HRR Week 4 Flashcards
What physiological mechanism leads to the formation of male genitalia from bipotential embryonic tissue?
At 8 weeks, 5-alpha reductase converts testosterone to DHT (dihydrotesterone), which stimulates the development of male genitalia
What’s the physiology behind congenital adrenal hyperplasia?
The enzyme that converts cholesterol to cortisol is dysfunctional, leading to a compensatory overproduction of androgens
What cells are responsible for production of testosterone in the testes?
Leydig cells
What is the function of sertoli cells?
- “Nurse” cells for sperm
- Sensitive to FSH and regulate spermatogenesis
- Secrete inhibin and androgen binding protein (which maintains high intra-tubular testosterone)
What’s the mechanism of action of Viagra (sildenafil)?
NO upregulates cGMP, leading to vasodilation and engorged tissues. Phosphodieserase type 5 (PDE5) is an enzyme that breaks down cGMP. Sildenafil inhibits this enzyme, thus sustaining high levels of cGMP.
True or false: you can maintain spermatogenesis after puberty with just testosterone and not FSH:
True. Both are needed for the first step in spermatogenesis, but only testosterone is needed for completion of meiosis.
True or false: migraines with or without aura are contraindicated for estrogen use.
False: only migraines with aura are contraindicated
True or false: estrogen is associated with increased clot risk.
True. Estrogen containing therapies are contraindicated in patients with a high risk of clots.
Diagnosis of abnormal pregnancy:
If HCG > 2000 (over-discriminatory zone):
- No intrauterine pregnancy seen on US
- May be “pseudo sac”
If HCG
How can SSRI’s be used to treat men with sexual issues?
Since SSRI’s are known to cause sexual side effects such as delayed ejaculation, they can be useful to treat men with rapid ejaculation.
Explain the PGE1 test:
Penile injection with prostaglandin E1. Wait 15 minutes and assess the level of erection. Can help diagnose the cause of erectile dysfunction.
What’s the test for urinary retention?
Post-void residual. Measured by scanner or catheterization. More than 100 mL is positive.
Primary locations for urethral stricture:
Bladder neck and bulbar urethra
Retrograde ejaculation is pathognomonic for what?
Urethral stricture
Screening worksheet used to assess symptoms of BPH:
AUA-SI (American Urological Association Symptom Index)
Treatment for BOO/BPH:
- alpha blockers
- 5-alpha reductase inhibitors
- PDE5 inhibitors (taldanefil)
What drug might interfere with PSA interpretation?
Finasteride: reduces PSA by 50 - 60%
MOA for leuprolide (Lupron):
GnRH agonist: Binds to GnRH receptors without activating them, leading to decreased FSH and LH secretion and therefore less testosterone/estrogen.
Contraindications for Lupron:
Breastfeeding, pregnancy
Flutamide (Eulexin):
Androgen receptor antagonist: prevents transport into nucleus and blocks negative feedback on pituitary, leading to very high FSH/LH, which is why is must be administered with Lupron or goserelin. Used to treat prostate CA.
What can you administer to treat UTI as well as stress incontinence in women?
Topical estrogen
What is a pessary used for?
To treat stress incontinence in women
What’s one thing to worry about when treating nocturnal enuresis with DDAVP? What population would this not be recommended for?
Hyponatremia. Patients over 65.
What are the most common causes of post-menopausal uterine bleeding?
- Atrophic endometrium
- Endometrial polyp
- Endometrial cancer
- Hormonal effects
What lab would you draw for a postmenopausal patient suspected of having ovarian cancer?
CA125
Note: CA125 is not a screening tool for ovarian cancer. However, you should order it for ANY post-menopausal women with a pelvic mass.
What are BRCA1 and BRCA2 mutations a big risk factor for?
Ovarian cancer
What is Lynch syndrome a risk factor for?
- Colorectal CA
- Endometrial CA
- Ovarian CA
- others
Initial imaging in a patient with suspected ovarian cancer:
US or CT with contrast
In addition to pelvic masses, what exam finding is suggestive of ovarian cancer?
Ascites
Definition and etiology of leiomyoma:
Benign tumor of smooth muscle cells of uterus (submucosal, subserosal, intramural). Etiology is unknown but estrogen is implicated in their growth
Define CIN I, II, and III:
All ways of grading cervical changes as a result of HPV:
CIN I: mild dysplasia, correlates with LGSIL
CIN II: moderate dysplasia, correlates with HGSIL
CIN III: severe dysplasia, correlates with HGSIL
Most common type of cervical cancer:
2nd most common:
- Squamous cell carcinoma
- Adenocarcinoma
Some red flags for cervical cancer:
- Post coital bleeding
- Fixed cervix
- Watery, bloody, purulent or malodorous discharge
What sort of imaging should be ordered for a patient suspected of having cervical cancer?
None. If the bimanual exam is abnormal, biopsy. Imaging is only used pre-surgically.
What’s the curative treatment for cervical cancer?
Radiation
What is a red flag for endometrial cancer?
Abnormal (ovulatory) uterine bleeding, or any bleeding in a post-menopausal woman
Why is obesity a risk factor for endometrial cancer?
Adipose tissue secretes estrogen, and excess estrogen is the biggest risk factor for endometrial cancer.
Risk factors for endometrial cancer:
- Obesity
- Tamoxifen use
- Chronic anovulation
- Long term exposure to estrogen
- Lynch syndrome or other genetic d/o
Describe type II endometrial cancer:
- Not estrogen dependent
- Atrophic endometrium
- Higher grade, poor prognosis
What’s the relationship between cigarettes and endometrial cancer?
Smoking actually helps endometrial cancer!
What’s the most deadly gynecologic cancer?
Ovarian cancer. Usually not caught until stage 3 or 4, at which point there’s already a poor prognosis.
Risk factors for ovarian cancer:
- Cigarettes (mucinous type only)
- Early menarche/late menopause (more lifetime ovulations)
- PCOS
- BRCA I,II, Lynch syndrome
- Obesity
- Nulligravidity
- Age
- Infertility
- Endometriosis
Protections against ovarian cancer:
- Having kids
- OCPs
- Breast feeding
- Gynecologic surgery
What’s the initial imaging modality or suspected ovarian cancer?
Transvaginal ultrasound. CT is second choice.
What are the ACOG guidelines for referral to a gynecological oncologist for pelvic mass?
- CA125 over 200
- Ascites
- Evidence of distant metastases
True or false: you should never biopsy an ovary.
True
Etiologies for vulvar cancer:
- HPV mediated
- Autoimmune
- Melanoma 2nd most common histology, so pay attention to moles
Describe the etiology and SSx of vaginal cancer:
- HPV mediated SCC
- Can be flat plaque, mass or ulcer, usually on posterior wall
- Post-coital bleeding or other bleeding
What’s unique about gestational trophoblastic diseases?
- They all arise from fetal tissue after an abberrant fertilization event.
- Are highly curable by chemotherapy
- Secrete hCG
Hydatidiform mole:
- Benign but may be locally invasive
- Highest incidence in younger than 20, older than 40, nulliparous, nutrient deficient, low socioeconomic women.
- Type O father with type A mother increases risk, AB mother has worse prognosis
Choriocarcinoma:
- In about half the cases, arises from a hydatidiform mole
- Often presents as late post-partum vaginal bleeding
- Enlarged uterus, ovaries, vaginal lesions on PE
Red flags for gestational trophoblastic disease?
- 1st trimester pre-eclampsia
- 1st trimester AUB
- Enlarged ovaries, abnormal uterine size for gestational age
Imaging modality and findings for gestational trophoblastic disease:
- US
- “Snowstorm” pattern of hypoechoic areas
- No gestational sac or fetus
When might you used estriol vs estrodiol?
To treat symptoms of menopause. Estriol has less estrogenic potential than estradiol.
TAHBSO:
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Uses for therapeutic estrogen:
AEs:
- Tx of primary hypogonadism or surgical menopause
- HRT
- Contraception (with progestin)
AEs: Can mimic the symptoms of pregnancy: nausea, breast tenderness, bleeding, thromboembolism, endometrial cancer
What is a good use of Estring (estradiol ring)?
Vaginal atrophy. The low dose of estrogen avoids many of the symptoms of larger dose Premarin, but is still sufficient for vaginal atrophy.
When should you use a combination estrogen/testosterone therapy?
In patients who have failed estrogen/progesterone therapy
Pharmacologic treatments for prostate cancer:
- GnRH agonists: Lupron (leuprolide)
- Estrogen: Premarin
- Anti-androgens: Eulexin (flutamide). Can only be used in conjunction with Lupron.
Other uses for Lupron:
- Breast cancer treatment
- Endometriosis
Treatment for bacterial vaginosis:
- Metronidazole (Metrogel or Flagyl)
- Possible disulfuram rxn so avoid alcohol
- Also approved for trichomonas
Risks associated with depo provera:
- Reduced bone mineral density
- Irregular bleeding
- Weight gain
- Amenorrhea
What’s the primary estrogen produced by the body after menopause?
Estrone
When should you consider prescribing a progestin-only OCP?
Older smokers or women at risk of thromboembolism, or for whom estrogen is contraindicated.
True or false: progestin-only contraceptives increase the risk of ectopic pregnancy.
True
Which treatment for BPH do you need to watch out for orthostatic HTN with?
Alpha blockers (the “osin” drugs) such as tamsulosin (Flomax).
What’s a common and unusual side effect of Phenazopyridine (pyridium)?
Can cause urine to be red/orange
What class of drugs are useful for treating urinary incontinence?
Anticholinergics: tolteradine (Detrol LA), oxybutynin (Ditropan), trospium chloride (Sanctura)
Medical treatment for spontaneous abortion:
Misoprostol: induces uterine contractions and expulsion of products of conception.
Low progesterone levels (less than 5 ng/mL) measured during pregnancy suggest what?
Abnormal pregnancy
