Will undergo degeneration, dystrophic calcification, hyalinization (fibroid)
73
Leiomyoma - Uterine Fibroids:
| -clinical Sx?
Menorrhagia
Obstructive delivery
Pressure on colon with constipation
Pressure on bladder with frequency, urgency, and incontinence
74
Leiomyoma - Uterine Fibroids:
| dx?
Ultrasound
| MRI
75
Leiomyoma - Uterine Fibroids:
| Surgery?
Myotomy, hysterectomy
76
Uterine Adenomyosis=
Endometrial glandular tissue within the myometrium
| --leads to enlarged uterus
77
Uterine Adenomyosis:
- MC age?
- Clinical sx:
- Dx?
Mid to late 40s
- Pelvic pain
- Menorrhagia
- Dysmenorrhea
-Myometrial Biopsy**
78
Uterine Adenomyosis:
| tx?
hysterectomy
79
**NOTE:
Although different conditions, Uterine Adenomyosis and Endometriosis are both
caused by the SAME estrogen sensitive ectopic endometrial glandular tissue.
endometriosis= tissue that normally lines the inside of your uterus= the endometrium — instead it grows OUTSIDE your uterus.
80
Endometrial Carcinoma of the Uterus= the MC _____
* *malignant gynecologic tumor
- Median age, 60 yrs
- **Post menopausal bleeding
81
Endometrial Carcinoma of the Uterus:
| -Pathogenesis=
prolonged estrogen stimulation
| -**OCPs decrease risk
82
Endometrial Carcinoma of the Uterus:
Types-->
-Dx?
-Well differentiated adenocarcinoma= MC
-Adenosquamous has squamous elements
=Papillary Adenocarcinoma
dx= Endometrial biopsy
83
Endometrium: Other Disorders
| -list Ex's
- endometrial hyperplasia
- Tuberculous endometritis
- multiple endometrial polyps
84
Endometriosis= functioning uterine glands and _____ located ______
-characterized by=
stroma**
-located outside of the uterus
* *cyclic bleeding of glandular and stromal elements
- MC Sx= Dysmenorrhea***
- other Sx: Infertility, endometrial cysts (aka chocolate covered cysts)
85
Endometriosis:
| -very high in women with ______
* *dysmenorrhea (pain) (40-60%)
| - 25-29 yo
86
Endometriosis:
| -MC site?
ovaries
87
**ALTHOUGH different conditions, Adenomyosis and Endometriosis are both:
** caused by the same estrogen sensitive ectopic endometrial glandular tissue.
(KNOW)
88
Endometriosis:
| -Diagnosis made by?
- Laparoscopy*
| - Increased CA 125
89
Gestational Trophoblastic Neoplasms:
| -Hydatidiform mole=
clump of growing tissue, aka molar pregnancy
=An abnormal form of pregnancy, the fertilized egg does not have a maternal DNA and does not develop into fetal tissue. The tissue grows from the chorion and placenta
-a benign tumor** of the chorionic villus
90
"dilated, "Grape-like," swollen villi without fetal blood vessels or parts" =
Hydatidiform mole= Molar pregnancy!!**
- May develop into choriocarcinoma in 20%
- Dx: US/CT/MRI
91
Gestational Trophoblastic Neoplasms:
| -Key clinical sx=
- Vaginal bleeding at 6-16 weeks
- Severe vomiting= hyperemesis gravidarum-10%
- MARKEDLY increased Beta hcg
92
Gestational Trophoblastic Neoplasms:
| -Tx?
- dilation and curettage
| - follow beta hCG levels
93
Gestational Trophoblastic Neoplasms:
| -Choriocarcinoma=
=Malignant tumor--> Chorionic villi are not present, tumor arises from trophoblastic cells
- 50% arise from molar pregnancy
- 25% from spontaneous abortion
- 20% from full term pregnancy
94
Gestational Trophoblastic Neoplasms:
-Choriocarcinoma:
Sx?
tx: ?
- lesions are hemorragic, vaginal bleeding
- Chest pain, elevated b hCG
- Mets: lungs/vagina/brain
excellent response to chemotherapy*****
95
Supporting structures of uterus: list 3
1. Pelvic Diaphragm (Pelvic Floor)= Levator Ani, Coccygeus Muscle, And associated fascia
2. Urogenital diaphragm/perineal membrane
3. Perineal body
96
Note: the Broad Ligament, Round Ligament, suspensory ligament of the ovary, and peritoneal folds associated with the uterus are ______
**NOT considered to be true uterine support structures
97
“Ligamentous Supporting” Structures of the Uterus:
Cardinal (=Transverse cervical, Mackenrodt) -- fibromuscular fascia from either side of cervix to the pelvic walls
Uterosacral ligaments--from posterior cervix to the sacrum--comprised of the Recto-uterine folds -- comprised of fibrous tissue and muscular fibers attached to front of sacrum
Anterior Pubocervical ligament - from the uterus to the pubic symphysis
98
Cul de sac=
rectouterine pouch, rectovaginal pouch/space, aka pouch of douglas
=a deep pouch posterior to the uterus and anterior to the rectum
99
Peritoneal folds associated with the Uterus=
Broad Ligament, Mesovarium, Mesosalpinx, Round Ligament
100
Supporting structures of the ovary= (list 3)
Mesovarium – a fold of peritoneum off of the Broad Ligament
Suspensory Ligament of Ovary – a fold of peritoneum from superiolateral pelvic wall and contains arteries, veins, lymphatics
Ligament of Ovary – continuous with Round Ligament of Uterus. Attached to lower pole of ovary to Uterus
101
the ______ fascia supports the bladder
-when this fascia weakens, often 2/2 childbirth, then the support of the _____ weakens and ______ occurs
**pubocervical
-bladder support weakens--> cystocele (prolapse)
