GU

Question 1

What is the vulva?

Answer 1

the skin and mucosa of the female genitalia external to the hymen, including the labia major, labia minor, mons pubis, and vestibule

Question 2

The vulva is lined by what sort of epithelium?

Answer 2

squamous

Question 3

Bartholin Cyst

Answer 3

• a dilation of the Bartholin gland
• arises as a unilateral, painful cystic lesion at the lower vestibule adjacent to the vaginal canal
• forms due to obstruction and inflammation
• most often in women of reproductive age

Question 4

What are the Bartholin glands?

Answer 4

two glands, one present on each side of the vaginal canal, which produce a mucus-like fluid for lubrication

Question 5

Condyloma

Answer 5

• a warty, often large, neoplasm of the vulvar skin
• most commonly due to HPV 6/11 or secondary syphilis
• histology is characterized by koilocytes
• rarely progress to carcinoma

Question 6

What are the low risk types of HPV? What are the high risk types?

Answer 6

• low risk: those with low malignant potential, including 6 and 11
• high risk: those likely to progress to carcinoma, including 16, 18, 31, and 33

Question 7

What is koilocytic change?

Answer 7

• a change in the cell morphology of HPV infected cells

- the nucleus takes on a wavy, raisin like shape

Question 8

Lichen Sclerosis

Answer 8

• a thinning of the epidermis and fibrosis of the dermis of the vulvar skin
• presents as a leukoplakia (white patch), with “parchment-like” skin
• most common in post-menopausal women
• carries some degree of risk for squamous cell carcinoma (more than Lichen simplex chronicus)

Question 9

Lichen Simplex Chronicus

Answer 9

• a hyperplasia of the vulvar squamous epithelium
• presents as a leukoplakia with thick, leathery skin
• associated with chronic irritation and scratchy
• benign and with no risk for squamous cell carcinoma

Question 10

How does Lichen Sclerosis compare to Lichen Simplex Chronicus?

Answer 10

• Lichen Sclerosis is a thinning of the epidermis and fibrosis of the dermis that results in thinning of the skin and carries a risk for squamous cell carcinoma
• Lichen Simplex Chronicus is a hyperplastic thickening of the skin that poses no risk for carcinoma

Question 11

Vulvar Carcinoma

Answer 11

• a carcinoma arising from the squamous epithelium lining the vulva
• presents as a leukoplakia and requires biopsy for diagnosis
• may be HPV or non-HPV related:
• HPV related is seen more often in young women with risk factors for HPV exposure and the carcinoma arises from pre-existing vulvar intraepithelial neoplasia, a dysplastic precursor lesion with koilocytic change
• non-HPV related is more often found in older women (>70) and arises from long-standing lichen sclerosis

Question 12

What are two pathways for the development of vulvar carcinoma?

Answer 12

• HPV related: seen in younger women following vulvar intraepithelial neoplasia
• non-HPV related: seen in older women following long-standing lichen sclerosis

Question 13

Extramammary Paget Disease

Answer 13

• the presence of malignant epithelial cells in the epidermis of the vulva
• it represents carcinoma in situ without underlying carcinoma (in contrast to Paget’s disease of the nipple , which is almost always associated with an underlying carcinoma)
• it presents as erythematous, pruritic, ulcerated vulvar skin
• must be distinguished from melanoma: Paget disease will be PAS+, keratin+ and S-100- while melanoma is keratin- and S-100+

Question 14

How does Extramammary Paget disease differ from Paget disease of the nipple?

Answer 14

• extramammary Paget disease represents carcinoma in situ, usually without underlying carcinoma
• however, Paget disease of the nipple is almost always associated with an underlying carcinoma

Question 15

What must extramammary Paget disease be differentiated from? How is this done?

Answer 15

• must be differentiated from melanoma
• Paget disease is keratin+ and S-100-
• melanoma is keratin- and S-100+

Question 16

The vaginal mucosa is lined by what sort of epithelium?

Answer 16

non-keratinizing, stratified squamous epithelium

Question 17

Adenosis

Answer 17

• a focal persistence of columnar epithelium in the upper vagina (the epithelium that was present during embryonic development from the Mullerian tubes but should have been resorbed)
• seen in females exposed to DES (diethylstilbestrol) in utero
• poses a risk for clear cell adenocarcinoma

Question 18

What is diethylstilbestrol?

Answer 18

an estrogenic compound no longer used because it increased the risk of breast cancer in pregnant mothers and the risk for adenosis and clear cell adenocarcinoma in females exposed in utero

Question 19

Clear Cell Adenocarcinoma

Answer 19

• a malignant proliferation of glands with clear cytoplasm

- a complication of DES-associated vaginal adenosis

Question 20

Embryonal Rhabdomyosarcoma

Answer 20

• a malignant proliferation of immature skeletal muscle also known as sarcoma botryoides
• presents as bleeding and a grape-like mass protruding from the vagina or penis of a child (<5)
• rhabdomyoblasts are the characteristic cell and they exhibit cytoplasmic cross-striations as well as positive immunohistochemistry for desmin and myogenin

Question 21

Which tumor presents as a grape-like mass protruding from the vagina or penis of a child?

Answer 21

embryonal rhabdomyosarcoma, consisting of rhabdomyoblasts

Question 22

Vaginal Carcinoma

Answer 22

• a carcinoma arising from the squamous epithelium of the vaginal mucosa
• related to high-risk HPV (16,18, 31, 33)
• develops from a precursor, dysplastic lesion known as vaginal intraepithelial neoplasia
• in the lower ⅓ of the vagina, it spreads to the inguinal nodes, and in the upper ⅔, it spreads to the iliac nodes

Question 23

To which lymph nodes does the vagina drain?

Answer 23

• lower ⅓ drains to the inguinal nodes

- upper ⅓ drains to the iliac nodes

Question 24

What sort of epithelium lines the cervix?

Answer 24

• the exocervix is lined by non-keratinizing squamous epithelium
• the endocervix is lined by a single layer of columnar cells

Question 25

Where along the female reproductive tract does HPV especially like to infect cells?

Answer 25

the transformation zone of the cervix

Question 26

What happens in most cases of HPV infection?

Answer 26

the infection is resolved by acute inflammation

Question 27

How is HPV type determined?

Answer 27

DNA sequencing

Question 28

What makes high risk HPV types more likely to cause CIN and carcinoma?

Answer 28

- they express the E6 and E7 proteins - E6 increases destruction of the p53 protein, which regulates the G1/S progression based on the presence of DNA damage, calling in repair mechanisms or inducing BAX to inhibit Bcl2 and induce apoptosis - E7 destroys or inactives the Rb protein, which frees E2F and allows for unrestricted progression from G1/S

Question 29

What are the functions of the E6 and E7 proteins expressed by high risk HPV?

Answer 29

E6 and E7 destroy or inhibit p53 and Rb proteins, respectively

Question 30

How are CIN I, II, III and carcinoma in situ defined?

Answer 30

- CIN I involves less than ⅓ of the thickness of the cervical epithelium - CIN II involves less than ⅔ the thickness - CIN III involves slightly less than the entire thickness - CIS involves the entire thickness - in the progression to each, the chances of reversal diminish

Question 31

What is the difference between CIN III and carcinoma in situ?

Answer 31

- CIN III involves slightly less than the entire thickness of the cervical epithelium while CIS involves the full thickness - more importantly, however, is that CIN III may, although rarely, be reversed while CIS is irreversible in all cases

Question 32

Cervical Carcinoma

Answer 32

- an invasive carcinoma arising from the cervical epithelium - presents as vaginal bleeding, especially postcoital, or a with a cervical discharge, most often in middle-aged women (40-50) - key risk factor is high-risk HPV infection, but secondary risk factors include smoking and immunodeficiency - most common subtypes are squamous cell carcinoma (80%) and adenocarcinoma (15%), which are both related to HPV - may invade through the anterior uterine wall into the bladder, blocking the ureters and causing hydronephrosis with post renal failure; a common cause of death in these patients

Question 33

What is the most common type of cervical carcinoma?

Answer 33

squamous cell carcinoma, followed far behind by adenocarcinoma

Question 34

What is a common cause of death in patients with cervical carcinoma?

Answer 34

invasion of the tumor through the anterior wall of the uterus, blocking the ureters and causing hydronephrosis with post-renal failure

Question 35

What is the goal of Pap smears?

Answer 35

to catch dysplasia before it develops into carcinoma

Question 36

The progression from CIN to carcinoma in situ usually takes how long? Why is this important?

Answer 36

10-20 years, making Pap smears an effective screening tool

Question 37

When does screening begin for cervical carcinoma? How often is it performed?

Answer 37

- Pap smears begin at age 21 | - repeated every three years

Question 38

How do high grade dysplasias present on a pap smear?

Answer 38

the cells have hyperchromatic nuclei and high nuclear to cytoplasmic ratios

Question 39

What is true about women who develop invasive cervical carcinoma today?

Answer 39

they have not undergone screening

Question 40

An abnormal Pap smear is followed by what sort of test?

Answer 40

a colposcopy, in which the dysplasia is visualized by a magnifying glass and biopsied

Question 41

What are the key limitations of the Pap smear?

Answer 41

- can result in false negatives if the transformation zone of the cervix isn't sampled - doesn't appear to be efficacious in screening for adenocarcinoma even though it too is caused by HPV

Question 42

Which sort of cervical carcinoma are Pap smears largely ineffectual at screening for?

Answer 42

adenocarcinoma

Question 43

What HPV types does the vaccine cover?

Answer 43

types 6, 11, 16, and 18

Question 44

Why should those who have received the HPV vaccine still receive Pap smears and monitoring?

Answer 44

because the vaccine only covers four HPV types

Question 45

Growth of the endometrium is driven by what hormone?

Answer 45

estrogen

Question 46

What hormonal change leads to shedding of the endometrium during menstruation?

Answer 46

loss of progesterone

Question 47

Asherman Syndrome

Answer 47

- secondary amenorrhea due to loss of the basalis and scaring - usually the result of overaggressive dilation and curettage of the uterus

Question 48

What is the regenerative layer of the endometrium called?

Answer 48

the basalis

Question 49

Anovulatory Cycle

Answer 49

- a lack of ovulation - results in an estrogen-drive proliferative phase without a subsequent progesterone-driven secretory phase - represents a common cause of dysfunctional uterine bleeding, especially during menarche and menopause

Question 50

Acute Endometritis

Answer 50

- a bacterial infection of the endometrium - most often associated with retained products of conception after delivery or miscarriage - presents with fever, uterine bleeding, and pelvic pain - treat with gentamicin + clindamycin +/- ampicillin

Question 51

Chronic Endometritis

Answer 51

- chronic inflammation of the endometrium - defined by the presence of plasma cells in the endometrium (never found there otherwise) - usually related to retained products of conception, PID, IUD, or TB - presents as abnormal uterine bleeding, pain, and infertility

Question 52

Plasma cells in the endometrium are required for the diagnosis of what?

Answer 52

chronic endometritis

Question 53

Endometrial Polyp

Answer 53

- a hyperplastic protrusion of endometrium - most often caused by tamoxifen, which has weak pro-estrogenic effects on the endometrium - presents with abnormal uterine bleeding

Question 54

Tamoxifen has weak estrogenic effects in what tissue? What side effect does this often give rise to?

Answer 54

- the endometrium | - endometrial polyp

Question 55

Endometriosis

Answer 55

- the presence of endometrial glands and stroma outside the uterine endometrial lining - current theory is that it is due to retrograde menstruation - presents as dysmenorrhea and pelvic pain because it cycles just like normal endometrium - most commonly involves the ovary and forms a "chocolate cyst" - may also involve the uterine ligaments (pelvic pain), pouch of Douglas (pain with defecation), bladder wall (pain with urination), bowel serosa (abdominal pain and adhesion), or fallopian tube mucosa (scarring with increases risk for ectopic tubal pregnancy) - adenomyosis is endometriosis within the myometrium - risk for carcinoma at the site of endometriosis - treat with NSAIDs, OCPs, progestins, GnRH agonists, danazol, or laparoscopic removal

Question 56

What is a "chocolate cyst"?

Answer 56

- a cyst that forms in the ovary as a result of endometriosis - fills with products of menstruation and has a chocolatey appearance

Question 57

What site is most commonly affected by endometriosis?

Answer 57

the ovary

Question 58

What is adenomyosis?

Answer 58

- endometriosis within the myometrium of the uterus | - treat with a GnRH agonist or hysterectomy

Question 59

Why does endometriosis contribute to infertility?

Answer 59

because it can involve the Fallopian tubes and induce scarring

Question 60

Endometrial Hyperplasia

Answer 60

- hyperplasia of the endometrial glands relative to stroma - most often due to unopposed estrogen - presents as postmenopausal bleeding - classified according to its architectural (simple or complex) and whether or not there is cellular atypia - the presence of atypia is the most important predictor of progression to carcinoma

Question 61

What is the most significant predictor of whether endometrial hyperplasia will progress to carcinoma?

Answer 61

the presence or absence of cellular atypia

Question 62

What causes endometrial hyperplasia?

Answer 62

unopposed estrogen

Question 63

Endometrial Carcinoma

Answer 63

- a malignant proliferation of endometrial glands - the most common invasive carcinoma of the female reproductive tract - presents with postmenopausal bleeding - may arise via either the hyperplastic or sporadic pathways: - hyperplastic is more common and involves carcinoma arising from pre-existing endometrial hyperplasia; risk is related to estrogen exposure and the histology is endometroid - sporadic arises in an atrophic endometrium without evidence of a precursor lesion; histology is usually serous and characterized by papillary structures as well as psammoma bodies; p53 mutation is common and these are aggressive tumors

Question 64

What is the most common invasive carcinoma of the female reproductive tract?

Answer 64

endometrial carcinoma

Question 65

Name and describe the two different pathways leading to endometrial carcinoma.

Answer 65

- hyperplastic: arising from pre-exisitng endometrial hyperplasia; most often due to unopposed estrogen; endometroid histology - sporadic: arising from an atrophic endometrium; most often associated with a p53 mutation; histology is serous with papillary structures and psammoma bodies

Question 66

Leiomyoma

Answer 66

- a benign proliferation of smooth muscle arising from the myometrium - risk is related to estrogen exposure - enlarge during pregnancy and shrink after menopause because they are estrogen sensitive - usually asymptomatic but may lead to uterine bleeding, infertility, and a pelvic mass - gross exam shows multiple, well-defined, white, whorled masses

Question 67

What is the most common tumor in females?

Answer 67

leiomyoma

Question 68

How can a leiomyosarcoma be distinguished form a leiomyoma on gross exam?

Answer 68

- leiomyoma is likely to be in multiple without necrosis or hemorrhage and found in premenopausal women - leiomyosarcoma is likely to be singular with necrosis and hemorrhage and found in post-menopausal women

Question 69

Leiomyosarcoma

Answer 69

- a malignant proliferation of smooth muscle arising from the myometrium - arises de novo, not from leiomyomas - usually seen in post-menopausal women - gross exam reveals a single lesion with areas of necrosis and hemorrhage

Question 70

Describe the basic structure of an ovarian follicle.

Answer 70

an oocyte surrounded by granuloma and theca cells

Question 71

What is a corpus luteum?

Answer 71

the residual follicle that remains after ovulation, which secretes progesterone to drive the secretory phase

Question 72

Polycystic Ovarian Disease

Answer 72

- multiple ovarian follicular cysts due to a hormone imbalance as hyperinsulinemia contributes to a rise in LH/FSH, which increases androgens - androgens contribute to hirsutism, effect negative feedback on the HPO, which decreases the rate of follicular maturation resulting in enraptured follicles and anovulation, and gets converted to estrone (not estradiol) which increases risk for endometrial carcinoma - presents as an obese young woman with infertility, oligomenorrhea, and hirsutism, often developing type 2 diabetes 10-15 years later; ovaries are bilaterally cystic - treat with weight reduction, OCPs, clomiphene citrate, ketoconazole, spironolactone - relatively common, affecting 5% of reproductive age women

Question 73

Polycystic Ovarian Disease is driven by what?

Answer 73

an increase in LH which leads to excess androgens and estrone but reduces FSH - androgens produce hirsutism and type 2 diabetes - estrogen produces oligomenorrhea and risk for endometrial carcinoma - low FSH produces cystic degeneration of ovarian follicles and infertility

Question 74

Ovarian tumors arise from what three types of cells?

Answer 74

- surface epithelium - germ cells - sex cord stroma (granulosa, theca, fibroblast)

Question 75

What is the most common type of ovarian tumor?

Answer 75

a tumor arising from surface epithelium

Question 76

What sort of epithelium covers the ovary?

Answer 76

coelomic epithelium

Question 77

Coelomic epithelium embryologically produces the epithelial lining of what structures?

Answer 77

- fallopian tube (serous cells) - endometrium - endocervix (mucinous cells)

Question 78

Ovarian Surface Epithelial Tumor

Answer 78

- a tumor arising from the coelomic epithelium overlying the ovary, which normally give rise to the epithelial lining of the fallopian tube, endometrium, and endocervix - classified as mucinous or serous based on the fluid it contains and as benign (cystadenoma), borderline, or malignant (cystadenocarcinoma) - cystadenomas are usually a simple cyst with a smooth lining whereas cystadenocarcinomas are complex cysts with shaggy linings - preset late with vague abdominal symptoms or signs of compression such as urinary frequency and the prognosis is generally poor - tend to spread locally and produce "omental caking" - CA-125 is a useful serum marker but not used for screening

Question 79

How do ovarian cystadenomas compare to cystadenocarcinomas?

Answer 79

- cystadenomas are benign, composed of a single cyst with a simple, flat lining, and are most common in premenopausal women - cystadenocarcinomas are malignant, composed of complex cysts with a thick, shaggy lining, and most common in postmenopausal women - both are derived from the surface epithelium of ovaries and can be of the mucinous or serous type

Question 80

Endometroid Tumor of the Ovary

Answer 80

- a malignant tumor derive from the coelomic epithelium of the ovary - composed of endometrial-like glands, which sometimes arises form endometriosis - 15% are associated with a second, independent endometrial carcinoma (of the hyperplastic/endometroid variety) - preset late with vague abdominal symptoms or signs of compression such as urinary frequency and the prognosis is generally poor - tend to spread locally and produce "omental caking" - CA-125 is a useful serum marker but not used for screening

Question 81

Those with an endometroid tumor of the ovary should be screened for what other condition?

Answer 81

an endometroid carcinoma of the endometrium

Question 82

Brenner Tumor

Answer 82

- a benign tumor derived from the coelomic epithelium of the ovary composed of bladder-like epithelium - preset late with vague abdominal symptoms or signs of compression such as urinary frequency - tend to spread locally and produce "omental caking" - CA-125 is a useful serum marker but not used for screening

Question 83

How does the prevalence of the varying types of ovarian cancers change with age? Which age groups are most likely to experience each kind?

Answer 83

- germ cell tumors affect younger women (15-40) - benign surface epithelial tumors tend to affect middle-aged premenopausal women - malignant surface epithelial tumors tend to affect older, post-menopausal women

Question 84

Germ cell tumors generally arise during what age range?

Answer 84

15-40 years of age

Question 85

Cystic Teratoma

Answer 85

- a cystic tumor composed of fetal tissue derived from two or three embryologic layers - the most common germ cell tumor in females - bilateral in 10% of cases - typically benign; however, the presence of immature tissue or somatic malignancy within the teratoma indicates malignant potential - may present in females with pain secondary to torsion or enlargement of the ovary - struma ovarii is a special teratoma that is composed mostly of thyroid tissue and may induce hyperthyroidism

Question 86

What is the most common type of immature tissue found in a teratoma?

Answer 86

neural ectoderm

Question 87

What is the most common type of somatic malignancy found in a teratoma?

Answer 87

squamous cell carcinoma of the skin

Question 88

What is struma ovarii?

Answer 88

a teratoma composed primarily of thyroid tissue, leading to hyperthyroidism

Question 89

What endocrine dysfunction is most likely to arise in females with a teratoma?

Answer 89

hyperthyroidism if the teratoma represents a struma ovarii

Question 90

Dysgerminoma of the Ovary

Answer 90

- a germ cell tumor composed of large, clear cells with central nuclei (resembling oocytes) - the most common malignant germ cell tumor - has a good prognosis as it responds well to radiotherapy - serum LDH (lactic acid dehydrogenase) may be elevated

Question 91

Endodermal Sinus Tumor

Answer 91

- a malignant germ cell tumor seen in men (as a nonseminoma) and women that mimics the yolk sac - the most common germ cell tumor in children - serum AFP is often elevated - histology is likely to reveal Schiller-Duval bodies (glomeruloid-like structures)

Question 92

What are Schiller-Duval bodies?

Answer 92

glomeruloid-like structures seen on histology of an endodermal sinus tumor

Question 93

Which germ cell tumor is most common in female children?

Answer 93

endodermal sinus tumor

Question 94

Choriocarcinoma

Answer 94

- a malignant germ cell tumor composed of cyto- and syncytiotrophoblasts - mimics placental tissue but villi are absent - it spreads via the hematogenous route early (makes sense because the usual function of trophoblasts is to establish fetal blood flow) and goes to the lungs - high B-hCG is characteristic and may lead to theca cysts in the ovary or hyperthyroidism (since the a subunit of B-hCG resembles that of FSH, LH, and TSH) - in women it can arise as a complication of gestation (following hydatidiform mole, spontaneous abortion, etc.) or as a spontaneous germ cell tumor - when it arises from the gestational pathway it tends to respond well to chemotherapy; but those that arise spontaneously do not - in men, it is classified as a nonseminoma

Question 95

Granulosa-Theca Cell Tumor

Answer 95

- a neoplastic proliferation of granuloma and/or theca cells - often produces estrogen leading to precocious puberty, menorrhagia/metrorrhagia, or endometrial hyperplasia with postmenopausal bleeding depending on the women's stage of life - histology shows Call-Exner bodies (granulosa cells arranged around collections f eosinophilic fluid, resembling primordial follicles) - malignant but with minimal risk for metastasis

Question 96

Sertoli-Leydig Cell Tumor of the Ovary

Answer 96

- a sex cord-stromal tumor composed of Sertoli cells that form tubules and Leydig cells - Leydig cells have characteristic Reinke crystals on histology - may produce androgens, leading to hirsutism and virilization

Question 97

Meigs syndrome

Answer 97

- a syndrome of ovarian fibroma, pleural effusions, and ascites - entire syndrome resolves with removal of the tumor

Question 98

Krukenberg Tumor

Answer 98

- a bilateral metastatic mucinous tumor of the ovaries - most often due to metastasis of a diffuse type gastric carcinoma; as such, signet cells are common - bilateral nature helps distinguish it from a mucinous cystadenocarcinoma

Question 99

A Krukenberg Tumor must be distinguished form what other ovarian carcinoma? How is this done?

Answer 99

- it is a mucinous tumor from gastric carcinoma - as such it must be distinguished from a mucinous cystadenocarcinoma of the ovary - this is accomplished because the Krukenberg tumor is most often bilateral while the primary ovarian carcinoma is unilateral

Question 100

Pseudomyxoma Peritonei

Answer 100

massive amounts of mucus in the peritoneum due to a mucinous tumor of the appendix, often with metastasis to the ovary

Question 101

What is the most likely place for an ectopic pregnancy?

Answer 101

the lumen of the fallopian tube

Question 102

What is the major risk factor for ectopic pregnancy?

Answer 102

scarring secondary to PID or endometriosis

Question 103

Ectopic pregnancy

Answer 103

- a pregnancy outside the uterine lining - most often found in the lumen of the fallopian tube - risk factors include prior ectopic pregnancy, history of infertility, PID (salpingitis), endometriosis, ruptured appendix, or prior tubal surgery - presents as lower quadrant abdominal pain a few weeks after a missed period and lower-than-expected hCG - is a surgical emergency as it may rupture or bleed into the Fallopian tube

Question 104

How do we define a spontaneous abortion?

Answer 104

miscarriage of a fetus occurring before 20 weeks gestation

Question 105

What percentage of recognized pregnancies end in spontaneous abortion?

Answer 105

about 1/4

Question 106

Teratogens can have a wide array of effects. How do their affects vary based on the point at gestation at which the exposure occurred?

Answer 106

- if exposure occurs in the first 2 weeks, it usually leads to spontaneous abortion - between weeks 3-8 it is likely to lead to organ malformation - after 8 weeks, the most likely outcome is organ hypoplasia

Question 107

What are the most common causes of spontaneous abortion?

Answer 107

- chromosomal anomalies, especially trisomy 16 - hypercoagulable states as in antiphospholipid syndrome - congenital infection - exposure to teratogens in the first two weeks of gestation

Question 108

Placenta Previa

Answer 108

- implantation of the placenta in the lower uterine segment with the placenta overlying the cervical os - risk factors include multiparty or prior C-section - presents as third trimester bleeding - requires delivery by C-section to avoid compressing the arteries in the placenta during vaginal delivery

Question 109

Placental Abruption

Answer 109

- separation of the placenta from the decider prior to delivery - risk factors include trauma, smoking, hypertension, and cocaine abuse - presents with abrupt pain and third-trimester bleeding (bleeding may be concealed if the separation doesn't extend to the cervical os) - may cause DIC, maternal shock, or fetal distress; life threatening to both the mother and fetus - examination of the placenta after delivery/removal will reveal a very blood maternal surface with lots of clots

Question 110

Placenta Accreta

Answer 110

- improper implantation of the placenta onto the myometrium with little or no intervening decidua - risk factors are prior C-section, inflammation, or placenta previa - presents with difficult delivery of the placenta and postpartum bleeding - often requires a hysterectomy to control the bleeding - placenta increta and percreta are varying degrees of penetration

Question 111

Pre-Eclampsia

Answer 111

- pregnancy-induced hypertension with either proteinuria or end-organ dysfunction after the 20th week gestation - due to an abnormality of the maternal-fetal vascular interface in the placenta - usually presents in the third trimester and affects 5% of pregnancies - more common in those with pre-existing hypertension, diabetes, chronic renal disease, or autoimmune disorders - may border on malignant hypertension with severe headaches and visual abnormalities - treatment is with anti-hypertensives and IV magnesium to prevent seizures but definitive treatment is delivery

Question 112

How does eclampsia compare to pre-eclampsia?

Answer 112

- eclampsia is pre-eclampsia (HTN, proteinuria, edema) plus seizures - may cause maternal death due to stroke, intracranial hemorrhage, or ARDS

Question 113

What is HELLP?

Answer 113

- pre-eclampsia with thrombotic microangiopathy of the liver - characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets - can lead to hepatic sub capsular hematomas, which may rupture and lead to severe hypotension

Question 114

Sudden Infant Death Syndrome

Answer 114

- death of a health infant (1 month to 1 year old) without obvious cause, typically during sleep - associated with sleeping on the stomach, exposure to cigarette smoke, and prematurity

Question 115

What are the teratogenic effects of cocaine?

Answer 115

intrauterine growth retardation and placental abruption

Question 116

What are the teratogenic effects of thalidomide?

Answer 116

limb defects

Question 117

What are the teratogenic effects of cigarette smoke?

Answer 117

intrauterine growth retardation

Question 118

What are the teratogenic effects of isotretinoin?

Answer 118

spontaneous abortion or hearing and visual impairment

Question 119

What are the teratogenic effects of tetracycline?

Answer 119

discolored teeth

Question 120

What are the teratogenic effects of warfarin?

Answer 120

fetal bleeding

Question 121

What are the teratogenic effects of phenytoin?

Answer 121

digit hypoplasia and cleft lip/palate

Question 122

Hydatidiform Mole

Answer 122

- an abnormal conception that yields growth of abnormal placental tissue instead of a child - characterized by swollen, edematous villi with proliferation of trophoblasts - the uterus expands as if a normal pregnancy but the uterus is much larger and B-hCG much higher than expected - without prenatal care, it presents in the second trimester as passage of grape-like masses - with prenatal care, it is diagnosed via routine US since fetal heart sounds are absent and there is a "snowstorm" appearance - can be classified as complete or partial depending on whether the two sperm fertilized an empty or normal egg - treatment is suction curettage and subsequent monitoring of B-hCG to ensure adequate removal - poses a risk for choriocarcinoma and requires monitoring

Question 123

What sets a partial hydatidiform mole apart from a complete mole?

Answer 123

- partial arises from fertilization of a normal egg by two sperm (69 chromosome) - some fetal tissue is present (hence the term partial) - some villi are hydropic and some are normal - focal proliferation is present around the hydropic villi - the risk for choriocarcinoma is minimal

Question 124

What sets a complete hydatidiform mole apart form a partial mole?

Answer 124

- complete arises from fertilization of an empty egg by two sperm (46 chromosome) - no fetal tissue is present (hence the term complete) - most villi are hydropic and there is diffuse, circumferential proliferation around hydropic villi - the risk for choriocarcinoma is 2-3%, which is higher than that of partial

Question 125

Hypospadias

Answer 125

- an opening of the urethra on the inferior surface of the penis due to failure of the urethral folds to close properly - associated with inguinal hernia and cryptorchidism

Question 126

Epispadias

Answer 126

- an opening of the urethra on the superior surface of the penis due to abnormal position of the genital tubercle - associated with bladder exstrophy

Question 127

Lymphogranuloma Venereum

Answer 127

- a necrotizing granulomatous inflammation of the inguinal lymphatics and lymph nodes in a male - results from sexual transmission of Chlamydia trachomatis, serotypes L1-L3 - eventually heals with fibrosis, which may cause rectal stricture if there was perianal involvement

Question 128

Squamous Cell Carcinoma of the Penis

Answer 128

- a malignant proliferation of squamous cells of the penile skin - risk factors include those that increase the risk for a high risk HPV as well as lack of circumcision which serves as a nidus for chronic inflammation and irritation - arises from precursor in situ lesions like Bowen disease or Erythroplasia of Queyrat

Question 129

Bowen Disease

Answer 129

an in situ carcinoma of the penile shaft or scrotum that presents as leukoplakia and serves as a precursor lesion for squamous cell carcinoma

Question 130

Erythroplasia of Queyrat

Answer 130

an in situ carcinoma of the penile glands that presents as erythroplaki and serves as a precursor lesion for squamous cell carcinoma

Question 131

Bowenoid Papulosis

Answer 131

- an in situ carcinoma of the penile skin that presents as multiple reddish papule - seen in younger patients than Bowen disease or Erythroplasia of Queyrat - does not progress to invasive carcinoma

Question 132

What is the difference between Bowen disease, Erythroplasia of Queyrat, and Bowenoid Papulosis.

Answer 132

- all are forms of in situ carcinoma involving the skin of the penis, but only Bowen disease and erythroplasia progress to squamous cell carcinoma - Bowen disease is a leukoplakia of the shaft - Erythroplasia of Queyrat is a erythroplakia of the glands - Bowenoid papulosis is presents as multiple reddish papules

Question 133

Cryptochidism

Answer 133

- failure of the testicle to descend into the scrotal sac after developing in the abdomen - it is the most common congenital male reproductive anomaly and is more common in premature infants - most cases resolve spontaneously, but if it hasn't by age 2 it requires surgical correction - after age 2, germ cells begin to be damaged by the lack of proper thermoregulation resulting in testicular atrophy with infertility and risk for seminoma

Question 134

What happens if cryptochidism doesn't resolve and isn't corrected by age 2?

Answer 134

- germ cells are damaged by the lack of proper thermoregulation - results in testicular atrophy with infertility - also increases the risk for seminoma

Question 135

What are the four most common causes of orchitis?

Answer 135

- Chlamydia or Neisseria in younger males (via sexual activity) - E. coli and Pseudomonas in older adults (spread of UTI) - mumps virus - autoimmune orchitis

Question 136

Chlamydia trachomatis Orchitis

Answer 136

- an inflammation of the testicle due to infection with serotypes D-K - seen primarily in young adults with highest STD risk - may cause sterility but libido is unaffected because Leydig cells are spared

Question 137

Which cell type is affected by Chlamydia trachomatis and Neisseria gonorrhoea orchitis?

Answer 137

- Sertoli cells are affected, potentially causing sterility | - Leydig cells are spared, leaving testosterone and libido in tact

Question 138

Mumps Virus Orchitis

Answer 138

- a potential complication of mumps virus usually only seen in those that contract mumps after the age of ten - risk for infertility

Question 139

Autoimmune Orchitis

Answer 139

granulomatous inflammation of the testicles involving the seminiferous tubules

Question 140

Testicular Torsion

Answer 140

- a twisting of the spermatic cord - causes the thin-walled veins to collapse while the arteries remain open, resulting in congestion and hemorrhage infarction - usually due to congenital failure of the testes to attach to the inner lining of the scrotum via the processes vaginalis - presents in adolescents with sudden testicular pain and an absent cremasteric reflex

Question 141

Describe the cremasteric reflex.

Answer 141

when you scrap upward on the inner thigh of a male, the scrotum should ascend

Question 142

Varicocele

Answer 142

- a dilation of the spermatic vein due to impaired drainage - usually left sided because the left vein drains into the left renal vein while the right vein drains directly into the IVC - presents as a "bag of worms" appearance upon standing examination and will not be transilluminated - seen in a large percentage of infertile males because it leaves lots of warm blood in the sac for longer periods

Question 143

Varicoceles are associated with what neoplasia?

Answer 143

left renal cell carcinoma, which tends to invade and obstruct the left renal vein, impairing drainage of the left spermatic vein

Question 144

Hydrocele

Answer 144

- a collection of fluid within the tunica vaginalis (a serous membrane covering the testicle and internal surface of the scrotum) - when it presents in infants, it is often associated with incomplete closure of the processus vaginalis, leaving communication between the scrotum and peritoneal cavity - in adults, it is more often associated with blocked lymphatic drainage - presents as a scrotal swelling that can be transilluminated

Question 145

What does a testicular mass that can be transilluminated suggest about that mass?

Answer 145

that it is not solid and is, instead, likely a hydrocele

Question 146

What causes hydroceles in infants?

Answer 146

failure of the processes vaginalis to close completely, leaving a duct between the peritoneal cavity and tunica vaginalis

Question 147

What structure fills with fluid in a hydrocele?

Answer 147

the tunica vaginalis, a remnant of the processus vaginalis

Question 148

Testicular tumors arise from what two sources?

Answer 148

germ cells and sex cord-stroma (there are no surface epithelial tumors as in ovaries)

Question 149

How are testicular masses biopsied?

Answer 149

they aren't because this risks seeding of the scrotum

Question 150

Why aren't testicular masses biopsied?

Answer 150

because this risks seeding the scrotum with tumor cells and most testicular tumors are malignant germ cell tumors

Question 151

What is the most common testicular tumor?

Answer 151

a malignant germ cell tumor

Question 152

What should be done when you suspect a testicular tumor.? Explain the logic behind this decision.

Answer 152

- do not biopsy because most testicular tumors are malignant germ cell tumors and biopsy risks seeding the scrotum with malignant cells - instead, proceed with a radical orchiectomy

Question 153

What are the risk factors for testicular germ cell tumors?

Answer 153

- cryptorchidism | - Klinefelter syndrome

Question 154

How do we divide testicular germ cell tumors?

Answer 154

as seminomas or nonseminomas

Question 155

How do seminomas and nonseminoma testicular germ cell tumors compare?

Answer 155

- seminomas are more common, highly responsive to radiotherapy, metastasize late, and have a good prognosis - nonseminomas are slightly less common, show a variable response to treatment, and often metastasize early

Question 156

Seminoma

Answer 156

- a malignant testicular germ cell tumor and the most common testicular tumor - comprised of large cells with clear cytoplasm and central nuclei, resembling an ovarian dysgerminoma - grossly, it form s homogenous was without hemorrhage or necrosis - it has the potential but rarely produces B-hCG - responds well to radiotherapy

Question 157

Embryonal Carcinoma of the Testicle

Answer 157

- a malignant nonseminoma (testicular germ cell tumor) - comprised of immature, primitive cells that may produce glands - in contrast to a seminoma, it forms a hemorrhagic mass with necrosis - it is aggressive with early hematogenous spread - may see increases in AFP or B-hCG - chemotherapy may result in differentiation into another type of germ cell tumor

Question 158

What reproductive tumor may respond to chemotherapy by differentiating into another type of tumor?

Answer 158

embryonal carcinoma

Question 159

Embryonal Carcinoma of the Ovary

Answer 159

- a malignant germ cell tumor composed of immature, primitive cells - aggressive with early hematogenous spread and a poor response to treatment

Question 160

Why do choriocarcinomas often induce hyperthyroidism?

Answer 160

because they produce B-hCG, which has an alpha subunit mimicking that of LH, FSH, and TSH, which can stimulate the receptors for those substances

Question 161

How do teratomas seen in men differ from those seen in women?

Answer 161

they are malignant in males, not in females (unless there are signs of immature tissue or somatic malignancy in the teratoma)

Question 162

How do we determine the prognosis of a mixed germ cell tumor?

Answer 162

the prognosis is based on that of the worst component

Question 163

Leydig Cell Tumor

Answer 163

- a benign sex cord-stromal tumor seen in men, which produces androgen - because of this it causes precocious puberty in children or gynecomastia in adults - characteristic Reinke crystals are seen on histology and gross exam reveals a golden brown mass

Question 164

Sertoli Cell Tumor

Answer 164

- a benign sex cord-stromal tumor seen in men | - the tumor is comprised of tubules and is clinically silent

Question 165

What is the most common cause of a testicular mass in males over the age of 60?

Answer 165

lymphoma

Question 166

Testicular Lymphoma

Answer 166

- the most common cause of a testicular mass in males over the age of 60 - often bilateral and usually of the DLBC type

Question 167

Prostatic glands are composed of what cells?

Answer 167

an inner layer of luminal cells and an outer layer of basal cells

Question 168

What sort of fluid does the prostate secrete?

Answer 168

an alkaline fluid

Question 169

Acute Prostatitis

Answer 169

- usually bacterial; Chlamydia trachomatis and Neisseria gonorrhoeae are common in younger males while E. coli and Pseudomonase are common in older adults (from spread of UTI) - presents with dysuria, fever, and chills, urgency, and low back pain - the prostate will feel warm, tender, boggy, and enlarged on digital rectal exam - prostatic secretions will show WBCs and culture will reveal bacteria

Question 170

Chronic Prostatitis

Answer 170

- chronic inflammation of the prostate - presents with dysuria and pelvic or low back pain - prostatic secretions show WBCs but cultures are usually negative

Question 171

How does the presentation of acute prostatitis differ from that of chronic prostatitis?

Answer 171

- acute is usually bacterial so prostatic secretions contain WBCs and are culture positive; however, secretions from those with chronic prostatitis are likely culture negative - additionally, acute presents with dysuria, fever, and chills whereas chronic presents with dysuria and pelvic or low back pain

Question 172

Benign Prostatic Hyperplasia

Answer 172

- hyperplasia of prostatic stroma and glands - an age related change, and seen in most men over 60 - poses no increased risk for cancer - driven by the androgen DHT - occurs the central periurethral zone of the prostate - presents with problems starting and stopping urination as well as overflow incontinence, which poses a risk for hydronephrosis - the obstruction causes hypertrophy of the bladder wall smooth muscle and increase risk for bladder diverticula - microscopic hematuria may be present - PSA is often slightly elevated (4 < PSA < 10) - treatment involves an a1- antagonist, which has the added benefit of lowering BP, or an a1A-antagonist for normotensive patients - another treatment option is a 5a-reductase inhibitor, to reduce conversion of testosterone to DHT

Question 173

What portion of the prostate is affected by BPH? What about by prostatic adenocarcinoma?

Answer 173

- BPH: the central, periurethal zone | - adenocarcinoma: the posterior peripheral area

Question 174

What complications arise from BPH?

Answer 174

- there is no risk for cancer - but the obstruction may cause overflow incontinence, hypertrophy of the bladder wall smooth muscle, or bladder diverticula

Question 175

What hormone drives BPH?

Answer 175

dihydrotestosterone (DHT)

Question 176

How is DHT synthesized in vivo?

Answer 176

testosterone is converted to DHT by 5a-reductase expressed by stromal cells in the prostate

Question 177

What is the function of PSA?

Answer 177

it is made by prostatic glands to liquefy semen

Question 178

What is a normal PSA? What level would be consistent with BPH or adenocarcinoma?

Answer 178

- normal is < 4 - BPH is between 4-10 - adenocarcinoma is often above 10

Question 179

Describe two treatment options of BPH.

Answer 179

- usually start with an a1-antagonist like terazoin, which relaxes smooth muscle to improve bladder function and blood pressure - if the patient is normotensive, however, consider an a1A-antagonist like tamsulosin, which will act only at the bladder - can also consider a 5a-reductase inhibitor, which blocks conversion of testosterone to DHT, the hormone that drives the hyperplasia; but this takes months to produce results and may cause gynecomastia or sexual dysfunction

Question 180

Prostate Adenocarcinoma

Answer 180

- a malignant proliferation of prostatic glands - risk factors include age, race (AA most and Asians least), and a diet high in saturated fats - most often, it is clinically silent as it arises in the peripheral, posterior region and does not affect the ureter until late - screening begins at age 50 with PSA and digital rectal exams - histology reveals small, invasive glands with prominent nucleoli - graded on Gleason system which is based solely on architecture (not nuclear atypia) as determined in two areas on a score of 1-5, which is then combined to determine prognosis - spreads to the lumbar spine or pelvis, forming osteoblastic metastases; at this point, PSA, prostatic acid phosphatase, and serum alkaline phosphatase are all likely elevated - prostatectomy is performed for localized disease and advanced disease is treated with hormone suppression to reduce testosterone and DHT

Question 181

At what age and via what methods do we begin screening for prostate cancer?

Answer 181

begin at age 50 with PSA levels and digital rectal exams

Question 182

What kind of PSA does adenocarcinoma make?

Answer 182

bound PSA, so low percentage free-PSA is suggestive of cancer

Question 183

What is the Gleason grading system?

Answer 183

- a system for grading prostatic adenocarcinoma - it takes into account only architecture and not nuclear atypia - two areas are assessed and scored from 1-5 with the combined score determining the prognosis

Question 184

When prostatic adenocarcinoma spreads, where is it most likely to go?

Answer 184

the lumbar spine or pelvis

Question 185

Metastatic prostate adenocarcinoma is likely to have what signs of labs?

Answer 185

- elevated PSA (mostly bound) - low % of free PSA - elevated prostatic acid phosphatase - elevated alkaline phosphatase

Question 186

How is prostate adenocarcinoma treated?

Answer 186

- prostatectomy is used in cases of localized disease - advanced disease is treated with hormone suppression aimed at reducing testosterone and DHT levels; this includes continuous GnRH analogs like leuprolide and androgen antagonists like flutamide

Question 187

The breast is a modified ___ gland.

Answer 187

sweat

Question 188

Where can breast tissue develop?

Answer 188

anywhere along the milk line between the axilla and the vulva

Question 189

What is the functional unit of the breast called and what does it consist of?

Answer 189

it is called the terminal duct lobular unit and it is composed of a lobule filled with glands, which drain into a common terminal duct

Question 190

Describe the ductal epithelium within the breast.

Answer 190

- there is the luminal cell layer, the inner layer which is responsible for milk production - and there is the myoepithelial layer, which has contractile ability and propels milk towards the nipple

Question 191

Describe breast tissue before puberty.

Answer 191

male and female breast tissue at this point consists of large ducts under the nipple

Question 192

Describe development after menarche.

Answer 192

- driven by estrogen and progesterone | - lobules and small ducts form

Question 193

Where in the breast is the highest density of terminal duct lobular units?

Answer 193

in the upper outer quadrant

Question 194

What happens to the breast tissue during pregnancy?

Answer 194

there is hyperplasia of the lobules, driven by estrogen and progesterone produced by the corpus lute, fetus, and placenta

Question 195

What is galactorrhea?

Answer 195

milk production outside of lactation

Question 196

What are three causes of galactorrhea?

Answer 196

- excessive nipple stimulation - drugs - prolactinoma of the anterior pituitary

Question 197

Acute Mastitis

Answer 197

- a bacterial infection of the breast, usually by S. aureus - associated with breast-feeding, which causes fissures to develop in the nipple, providing a route for microbe entry - presents as an erythematous breast with purulent nipple discharge - an abscess may form and would be palpable - treatment involves continued drainage (i.e. feeding) and antibiotics (namely, dicloxacillin) - could be confused with inflammatory type invasive ductal carcinoma

Question 198

Periductal Mastitis

Answer 198

- inflammation of the subareolar ducts - seen in smokers because the subareolar ducts are lined by a specialized epithelium requiring vitamin A and smoking reduces the availability of vitamin A - the lack of vitamin A results in squamous metaplasia of the lactiferous ducts and the keratin that is formed by this epithelium blocks the ducts and results in inflammation - presents as a subareolar mass with nipple retraction caused by secondary healing and myofibroblast activity

Question 199

What benign condition of the breast often presents with nipple retraction? Why?

Answer 199

- periductal mastitis | - healing of this process is by secondary intent and myofibroblast activity has the potential to cause nipple retraction

Question 200

Mammary Duct Ectasia

Answer 200

- chronic inflammation with dilation of the subareolar ducts - classically arises in multiparous postmenopausal women - presents as a periareolar mass with a green-brown nipple discharge composed of inflammatory debris

Question 201

Mammary duct ectasia must be distinguished form what other disorder of the breast? How is this done?

Answer 201

- because it presents as a mass in a postmenopausal women, it needs to be distinguished from malignancy - the green-brown nipple discharge that is seen in those with mammary duct ectasia allows for this

Question 202

Fat Necrosis of the Breast

Answer 202

- usually related to trauma although a history of trauma may not be obvious or apparent - presents as a mass or abnormal calcification on mammography - biopsy shows necrotic fat with associated calcifications and giant cells - this biopsy, especially the giant cells, helps distinguish it from malignancy

Question 203

How is fat necrosis of the breast usually distinguished form malignancy?

Answer 203

- history of trauma | - presence of giant cells and calcifications on biopsy

Question 204

Fibrocystic Change of the Breast

Answer 204

- development of fibrosis and cysts in the breast; thought to be hormone driven - the most common change in the premenopausal breast - presents as vague irregularity of the breast tissue bilaterally, usually in the upper outer quadrant, and cysts have a blue-dome appearance on gross exam - benign but associated with an increased risk for invasive carcinoma IN BOTH BREASTS

Question 205

How does fibrocystic change affect your risk for invasive carcinoma?

Answer 205

- fibrosis, cysts, and apocrine metaplasia carry no increased risk - when also found with ductal hyperplasia (more than two epithelial layers in duct) and sclerosing adenosis (too many glands in lobule), the risk doubles in both breasts - when also found with atypical hyperplasia, the risk is 5x baseline in both breast

Question 206

What risk of invasive carcinoma of the breast does apocrine metaplasia carry?

Answer 206

none, it is one of few instances in which metaplasia doesn't increase cancer risk

Question 207

What is ductal hyperplasia of the breast?

Answer 207

the finding of more than one layer of each epithelial cell in the ducts of the breast

Question 208

What is sclerosing adenosis of the breast?

Answer 208

fibrosis change plus too many glands in the lobule, which are often calcified

Question 209

Intraductal Papilloma

Answer 209

- a papillary growth into a large duct - characterized by fibrovascular projections lined by luminal and myoepithelial cells - classically presents as a bloody nipple discharge in premenopausal women - must be distinguished from papillary carcinoma, which also presents with a bloody nipple discharge; this is done on the basis that papillary carcinoma has fibrovascular projections lined with luminal but not myoepithelial cells

Question 210

How can we differentiate between intraductal papilloma of the breast and papillary carcinoma?

Answer 210

- both are fibrovascular projections into the duct; however, a papilloma is lined by both luminal and myoepithelial cells whereas a papillary carcinoma is lined by only luminal cells - furthermore age is a defining risk factor for papillary carcinoma so it is more often seen in postmenopausal women whereas papillomas are more often in premenopausal women

Question 211

Fibroadenoma of the Breast

Answer 211

- a tumor of fibrous tissue and glands - the most common benign neoplasm of the breast - presents in premenopausal women as a well-circumscribed, mobile, marble-like mass - estrogen sensitive so it grows during pregnancy and may be painful during the menstrual cycle - carries no risk for carcinoma

Question 212

Phyllodes Tumor

Answer 212

- a fibroadenoma-like tumor of the breast with overgrowth of the fibrous component, which pushes it out into the lumen, appearing with "leaf like" projections - most common in postmenopausal women - very rarely it can be malignant

Question 213

Which benign tumors and changes of the breast are more common in premenopausal women and which are more common in postmenopausal women?

Answer 213

- premenopausal: acute mastitis, fibrocystic change, intraductal papilloma, fibroadenoma - postmenopausal: mammary duct ectasia, phyllodes tumor

Question 214

List six important risk factors for breast cancer.

Answer 214

- female gender - age - early menarche/late menopause - obesity - atypical hyperplasia seen on prior biopsy - first-degree relative with breast cancer

Question 215

Ductal Carcinoma In Situ

Answer 215

- a malignant proliferation of cells in ducts without invasion of the BM - often detected as calcification on mammography, but does not usually produce a mass - histologic subtypes are based on architecture, and the most important one is comedo type - comedo type is characterized by high-grade cells with necrosis and dystrophic calcification in the center of ducts - Paget disease of the breast is another form of DCIS

Question 216

Comedo Type DCIS

Answer 216

- an architectural type of ductal carcinoma in situ | - characterized by high-grade cells with necrosis and dystrophic calcification in the center of ducts

Question 217

Paget Disease of the Nipple

Answer 217

- a form of DCIS i which malignant cells extend up the ducts to involve the skin of the nipple - presents as nipple ulceration and erythema - nearly always associated with an underlying carcinoma

Question 218

Invasive Ductal Carcinoma of the Breast

Answer 218

- presents as a mass on exam or by mammography - biopsy usually reveals duct-like structures in a desmoplastic stroma - can be of either the tubular, mucinous, medullary, or inflammatory type: - tubular forms well-differentiated tubules that lack myoepithelial cells and has a relatively good prognosis - mucinous are characterized by abundant extracellular mucin, tend to occur in older women, and have a relatively good prognosis - medullary are characterized by large, high-grade cells growing in sheets with associated lymphocytes and plasma cells; they grow as well-circumscribed and can mimic a fibroadenoma; relatively good prognosis; risk increases with BRCA1 mutation - inflammatory is carcinoma in dermal lymphatics, which impairs drainage and results in an inflamed, swollen breast with no discrete mass, which can be mistaken for acute mastitis; carries a poor prognosis because it's already in lymphatic space

Question 219

What size masses are mammography and physical examination able to detect in the breast?

Answer 219

- mammography typically detects those 1 cm or greater | - physical exam usually detects those 2 cm or larger

Question 220

Inflammatory Type Invasive Ductal Carcinoma of the Breast

Answer 220

- a form of carcinoma which is found in the dermal lymphatics - blockage of the lymphatics results in the breast becoming inflamed and swollen without a discreet mass - may be mistaken for acute mastitis - carries a poor prognosis because it's already in the lymphatic space

Question 221

Medullary Type Invasive Ductal Carcinoma of the Breast

Answer 221

- a form of carcinoma characterized by large, high-grade cells growing in sheets with associated lymphocyte and plasma cells - typically well-circumscribed - may mimic fibroadenoma - carries a relatively good prognosis - those with a BRCA1 mutation are at increased risk

Question 222

Lobular Carcinoma In Situ

Answer 222

- a malignant proliferation of cells in lobules with no invasion of the basement membrane - does not produce a mass or calcifications and is usually discovered incidentally on biopsy - characterized by dyscohesive cells lacking the E-cadherin adhesion protein - often multifocal and bilateral - it has a low risk of progressing to invasive carcinoma but treat with tamoxifen and close follow up

Question 223

Invasive Lobular Carcinoma

Answer 223

- an invasive carcinoma that characteristically grows in a single-file pattern on biopsy - may exhibit signet-ring morphology - don't form ducts because they lack E-cadherin

Question 224

What feature is shared by LCIS and invasive lobular carcinoma?

Answer 224

both have cells lacking E-cadherin

Question 225

What is the most important prognostic factor for patients with breast cancer?

Answer 225

whether there has been metastasis

Question 226

What is the most useful prognostic factor for patients with breast cancer? Why?

Answer 226

- spread to axillary lymph nodes - because most patients present before metastasis occurs, so even though metastasis is the most important factor, it doesn't apply for most of the presenting population

Question 227

What three factors predict the response of breast cancer to treatment?

Answer 227

expression of estrogen receptors, expression of progesterone receptors, or amplification of the HER2/neu gene

Question 228

What does the HER2/neu gene code for?

Answer 228

a growth factor receptor

Question 229

Which population of women is most likely to have "triple negative" breast carcinoma?

Answer 229

African American women

Question 230

The presence of ER or PR within a breast carcinoma indicates what?

Answer 230

that it will respond to anti-estrogenic agents such as tamoxifen, giving it a better prognosis

Question 231

Tumors expressing HER2/neu are treated with what agent?

Answer 231

trastuzumab (aka Herceptin), which is an antibody directed against the HER2 receptor

Question 232

What percentage of breast cancers are hereditary?

Answer 232

10%

Question 233

What clinical features could suggest that a breast cancer is hereditary?

Answer 233

- the patient has first degree relatives with breast cancer - the tumor arises at an early age (premenopausal) - the patient has multiple tumors

Question 234

BRCA1 is associated with what?

Answer 234

- medullary carcinoma of the breast | - serous cyst adenoma of the ovary and fallopian tubes

Question 235

BRCA2 is associated with what?

Answer 235

breast carcinoma in males

Question 236

After someone with a BRCA mutation has a prophylactic mastectomy, what is the next step?

Answer 236

continued monitoring because a small risk for cancer remains

Question 237

Why must someone with a BRCA mutation who has undergone prophylactic bilateral mastectomy still be monitored for breast cancer?

Answer 237

because some breast tissue may extend into the axilla or elsewhere are remain after the surgery, so there is still a small risk of cancer

Question 238

How does breast cancer usually present in males?

Answer 238

as a subareolar mass in older males with a nipple discharge

Question 239

What histologic subtype of breast cancer is most common in males?

Answer 239

- invasive ductal carcinoma | - invasive lobular carcinoma is very rare because men develop very few lobules

Question 240

Male breast cancer is associated with what two risk factors?

Answer 240

BRCA2 and Klinefelter syndrome

Question 241

What is the function of the sonic hedgehog gene during fetal development?

Answer 241

produced at the bast of limbs, it is involved in patterning along the AP axis and in CNS development

Question 242

What is the function of the Wnt-7 gene during fetal development?

Answer 242

produced at the apical ectodermal ridge (the thickened ectoderm at the distal end of each developing limb), it is necessary for proper organization along the dorsal-ventral axis

Question 243

What is the function of the FGF gene during fetal development?

Answer 243

produced at the apical ectodermal ridge, it stimulates mitosis of underlying mesoderm to promote lengthening of limbs

Question 244

What is the function of Homeobox genes during fetal development?

Answer 244

they code for transcription factors involved in segmental organization along the craniocaudal axis

Question 245

Homebox (HOX) gene mutations result in what?

Answer 245

appendages in the wrong locations

Question 246

What is the apical ectodermal ridge?

Answer 246

a thickened ectoderm at the distal end of each developing limb

Question 247

What stages follow fertilization of an oocyte prior to implantation?

Answer 247

- a morula forms around day 4 - a blastocyst forms around day 5 - implantation occurs at day 6

Question 248

On what day does a fertilized oocyte typically implant into the endometrium? What is it called at that point?

Answer 248

day 6 as a blastocyte

Question 249

What happens during week one following fertilization of an oocyte?

Answer 249

- formation of a morula around day 4 - formation of a blastocyte around day 5 - implantation around day 6

Question 250

What is a blastocyte?

Answer 250

- a structure formed early in embryogenesis (around day 5 in humans) - consists of an inner cell mass that will give rise to the embryo and an outer cell layer that will give rise to the trophoblasts

Question 251

Describe the embryonic disc.

Answer 251

- a bilaminar disc that forms from a blastocyte - consists of an epiblast and hypoblast, which arise form the inner cell mass - the epiblast is primitive ectoderm while the hypoblast is primitive endoderm

Question 252

What happens to an embryo after formation of the embryonic disc?

Answer 252

- gastrulation forms a trilaminar embryonic disc, consisting of ectoderm, mesoderm, and endoderm, as epiblast cells invaginate through the primitive streak

Question 253

What germ layer gives rise to the notochord?

Answer 253

the mesoderm

Question 254

When does the neural tube close during fetal development?

Answer 254

by the end of week four

Question 255

What happens during week four of fetal development?

Answer 255

the heart begins to pump ("4 chambers") and the limb buds begin to form ("4 limbs")

Question 256

At what point does fetal cardiac activity become visible by transvaginal ultrasound?

Answer 256

during week 6

Question 257

At what point do fetal movements start?

Answer 257

during week 8

Question 258

When during fetal development do the genitalia have male and female characteristics?

Answer 258

during week 10

Question 259

Surface ectoderm gives rise to what adult structures?

Answer 259

- epidermis - adenohypophysis (anterior pituitary from Rathke pouch) - lens and retina of the eye - epithelial lining of the oral cavity - sensory organs of the ear - olfactory epithelium - parotid, sweat, and mammary glands - CNS - neural crest cells

Question 260

What is Rathke's pouch?

Answer 260

an evagination of the ectoderm in what will be the roof of the mouth, which ultimately gives rise to the anterior pituitary (adenohypophysis)

Question 261

Neural crest cells are a subset of which germ layer?

Answer 261

ectoderm

Question 262

Neural crest cells give rise to what adult structures?

Answer 262

- the PNS, including dorsal root ganglia, cranial nerves, autonomic ganglia, and Schwann cells - melanocytes - chromatin cells of the adrenal medulla - parafollicular cells of the thyroid - pia and arachnoid mater - bones of the skull - odontoblasts - aorticopulmonary septum and endocardial cushions

Question 263

Mesoderm gives rise to what adult structures?

Answer 263

- muscle, bone, and connective tissue - serous linings of body cavities - spleen, kidneys, adrenal cortex, and wall of gut tube - cardiovascular structures and blood - lymphatics - upper vagina - dermis - testes and ovaries

Question 264

What is the only adult structure derived from notochord?

Answer 264

the nucleus pulpous of the intervertebral disc

Question 265

What pneumonic is used to remember the mesodermal defects?

Answer 265

VACTERL - Vertebral defects - Anal atresia - Cardiac defects - TE fistula - Renal defects - Limb defects

Question 266

What adult structures are derived from endoderm?

Answer 266

- gut tube epithelium - most of the urethra and lower vagina - luminal epithelial derivatives like lungs, liver, gallbladder, pancreas, eustachian tube, thymus, parathyroid, and thyroid follicular cells

Question 267

What is the difference between agenesis and aplasia?

Answer 267

- agenesis is the absence of an organ due to the absence of primordial tissue - aplasia is absence of an organ despite the presence of that primordial tissue

Question 268

What is the difference between a malformation and a deformation?

Answer 268

- deformations result from an extrinsic disruption and occur after the embryonic period - malformations result from an intrinsic disruption and occur during the embryonic period

Question 269

When is the developing fetus most susceptible to teratogens?

Answer 269

- between weeks 3 and 8 | - before that it leads to spontaneous abortion and after it affects growth and function

Question 270

What are the teratogenic effects of ACE inhibitors?

Answer 270

renal damage

Question 271

What are the teratogenic effects of alkylating agents?

Answer 271

absence of digits

Question 272

What are the teratogenic effects of aminoglycosides?

Answer 272

ototoxicity

Question 273

What are the teratogenic effects of antiepileptics?

Answer 273

neural tube defects, cardiac defects, cleft palate, skeletal abnormalities

Question 274

What are the teratogenic effects of DES?

Answer 274

increases risk for vaginal clear cell adenocarcinoma

Question 275

What are the teratogenic effects of folate antagonists?

Answer 275

neural tube defects

Question 276

What are the teratogenic effects of isotretinoin?

Answer 276

multiple severe birth defects; contraception is required while patients are treated with isotretinoin

Question 277

What are the teratogenic effects of lithium?

Answer 277

abstain anomaly (apical displacement of the tricuspid valve)

Question 278

What are the teratogenic effects of methimazole?

Answer 278

aplasia cutis congenita (absence of skin)

Question 279

What are the teratogenic effects of tetracyclines?

Answer 279

discolored teeth and inhibited bone growth

Question 280

What are the teratogenic effects of thalidomide?

Answer 280

limb defects

Question 281

What are the teratogenic effects of warfarin?

Answer 281

bone deformities, fetal hemorrhage, abortion, ophthalmologic abnormalities

Question 282

What are the teratogenic effects of cocaine?

Answer 282

problem is vasoconstriction: low birth weight, preterm birth, intrauterine growth restriction, placenta abruption

Question 283

What are the teratogenic effects of smoking?

Answer 283

- problem is nicotine induced vasoconstriction and CO impairing oxygen delivery - low birth weight, preterm labor, placental problems intrauterine growth restriction, SIDS

Question 284

What are the teratogenic effects of iodine deficiency or excess?

Answer 284

congenital goiter or hypothyroidism

Question 285

What are the teratogenic effects of maternal diabetes?

Answer 285

caudal regression syndrome (anal atresia to sirenomelia ("Mermaid syndrome")), congenital heart defects, neural tube defects, macrosomia

Question 286

What are the teratogenic effects of methylmercury?

Answer 286

neurotoxicity

Question 287

What are the teratogenic effects of vitamin A excess?

Answer 287

extremely high risk for spontaneous abortions and bird defects

Question 288

What are the teratogenic effects of x-rays?

Answer 288

microcephaly, intellectual disability

Question 289

Fetal Alcohol Syndrome

Answer 289

- the leading cause of intellectual disability in the US - alcohol results in failure of cell migration - presents with pre- and post-natal developmental retardation, microcephaly, facial abnormalities (these include a smooth philtrum, thin upper lip, and small palpebral fissures), limb dislocation, and heart defects - heart-lung fistulas and holoprosencephaly are the most severe form

Question 290

What are chorionicity and amnionicity?

Answer 290

- the number of chorions and amnions that develop during an instance of monozygotic twinning - a function of the time at which the fertilized egg splits

Question 291

At what time period must a fertilized oocyte divide to form dichorionic, diamniotic monozygotic twins? Monochorionic, diamniotic? Monochorionic, monoamniotic?

Answer 291

- di-, di- arises from an early split between 0-4 days after fertilization - monochorionic, diamniotic arises from a split between 4-8 days post-conception - mono-, mono- arises from a split between 8-12 days post-conception

Question 292

What causes conjoined twins?

Answer 292

a division that arises more than 13 days after fertilization

Question 293

WhatWhat are cytotrophoblasts and syncytiotrophoblasts?

Answer 293

- the fetal component of the placenta - cytotrophoblasts are the inner layer (nearest fetus) - syncytiotrophoblasts are the outer layer

Question 294

What is the function of cytotrophoblasts?

Answer 294

they are the trophoblast stem cell

Question 295

What is the function of syncytiotrophoblasts?

Answer 295

- they synthesize and secrete hormones, particularly hCG | - additionally they lack MHC-I, reducing the chance the maternal immune system will attack it

Question 296

What prevents the maternal immune system from attacking the syncytiotrophoblast layer of the placenta?

Answer 296

the syncytiotrophoblast cells lack MHC-I

Question 297

Which delivers oxygenated blood to the fetus, umbilical arteries or the umbilical vein?

Answer 297

the umbilical vein

Question 298

The umbilical arteries and vein are derived from what earlier structure?

Answer 298

the allantois

Question 299

What is the allantois?

Answer 299

a fetal structure that arises during the third week from the yolk sac and gives rise to the urachus as well as the umbilical arteries and vein

Question 300

What is the function of the urachus in utero?

Answer 300

it is a duct between the fetal bladder and umbilicus, which drains into the allantoic duct

Question 301

Urachal Cyst

Answer 301

- a partial failure of the urachus to obliterate, leaving a fluid-filled cavity one by urothelium between the umbilicus and bladder - can lead to infection or adenocarcinoma

Question 302

What is a vesicourachal diverticulum?

Answer 302

a slight failure of the urachus to obliteration, which leads to an asymptomatic out pouching of the bladder in adults

Question 303

What would cause urine to discharge from the umbilicus after birth?

Answer 303

a patent urachus

Question 304

What is the vitelline duct?

Answer 304

a structure which connects the yolk sac to the midgut lumen

Question 305

What do the 1st, 2nd, 3rd, 4th, and 6th aortic arches give rise to?

Answer 305

- 1st: part of the maxillary artery - 2nd: the stapedial artery which normally involutes - 3rd: the common carotid and proximal internal carotid - 4th: the aortic arch and proximal right subclavian - 6th: the proximal part of the pulmonary arteries and ductus arteroisus

Question 306

Where does the left recurrent laryngeal nerve branch off the vagus?

Answer 306

it branches off and loops around the aortic arch, distal to the ductus arteriosus

Question 307

Describe the structure of the branchial apparatus and the germ layers that contribute to each.

Answer 307

- the cleft is ectoderm and exterior - the arch is mesoderm and neural crest - the pouch is endoderm and is interior

Question 308

What important structures do the branchial clefts give rise to?

Answer 308

- the first develops into the external auditory meatus | - the 2nd-4th form temporary cervical sinuses, which are obliterated by proliferation of the 2nd arch

Question 309

What is a persistent cervical sinus?

Answer 309

a branchial cleft cyst within the lateral neck, found anterior to the sternocleidomastoid and typically immobile during swallowing

Question 310

The first branchial arch gives rise to what?

Answer 310

- cartilage: the maxillary process (maxilla and zygomatic), mandibular process (Meckel cartilage and mandible), malleus and incus, and the sphenomandibular ligament - muscle: muscles of mastication (temporalis, master, pterygoids), mylohyoid, anterior belly of digastric, tensor tympani, and tensor vela palatini - nerves: CN V2 and V3

Question 311

The second branchial arch gives rise to what?

Answer 311

- cartilage: stapes, styloid, lesser horn of hyoid, stylohoid ligament - muscles: muscles of facial expression, stapedius, stylohoid, platysma, posterior belly of digastric - nerve: CN VII

Question 312

The third branchial arch gives rise to what?

Answer 312

- cartilage: greater horn of hyoid - muscle: stylopharyngeus - nerve: CN IX

Question 313

The 4th-6th branchial arches give rise to what?

Answer 313

- cartilage: arytenoids, cricoid, corniculate, cuneiform, thyroid - muscle: 4th to most pharyngeal constrictors, cricothyroid, elevator veil palatini; 6th to all intrinsic muscles of the larynx except the cricothyroid - nerve: 4th - superior laryngeal branch of CN X; 6th - recurrent laryngeal branch of CN X

Question 314

Pierre Robin Sequence

Answer 314

- micrognathia - glossoptosis - cleft palate - airway obstruction

Question 315

Treacher Collins Syndrome

Answer 315

neural crest dysfunction leads to mandibular hypoplasia and facial abnormalities

Question 316

The first branchial pouch gives rise to what?

Answer 316

middle ear cavity, eustachian tube, and mastoid air cells

Question 317

The second branchial pouch gives rise to what?

Answer 317

epithelial lining of palatine tonsil

Question 318

The third branchial pouch gives rise to what?

Answer 318

dorsal wings to the inferior parathyroids and ventral wings to the thymus

Question 319

The fourth branchial pouch gives rise to what?

Answer 319

dorsal wings to the superior parathyroids and ventral wings to the ultimobranchial body and parafollicular C cells of the thyroid

Question 320

Describe how an embryo becomes male.

Answer 320

- the SRY gene on the Y chromosome results in the production of testis-determinng factor - testes develop from the gonadal tissue, giving rise to Sertoli and Leydig cells - Sertoli cells secrete Mullerian inhibitory factor - Leydig cells secrete androgens that stimulate development of the mesonephric ducts

Question 321

The Mullerian duct gives rise to what female structures?

Answer 321

- fallopian tubes - uterus - upper portion of vagina

Question 322

The vagina is derived form what embryologic structures?

Answer 322

- the upper portion is derived from the Mullerian duct | - the lower portion is derived from the urogenital sinus

Question 323

Mullerian Agenesis

Answer 323

- a potential developmental defect in women - presents as primary amenorrhea, because the uterus doesn't develop, in females with fully developed secondary sexual characteristics (ovaries still present)

Question 324

The Mesonephric duct gives rise to what male structures?

Answer 324

- Seminal vesicles - Epididymis - Ejaculatory duct - Ductus deferens

Question 325

What role do Sertoli cells play in determining the sex of a fetus?

Answer 325

they secrete Mullerian inhibitory factor to promote degeneration of the Mullerian duct

Question 326

What role do testosterone and DHT play in fetal development of the reproductive system?

Answer 326

- testosterone drives development of the male internal genitalia from the mesonephric duct except for the prostate - DHT drives development of the external male genialia sn prostate

Question 327

Describe the phenotype of an XY individual who fails to properly develop Sertoli cells.

Answer 327

they will lack Mullerian inhibitory factor and develop both male and female internal genitalia but will develop only male genitalia

Question 328

How would a 5a-reductase deficiency affect sexual development of an XY fetus?

Answer 328

- it would lead to the inability to convert testosterone to DHT - as such, the individual would have normal internal genitalia (except prostate), and ambiguous external genitalia until puberty when testosterone levels cause masculinization

Question 329

Describe the roles of testis-determining factor, Mullerian inhibitory factor, testosterone, and DHT in male development and puberty.

Answer 329

- testis-determing factor drives development of the testes, which forms Sertoli and Leydig cells - Mullerian inhibitory factor promotes degeneration of the Mullerian duct - testosterone drives development of the internal genitalia except the prostate and later drives masculinization and acquisition of secondary sex characteristics during puberty - DHT is responsible for driving development of male external genitalia and the prostate in utero

Question 330

Uterine anomalies arise due to what failure?

Answer 330

failure of the Mullerian ducts to properly fuse or of the septum to complete resorb

Question 331

What is a septate uterus?

Answer 331

failure of the septum to be resorbed after the Mullerian ducts fuse at the midline

Question 332

What is a bicornuate uterus?

Answer 332

a uterus that arises due to incomplete fusion of the Mullerian ducts

Question 333

What is uterus didelphys? How difficult will pregnancy be?

Answer 333

- a double uterus, vagina, and cervix that arises from complete failure of the Mullerian ducts to fuse - pregnancy is still very much possible

Question 334

The genital tubercle, urogenital sinus, urogenital folds, and labioscrotal swelling give rise to what male structures?

Answer 334

- tubercle: glans, corpus cavernosum, and corpus spongiosum - sinus: bulbourethral glands and prostate gland - folds: ventral shaft and penile urethra - swelling: scrotum

Question 335

The genital tubercle, urogenital sinus, urogenital folds, and labioscrotal swelling give rise to what female structures?

Answer 335

- tubercle: glans clitoris and vestibular bulbs - sinus: Bartholin glands, uruethral/paraurethral glands, and lower vagina - folds: labia minora - swellings: labia majora

Question 336

What is the gabernaculum? What adult structures does it give rise to?

Answer 336

- a band of fibrous tissue | - anchors the testes within the scrotum or forms the ovarian and young ligaments

Question 337

What is the processes vaginalis? What adult structures does it give rise to?

Answer 337

- it is an evagination of the peritoneum | - gives rise to the tunica vaginalis in men and is obliterated in women

Question 338

Where does venous blood drain from the gonads?

Answer 338

- left gonad to the left gonadal vein and left renal vein before leading to the IVC - right gonad to the right gonadal vein, which drains directly into the IVC

Question 339

Where is the infudibulopelvic ligament? What does it contain and what is clinically relevant about it?

Answer 339

- it is also known as the suspensory ligament of the ovary - it connects the ovaries to the lateral pelvic wall - it contains the ovarian vessels and is therefore ligated during oophorectomy

Question 340

Where is the cardinal ligament? What does it contain and what is clinically relevant about it?

Answer 340

- it connects the cervix to the side wall of the pelvis | - it contains uterine vessels and is ligated during a hysterectomy

Question 341

The ureter is at risk when ligating which ligaments of the female reproductive system?

Answer 341

- the infundibulopelvic ligament (suspensory of ovary) | - the cardinal ligament

Question 342

Where is the round ligament of the uterus? What does it contain and what is clinically relevant about it?

Answer 342

derived from the gubernaculum, it connects the fundus of the uterus to the labia major, passing through the inguinal canal as it does

Question 343

Where is the broad ligament? What does it contain and what is clinically relevant about it?

Answer 343

- it connects the uterus, fallopian tubes, and ovaries to the pelvic side wall - it actually contains the ovaries, fallopian tubes, and round ligaments of the uterus - it can be divided into the mesosalpinx, mesometrium, and mesovarium

Question 344

Where is the ovarian ligament? What does it contain and what is clinically relevant about it?

Answer 344

- it connects the medial pole of the ovary to the lateral uterus - it too is a derivative of the gubernaculum

Question 345

The gubernaculum contributes to which ligaments within the female reproductive tract?

Answer 345

the ovarian ligament and the round ligament of the uterus

Question 346

The vagina is lined by what sort of epithelium?

Answer 346

nonkeratinized, stratified squamous

Question 347

The endocervix is lined by what sort of epithelium?

Answer 347

simple columnar epithelium

Question 348

The uterus is lined by what sort of epithelium?

Answer 348

simple columnar with long tubular glands in the proliferative phase and could glands in the secretory phase

Question 349

The fallopian tubes are lined by what sort of epithelium?

Answer 349

ciliated, simple columnar epithelium

Question 350

The surface of the ovary is lined by what sort of epithelium?

Answer 350

simple cuboidal

Question 351

Where are the corpus cavernosum and corpus spongiosum? Which contains the urethra?

Answer 351

- the corpus cavernosum is more superior than the spongiosum | - the spongiosum contains the urethra

Question 352

Describe the pathway of sperm during ejaculation.

Answer 352

SEVEn UP - seminiferous tubules - epididymis - vas deferens - ejaculatory duct - urethra - penis

Question 353

What would indicate a urethral injury?

Answer 353

blood at the urethral meatus

Question 354

What is the difference between an anterior and posterior urethral injury in males?

Answer 354

- the posterior segment is the membranous urethra, most likely damaged by pelvic fracture; urine leaks into the retropubic space and with present as blood at the meatus and a high-riding prostate - the anterior segment is the bulbar urethra, most likely damaged by perineal straddle injury; blood accumulates in the scrotum and if Buck's fascia is torn, urine escapes into the perineal space; presents with blood at the meatus and scrotal hematoma

Question 355

What is the deep fascia of Buck? What is it's clinical relevance?

Answer 355

- it surrounds both corpus cavernosi and the corpus spongiosum - in the case of a straddle injury damaging the anterior urethra, it will contain the urine - if it is ruptured by the injury, urine will instead leak into the superficial perineal space

Question 356

What is the difference between emission and ejaculation?

Answer 356

emission is movement of semen into the urethra while ejaculation is release of that fluid

Question 357

What innervation/nerves control male emission and ejaculation?

Answer 357

- emission is controlled by the sympathetic nervous system via the hypogastric nerve - ejaculation is controlled by visceral and somatic innervation via the pudendal nerve

Question 358

What are spermatogonia?

Answer 358

male germ cells lining the seminiferous tubules and serve to maintain the germ pool by producing primary spermatocytes

Question 359

What are Sertoli cells? What functions do they perform?

Answer 359

- they are non-germ cells found lining the seminiferous tubules, which support spermatogenesis - they secrete inhibin B, androgen-binding protein, and Mullerian inhibiting factor - they form tight junctions and form the blood-testis barrier, isolating gametes from autoimmune attack - they support and nourish developing spermatozoa while regulating spermatogenesis - they are also temperature sensitive, and will down regulate sperm production and inhibin B secretion when temperatures rise

Question 360

What are three secretory products of Sertoli cells?

Answer 360

- Mullerian inhibiting factor - inhibin B (inhibits FSH release) - androgen-binding protein

Question 361

What is inhibin B?

Answer 361

a hormone secreted by the gonads, which serves to inhibit FSH release

Question 362

What are Leydig cells?

Answer 362

those found in the interstitium of the testes, which secrete testosterone in response to LH

Question 363

Why do Sertoli cells produce androgen-binding protein?

Answer 363

to regulate local levels of testosterone

Question 364

What is the most potent form of endogenous estrogen?

Answer 364

estradiol > estrone > estriol (i.e. E2 > E1 > E3

Question 365

Where is estrogen produced in males and females? What form of estrogen arises from each source?

Answer 365

- the ovaries produce estradiol - the placenta produces estriol - adipose tissue forms estrone - Sertoli cells produce various estrogens

Question 366

What sort of GnRH stimulates release of LH and FSH?

Answer 366

pulsatile

Question 367

Estrogen has what roles in females?

Answer 367

- development of genitalia and breasts - female fate distribution - growth of follicles - endometrial proliferation - feedback inhibition - triggering the LH surge - impairs prolactin secretion - increases levels of SHBG, transport proteins, and HDL - lowers LDL

Question 368

What degree of estrogen increase is expected during pregnancy?

Answer 368

- 50 fold increase in estradiol and estrone | - 1000 fold increase in estriol

Question 369

What kind of estrogen is produced by the placenta?

Answer 369

estriol

Question 370

What changes do LH and FSH elicit in theca and granulosa cells?

Answer 370

- LH induces expression of desmolase by theca cells, which produces androgens - FSH induces expression of aromatase by granulosa cells, which convert those androgens to estrogens, driving endometrial growth, follicle development, and eventually the LH surge that triggers ovulation

Question 371

How do estrogen and progesterone affect prolactin levels?

Answer 371

they inhibit prolactin secretion until delivery has occurred

Question 372

What are the functions of progesterone?

Answer 372

- stimulate endometrial glandular secretions and spiral artery development for implantation - maintenance of pregnancy - reduced myometrial excitability - production of a thick cervical mucus - increase body temperature - reduce estrogen receptor expression

Question 373

What is the effect of estrogen or progesterone on myometrial excitability?

Answer 373

- estrogen increases excitability | - progesterone decreases it

Question 374

When do oocytes complete the various stages of meiosis?

Answer 374

- meiosis I begins in utero and is arrested in prophase I - meiosis I is completed just prior to ovulation - meiosis II is arrested in metaphase II until fertilization

Question 375

What triggers ovulation?

Answer 375

an estrogen surge stimulates LH release, which induces rupture of the follicle

Question 376

What hormone is responsible for the increase in temperature that coincides with ovulation?

Answer 376

progesterone

Question 377

What is Mittelschmerz?

Answer 377

a transient mid-cycle ovulatory pain classically that is associated with peritoneal irritation and mimics appendicitis

Question 378

The menstrual cycle is divided into what two phases?

Answer 378

follicular and luteal

Question 379

Describe the follicular and luteal phases of the menstrual cycle as well as the hormones controlling progression.

Answer 379

- pulsatile GnRH stimulates the release of a little FSH and LH - these gonadotropins stimulate theca and granulosa cells, resulting in follicle development and production of estrogen - estrogen stimulates endometrial growth - eventually follicular development progresses far enough that estrogen levels rise significantly and induce release of LH, which triggers ovulation - after ovulation, the follicle becomes a corpus lutem, which shifts more toward the production of progesterone - progesterone maintains the endometrium to support implantation - if fertilization does not occur, there is no hCG to maintain the corpus luteum, progesterone levels fall, and the endometrium is sloughed off - if fertilization does occur, syncytiotrophoblasts produce hCG, which maintains the corpus luteum until the placenta and fetus can take over progesterone production

Question 380

How long are the follicular and luteal phases of the menstrual cycle?

Answer 380

- the follicular phase varies in length but is usually fourteen days - the luteal phase is invariably 14 days

Question 381

Ovulation occurs when during the menstrual cycle?

Answer 381

fourteen days before menstruation begins

Question 382

What is responsible for the estrogen surge that induces ovulation?

Answer 382

an accelerated growth of the follicle during the second week of the follicular phase

Question 383

What is dysmenorrhea? What is it most often associated with?

Answer 383

- pain with menses | - often associated with endometriosis

Question 384

What is oligomenorrhea and polymenorrhea?

Answer 384

- oligo: a cycle lasting more than 35 days | - poly: a cycle lasting less than 21 days

Question 385

What are metrorrhagia and menorrhagia?

Answer 385

- metrorrhagia: frequent or irregular menstruation | - menorrhagia: heavy menstrual bleeding (> 80 mL or > 7 days)

Question 386

Where and where are ovulated oocytes usually fertilized?

Answer 386

in the ampulla of the fallopian tube on day 1 of ovulation

Question 387

What do we used to detect pregnancy? At what point can we detect pregnancy using blood and at home tests?

Answer 387

- we detect the hCG secreted by syncytiotrophoblasts | - this can be detected by 1 week post-conception in the blood and 2 weeks post-conception by a home test

Question 388

What is the difference between gestational and embryonic age of a developing fetus?

Answer 388

- gestational: calculated from date of last menstrual period | - embryonic: calculated from date of conception (= gestational age - 2 weeks)

Question 389

What cardiovascular changes occur during pregnancy?

Answer 389

- increase in preload, decrease in afterload, and increase in HR drive an increase in CO - anemia (because plasma volume increases more than number of RBCs) - hypercoagulability - hyperventilation

Question 390

Why do pregnant women experience an anemia?

Answer 390

because their plasma volume increases more than their hemoglobin does, so there is a dilution anemia

Question 391

When do hCG levels peak during pregnancy?

Answer 391

8-10 weeks (which is when the corpus luteum is allowed to degenerate because the placenta synthesizes it's own hormones)

Question 392

At what point during a pregnancy does the corpus luteum degenerate?

Answer 392

around 8-10 weeks, the time when the placenta is capable of producing it's own hormones and stops producing hCG

Question 393

hCG is a structural analog to which other hormones?

Answer 393

it shares an alpha subunit with LH, FSH, TSH but has a unique beta subunit

Question 394

What part of hCG does a pregnancy test detect?

Answer 394

the beta subunit, because the alpha subunit is shared by LH, FSH, and TSH

Question 395

What would cause hCG to be higher than usual during a normal pregnancy? What would cause it to be lower than expected?

Answer 395

- higher: multiple gestations, hydatidiform moles, choriocarcinomas, Down syndrome - lower: ectopic or failing pregnancy, Edward syndrome, Patau syndrome (trisomy 13)

Question 396

What is Edward syndrome? Patau syndrome?

Answer 396

trisomy 18 and trisomy 13, respectively

Question 397

How is APGAR score calculated? When is it taken? What score suggests a need for further evaluation?

Answer 397

- score of 0, 1, or 2 is awarded for appearance (how pink), pulse, grimace (pain response), activity, and respiration - taken at 1 and 5 minutes post-birth - score of less than 7 requires further evaluation

Question 398

What would qualify for a 2 on each of the APGAR measures? For a 1 on each? For a 0 on each?

Answer 398

- 2: pink, >100 bpm, cries and pulls away, active movements, strong cry (respirations) - 1: extremities are blue, <100 bpm, grimaces or weak cry, arms and legs flexed, slow/irregular breathing - 0: pale or blue, no pulse, no response to stimuli, no movement, no breathing

Question 399

What does a low apgar score predict?

Answer 399

risk for long-term neurologic damage

Question 400

How do we define low birth weight?

Answer 400

less than 2500 grams

Question 401

Low Birth Weight

Answer 401

- defined as weighing less than 2500 grams - caused by prematurity or intrauterine growth restriction - increased risk for SIDS and overall mortality - may contribute to impaired thermoregulation and immune function, hypoglycemia, polycythemia, impaired development, infections, RDS, necrotizing enterocolitis, etc.

Question 402

What is required to maintain milk production after birth?

Answer 402

suckling is required to maintain prolactin and oxytocin release, which drive lactation

Question 403

What roles do prolactin and oxytocin play in lactation?

Answer 403

prolactin induces lactation while oxytocin assists with milk letdown

Question 404

What are the two functions of oxytocin?

Answer 404

promote uterine contractions and milk letdown

Question 405

What immune components are transferred in breast milk?

Answer 405

- immunoglobulins (mostly IgA) - lymphocytes - macrophages

Question 406

Breast feeding reduces the risk for what diseases in the newborn?

Answer 406

- development of asthma - allergies - diabetes mellitus - obesity

Question 407

Infants who are breast fed require what additional supplement not found in breast milk?

Answer 407

vitamin D

Question 408

Why does breast feeding benefit the mother?

Answer 408

- facilitates bonding | - reduces estrogen exposure reducing the risk for breast and ovarian cancer

Question 409

Menopause

Answer 409

- defined by amenorrhea for 12 months - caused by an age-related decline in number of ovarian follicles with an average age of onset at 51 - this decline leaves peripheral conversion of androgens as the sole source for estrogen (so androgens rise and contribute to hirsutism) - FSH levels rise dramatically, estrogen levels drop, LH increases, and GnRH increases - causes HAVOCS: hot flashes, atrophy of the vagina, osteoporosis, coronary artery disease, and sleep disturbance - usually proceeded by 4-5 years of abnormal cycles

Question 410

Menopause before what age suggests primary ovarian insufficiency?

Answer 410

before age 40

Question 411

How do DHT, testosterone, a nd androstenedione compare?

Answer 411

- they are all androgens - testosterone and DHT from the testes while androstenedione comes from the adrenal cortex - DHT > testosterone > androstenedione in terms of potency

Question 412

What is responsible for closing the epiphyseal plates after puberty?

Answer 412

testosterone converted to estrogen

Question 413

DHT is responsible for what male changes?

Answer 413

- early: differentiation of external male genitalia | - late: prostate growth, balding, sebaceous gland activity

Question 414

How is testosterone converted to DHT?

Answer 414

5a-reductase

Question 415

In the male, where is estrogen produced?

Answer 415

by aromatase in adipose tissue and in the testes (found in Sertoli cells)

Question 416

Spermatogenesis takes how long?

Answer 416

two months (74 days)

Question 417

What is the difference between spermatogenesis and spermiogenesis?

Answer 417

- spermatogenesis is the progression from spermatogonium to spermatid - spermiogenesis is maturation of the spermatid to a spermatozoon via loss of cytoplasmic contents and acquisition of an acrosomal cap

Question 418

What defines a primary spermatocyte, secondary spermatocyte, spermatid, and spermatozoon?

Answer 418

- a primary spermatocyte is diploid (2N, 4C), poised at the end of G2 - a secondary spermatocyte is haploid (1N, 2C), which has completed meiosis I - a spermatid is haploid (1N, 1C), which has completed meiosis II - a spermatozoon is a spermatid that has lost it's cytoplasmic contents, taken the shape of a sperm, and acquired an acrosomal cap

Question 419

Tanner staging involves assessment of what features?

Answer 419

genitalia, pubic hair, and breast tissue

Question 420

What are Tanner stages I-V?

Answer 420

- I is pre-pubertal, II is 8-11.5 years old, III is 11.5-13, IV is 13-15, and V is over 15 - hair: none, sparse, coarsening, coarse but sparing medial thigh, coarse across medial thigh - breast: flat with raised nipple, breast bud, mound forms, mound on mound with raised areola, adult contour with flattened areola - penis: pre-pubertal, testicular enlargement, increase in length, increase in width and glands, adult

Question 421

Klinefelter Syndrome

Answer 421

- XXY males - causes dysgenesis of the seminiferous tubules, which leads to less inhibin B and more FSH, as well as abnormal Leydig cell function, which causes low testosterone, high LH, and high estrogen - presents with testicular atrophy, eunuchoid body shape, tall with long extremities, gynecomastia, and a female hair distribution - it may also present with developmental delay - often not diagnosed until after puberty and is a common cause of hypogonadism found when working up a patient for infertility - will find the presence of Barr bodies

Question 422

Turner Syndrome

Answer 422

- XO females - most often resulting from meiotic error (in the father), but can be due to a mitotic error after fertilization, which results in mosaicism - gonadal dysgenesis results in low estrogen and high LH/FSH - presents with short stature, shield chest with wide nipples, streak ovaries, bicuspid aortic valve, coarctation, lymphatic defects (e.g. webbed neck, lymphedema in feet or hands, cystic hygroma), and a horseshoe kidney - it is the most common cause of primary amenorrhea - no Barr body is found

Question 423

XYY Male

Answer 423

- usually goes undiagnosed and individual is phenotypically normal but very tall - may be associated with severe acne, learning disability, and autism spectrum disorders

Question 424

Ovotesticular Disorder of Sex Development

Answer 424

- also known as "true hermaphroditism" - more common as a 46,XX than 46,XY - results in the presence of both ovarian and testicular tissue being present with ambiguous genitalia

Question 425

How will levels of testosterone and LH be altered in those with a defective androgen receptor?

Answer 425

both testosterone and LH are high

Question 426

How will levels of testosterone and LH be altered in those with primary hypogonadism?

Answer 426

testosterone is low and LH will be high

Question 427

How will levels of testosterone and LH be altered in those with hypogonadotropic hypogonadism?

Answer 427

both testosterone and LH will be low

Question 428

46,XX Disorder of Sex Development

Answer 428

- presence of ovaries but virulized or ambiguous external genitalia - due to excessive or inappropriate exposure to androgenic steroids during early gestation; most often from congenial adrenal hyperplasia or exogenous administration of androgens during pregnancy

Question 429

46,XY Disorders of Sex Development

Answer 429

- those characterized by the presence of testes but female or ambiguous external genitalia - most often due to androgen insensitivity syndrome

Question 430

Placental Aromatase Deficiency

Answer 430

- an inability of the placenta to synthesize estrogens from androgens - results in 46,XX infants with ambiguous genitalia - serum testosterone and androstenedione will be high and may cause maternal virilization during pregnancy

Question 431

Androgen Insensitivity Syndrome

Answer 431

- a defect in the androgen receptor - patients develop normal functioning testes, which are often localized to the labia majora, but develop as a female otherwise (external genitalia and secondary sex characteristics along with a rudimentary vagina) - uterus and fallopian tubes are absent because Mullerian inhibiting factor still functions

Question 432

5a-Reductase Deficiency

Answer 432

- an autosomal recessive condition seen in 46,XY individuals - lack DHT so they have ambiguous genitalia until puberty when testosterone causes masculinization and growth of external genitalia - testosterone and estrogen levels are normal; LH is normal or elevated - internal genitalia are unaffected

Question 433

Kallmann Syndrome

Answer 433

- failure to complete puberty due to hypogonadotropic hypogonadism - results from defective migration of GnRH cells and formation of the olfactory bulb - presents with low GnRH, FSH, LH, and testosterone as well as anosmia - patient is infertile and will have amenorrhea if female

Question 434

What is the difference between placenta accreta, increta, and percreta?

Answer 434

- accreta: placenta attaches to the myometrium without penetrating it - increta: placenta penetrates into the myometrium - percreta: placenta penetrates through the myometrium and into the uterine serosa

Question 435

Vasa Previa

Answer 435

- a complication of pregnancy in which the fetal vessels run over or in close proximity to the cervical os - vessels may rupture when the supporting membranes rupture, presenting with membrane rupture, painless vaginal bleeding, and fetal bradycardia - frequently associated with velamentous insertion (of the umbilical cord into the chorioamniotic membrane rather than the placenta) - requires an emergency C-section

Question 436

What are the causes of postpartum hemorrhage to know?

Answer 436

the 4 T's - Tone (uterine atony; most common) - Trauma - Thrombin (coagulopathy) - Tissue (retained products of conception)

Question 437

What is uterine atony? Why is it clinically relevant?

Answer 437

- a loss of tone in the uterine musculature - problematic because contraction of uterine muscles during labor normally compresses blood vessels and reduces flow to increase the likelihood of coagulation - atony is the most common cause of postpartum hemorrhage

Question 438

Polyhydramnios

Answer 438

- the condition of too much amniotic fluid | - associated with fetal malformations, maternal diabetes, fetal anemia, and multiple gestations

Question 439

Oligohydramnios

Answer 439

- the condition of too little amniotic fluid - associated with placental insufficiency, bilateral renal genesis, and posterior urethral valves in males - may result in Potter sequence

Question 440

What is gestational hypertension?

Answer 440

- aka pregnancy-induced hypertension - defined by a BP > 140/90 after the 20th week of gestation without pre-existing hypertension - lack of proteinuria and end-organ damage differentiates it from pre-eclampsia - treat with hydrazine, methyldopa, labetalol, or nifedipine

Question 441

What are the treatment options for gestational hypertension?

Answer 441

Hypertensive Moms Love Nifedipine - hydralazine - methyldopa - labetolol - nifedipine

Question 442

Are ovarian, cervical, or endometrial cancers most common in the US? Worldwide?

Answer 442

- cervical is most common worldwide due to lack of screening | - endometrial > ovarian > cervical in the US

Question 443

What are the most common causes of an ovulation?

Answer 443

pregnancy, PCOD, obesity, HPO abnormalities, premature ovarian failure, hyperprolactinemia, thyroid disorder, eating disorder, competitive athletics, Cushing syndrome, adrenal insufficency

Question 444

Follicular Cyst

Answer 444

- a distended, enraptured graafian follicle - may be associated with hyper-estrogenism or endometrial hyperplasia - the most common ovarian mass in young women

Question 445

Theca-Lutein Cyst

Answer 445

- a functional cyst filled with serous fluid - usually bilateral and multiple - driven by hCG and therefore associated with choriocarcinoma and hydatidiform moles

Question 446

Gynecomastia

Answer 446

- breast enlargement in males due to increased estrogens relative to testosterone - physiologic in newborns, during puberty, and in elderly males - pathologic in cases of cirrhosis, hypogonadism, testicular tumors, and meds - meds include spironolactone, hormones, cimetidine, ketoconazole (Some Hormones Create Knockers)

Question 447

Peyronie Disease

Answer 447

- an abnormal curvature of the penis due to a fibrous plaque within the tunica albuginea - associated with erectile dysfunction and may cause pain or anxiety - repair surgically once the curvature stabilizes

Question 448

What is a "penile fracture"?

Answer 448

reupture of the corpora cavernosa due to forced bending

Question 449

Priapism

Answer 449

- a painful, sustained erection lasting more than four hours - associated with sickle cell disease and medications such as sildenafil and trazodone - must be teated promptly with corporal aspiration, intracavernosal phenylephrine, or surgical decompression to prevent ischemia

Question 450

Spermatocele

Answer 450

- a cyst due to dilated epididymal duct or retention testis | - presents as a fluctuant, paratesticular nodule

Question 451

What is Leuprolide and how is it used clinically?

Answer 451

- a GnRH analog with agonist properties when used in pulsatile fashion or antagonist properties when used continuously - indicated for uterine fibroids, endometriosis, precocious puberty, prostate cancer, or infertility

Question 452

What is the most significant adverse effect associated with estrogens?

Answer 452

risk for thrombotic event

Question 453

Estrogens are contraindicated in which patients?

Answer 453

those with ER+ breast cancer or a history of DVTs

Question 454

What is Clomiphene, how does it work, and what are the accompanying side effects?

Answer 454

- it is a SERM with antagonist activities in the hypothalamus to prevent normal feedback inhibition, thereby increasing the release of LH and FSH - it is used to treat infertility due to an ovulation - may cause hot flashes, ovarian enlargement, multiple simultaneous pregnancies, or visual disturbances

Question 455

What is Tamoxifen, how does it work, and what are the accompanying side effects?

Answer 455

- it is a SERM with antagonist activities at breast and agonist activities at bone and in the uterus - used to treat and prevent the recurrence of ER/PR+ breast cancer - increases the risk for thromboembolic events and endometrial cancer

Question 456

What is Raloxifene, how does it work, and what are the accompanying side effects?

Answer 456

- a SERM with antagonist activities at breast and uterus but agonist activities at bone - used to treat osteoporosis - increases risk of thromboembolic events but not the risk of endometrial cancer

Question 457

How does Raloxifene differ from Tamoxifen?

Answer 457

Raloxifene is an estrogen antagonist in the uterus whereas Tamoxifen is a weak agonist, which means that Raloxifene does not increase the risk for endometrial cancers like Tamoxifen does

Question 458

Anastrozole

Answer 458

an aromatase inhibitor used to treat ER+ breast cancer in postmenopausal women

Question 459

Letrozole

Answer 459

an aromatase inhibitor used to treat ER+ breast cancer in postmenopausal women

Question 460

Exemestane

Answer 460

an aromatase inhibitor used to treat ER+ breast cancer in postmenopausal women

Question 461

Unopposed estrogen replacement therapy in post-menopausal women is a problem for what reason? What is used to oppose it?

Answer 461

- increases the risk for endometrial cancer | - progesterone is added to oppose it

Question 462

What are the clinical uses of progestins?

Answer 462

contraception, treatment of endometrial cancer, and control of abnormal uterine bleeding

Question 463

Levonorgestrel

Answer 463

a progestin used for contraception, treatment of endometrial cancer, and control of abnormal uterine bleeding

Question 464

Progestin Challenge

Answer 464

- a test used to narrow down the source of amenorrhea - progestin is given and if the patient has sufficient serum estradiol, bleeding should occur in 2-7 days, indicating the patient's amenorrhea is due to anovulation

Question 465

Etonogestrel

Answer 465

a progestin used for contraception, treatment of endometrial cancer, and control of abnormal uterine bleeding

Question 466

Norethindrone

Answer 466

a progestin used for contraception, treatment of endometrial cancer, and control of abnormal uterine bleeding

Question 467

Megestrol

Answer 467

a progestin used for contraception, treatment of endometrial cancer, and control of abnormal uterine bleeding

Question 468

What is Mifepristone and how is it used clinically?

Answer 468

a competitive progesterone inhibitor used with misoprostol to terminate a pregnancy

Question 469

What is Ulipristal and how is it used clinically?

Answer 469

a competitive progesterone inhibitor used as emergency contraception

Question 470

How does oral estrogen/progestin contraception work?

Answer 470

- they inhibit LH/FSH to prevent ovulation - progestin causes a thickening of the cervical mucus, which poses a barrier to sperm, and inhibits endometrial proliferation

Question 471

For whom is combined oral contraception contraindicated?

Answer 471

- smokers over 35 (due to risk of DVT) - those with increased risk of CVD - those with migraines (especially with aura) - those with breast cancer

Question 472

Explain the mechanism, use, and adverse effects of a copper IUD.

Answer 472

- hormone free; instead, it produces a local inflammatory reaction toxic to sperm and ova - can be used as long-acting reversible contraception and is the most effective emergency contraception - disadvantages are heavier/longer menses, dysmenorrhea, and risk of PID with insertion

Question 473

What is the most effective emergency contraceptive?

Answer 473

placement of a copper IUD

Question 474

Terbutaline

Answer 474

a B2 agonist used to relax the uterus

Question 475

Ritodrine

Answer 475

a B2 agonist used to relax the uterus

Question 476

What is danazol, how is it used, and what are it's adverse effects?

Answer 476

- it is a synthetic androgen that acts as a partial agonist - used to treat endometriosis and hereditary angioedema - may cause weight gain, edema, acne, hirsutism, masculinization, low HDL, or hepatotoxicity

Question 477

What are the clinical uses and adverse effects of androgen therapy?

Answer 477

- treat hypogonadism and promote the development of secondary sex characteristics in addition to stimulating anabolism in patients after a burn or other injury - may cause gonadal atrophy, premature closure of the epiphyseal plates, or an increase in LDL and decrease in HDL

Question 478

What is finasteride and how is it used clinically?

Answer 478

a 5a-reductase inhibitor, which reduces DHT levels, for use in those with BPH or male-pattern baldness

Question 479

What is flutamide and how is it used clinically?

Answer 479

a non steroidal competitive inhibitor of androgens used to treat prostate carcinoma

Question 480

What is ketoconazole and how is it used clinically? What are it's adverse effects?

Answer 480

- a drug used to inhibit steroid synthesis via 17,20-desmolase in those with POCD - may cause gynecomastia or amenorrhea

Question 481

What is spironolactone and how is it used clinically in the treatment of GU conditions? What are it's adverse effects?

Answer 481

- inhibits steroid binding, 17a-hydroxylase, and 17,20-desmolase for use in those with POCD - may cause gynecomastia or amenorrhea

Question 482

What is tamsulosin and how is it used clinically?

Answer 482

- it is an a1-antagonist selective for the a1A,D subset of receptors found in the prostate - used to treat BPH

Question 483

What naming convention is used for PDE5 Inhibitors? How are they used clinically? What are their adverse effects?

Answer 483

- they end in "-denafil" - they increase cGMP to prolong smooth muscle relaxation - used to treat ED, pulmonary HTN, and BPH - cause headache, flushing, cyanosis, and a life-threatening hypotension in patients taking nitrates

Question 484

What is minoxidil and what is it used for clinically?

Answer 484

- it is a direct arteriolar vasodilator | - used to treat androgenetic alopecia and severe refractory hypertension