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ESA 4 > Repro > Flashcards

Repro Flashcards

1
Q

List which cell types in the anterior pituitary gland produce which hormones and the chemical nature and target of the hormones

A
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2
Q

Describe the microscopic structure of the testis, including the main compartments and cells types

A
  • Surrounded by tough, fibrous tunica albuginea and visceral layer of tunica vaginalis
  • Seminiferous tubules → Rete testis → Epidydimis → Vas deferens
  • Sertoli cells - aids in spermatazoa development and secretion of MIH
  • Leydig cells - secrete testosterone
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3
Q

Describe the process of spermatogenesis

A
  • Germ cells colonise the seminiferous cords in the medulla of the primordial gonad
    • Form spermatogonia stem cells
  • Differentiate into:
    • A1 spermatogonia which continue mitosis
    • B type which further differentiates into primary spermatocytes
  • Primary spermatocytes push into the tubular lumen and begin meiosis to produce secondary spermatocytes
  • They further divide to produce spermatids
  • Undergo spermiogenesis to produce spermatoza which are washed down the rete testis by fluid from Sertoli cells
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4
Q

Describe the maturation and release of spermatozoa

A
  • Mature as they progress through the epidydimis
  • Contractions of the vas deferens mixes sperm with fluid from seminal vesicles (60%) and prostate (20%)
    • This is called emission and is controlled by the sympathetic nervous system
  • Ejaculation is controlled by the parasympathetic nervous sytem
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5
Q

Distinguish between the spermatogenic cycle and spermatogenic wave

A

Spermatogenic cycle = The amount of time it takes for the development of 256 spermatozoa from 1 A1 spermatogonia

Spermatogenic wave = Ensuring the production of sperm is constant by beginning the cycle at different parts of the tube at different times

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6
Q

Describe the roles of the rete testis, the epididymis and vas deferens

A

Rete testis = A network of canals that the seminferous tubules drain into

Epidydimis = A onvoluted duct where sperm is stored and matured

Vas deferens = A continuation of the epidydimis with thick muscular walls that contract to force sperm along the tube during copulation

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7
Q

Describe the roles of seminal vesicles, prostate and bulbo-urethral glands

A

Seminal vesicles = secrete a thick, alkaline fluid that mixes with sperm and is rich with fructose and a coagulating agent

Prostate = Secretes fluid to mix with sperm and plays a role in activating sperm

Bulbo-urethral glands = Secretes a mucus-like fluid that enters the urethra during secual arousal

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8
Q

Describe the microscopic structure of the ovary

A
  • Suspended by a short peritoneal fold = mesovarium
  • Ovarian ligament tethers the ovary to the uterus
    • Remnant of overian gubernaculum
  • Tunica albuginea = connective tissue capsule
    *
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9
Q

Describe the production of oocytes

A
  • Germ cells colonise the gonadal cortex = oogonia
  • They proliferate rapidly by mitosis to create 7 million
  • 5 million die off in selection process during gestation
  • Enter meiosis BEFORE birth (stimulated by surrounding cells)
    • Stops at prophase due to OMI from follicular cells
  • Becomes a primordial follicle when the primary oocyte is surrounded by granulosa cells
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10
Q

List the stages of follicular development

A
  1. Pre-antral
  2. Antral
  3. Pre-ovulatory
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11
Q

Describe the pre-antral stageof follicular development

A
  • Primary oocyte grows dramatically
  • Folliular cells proliferate into multiple-layered epithelium (granulosa cells)
    • Secrete glycoprotein to produce zona pellucida
  • Surrounding stromal cells from theca folliculi
    • Theca interna is vascular and endocrine
    • Theca externa is the fibrous capsule
  • Theca and granulosa cells secrete oestrogen
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12
Q

Describe the antral stage of follicular development

A
  • Fluid forms between granulosa cells = antrum
  • LH stimulates thecal cells to secrete angrogens
  • FSH stimulates granulosa cells to convert androgens into oestrogens
  • Expansion of Graafian follicle
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13
Q

Describe the pre-ovulatory stage of follicular development

A
  • LH surge causes the oocyte to re-start meiosis
  • Forms 1 daughter cell and 1 polar body
  • Secondary follicle enters meiosis II and then arrests 3 hours before ovulation
  • Antral fluid volume increases to weaken follicle
  • Collagenase is stimulated by LH to cause the follicle to rupture
  • Ovum carried out in fluid and into the Fallopian tubes by fimbriae
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14
Q

Describe the formation of the corpus luteum

A

After ovulation, the remains of the follicle reorganise into a corpus luteum

  • Secretes progesterone and oestrogen
  • Spontaneously regresses after 14 days without fertilisation
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15
Q

Describe the stages of the menstrual cycle

A

Begins on 1st day of bleeding where the endothelium of the uterus is shed

  • Days 0-12 = follicular/proliferative phase
  • Days 12-14 = ovulation
  • Days 14-28 = luteal/secretory phase
    • Uterus secretes fluid to feed conceptus
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16
Q

Describe the origin of germ cells

A

Primordial germ cells arise in the yolk sac and migrate along the dorsal mesentery into the retroperitoneum

  • Carries the Y chromosome in males
  • Forms the gonad when combined with intermediate mesoderm at the urogenital ridge
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17
Q

Describe the formation of the ductal system

A
  • Mesonephric (Wolffian) duct makes contact with cloaca
  • Cloaca splits into anal canal and urogenital sinus via urorectal septum
  • Ureteric bud sprouts from Wolffian duct
  • MALES - UGS absorbes the proximal parts of the Wolffian duct and the ureteric bud to make independent openings
    • Driven by expression of SRY gene
  • FEMALES - Wolffian duct regresses due to lack of male hormones
    • Only ureteric bud makes an opening
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18
Q

Describe the role of testosterone and MIS in the development of the male gonads

A
  • Testis develop due to SRY gene
  • Testosterone secreted by Leydig cells supports the Wolffian duct
    • Forms the epidydimis, vas deferns and seminal vesicles
  • Mullerian Inhibiting Substance secreted by Sertoli cells cause the Mullerian ducts to degenerate
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19
Q

Describe the role of testosterone and MIS in the development of the female gonads

A
  • Ovaries develop
  • No testis so no testosterone causes Wolffian duct to degenerate
  • No MIS causes Mullerian ducts to persist
    • Forms the uterine tubes, uterus, cervix and upper third of vagina
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20
Q

Describe the role of the paramesonephric ducts in the formation of the uterus

A

AKA Mullerian ducts

  • Invaginations of epithelium of the urogenital ridge
  • Grows into peritoneal cavity, bringing the gonads with it
  • Fuse in the lidline to form the uterus
    • Supported by broad ligament
  • Uterus opens into vagina
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21
Q

Describe the development of the external male genitalia

A
  • Genital tubercle elongates = glans of penis
  • Genital folds fuse = shaft of penis
  • Genital swelling = scrotum
  • Influenced by dihydrotestosterone from testis
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22
Q

Describe the development of the external female genitalia

A
  • Genital tubercle = clitoris
  • Urethra opens into vestibule
  • Genital folds = labia minora
  • Genital swelling - labia majora
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23
Q

List the hormones involved in reproduction produced in the hypothalamus the anterior and posterior pituitary glands and the gonads

A
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24
Q

Describe the control of secretion in the hypothalamus

A
  • GnRH released from median eminence of hypothalamus in pulsatile waves
  • Travels through hypophyseal circulation portal circulation to stimulate the anterior pituitary
  • GnRH secretion is increased by high levels of oestrogen
    • Progesterone blocks this action
  • GnRH secretion is decreased by testosterone, moderate levels of oestrogen
  • Body weight and the environment can also influence secretion
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25
Q

Describe the control of secretion of gonadotrophs

A
  • LH and FSH secreted from anterior pituitary in response to GnRH
  • FSH is inhibited by inhibin from Granulosa/Sertoli cells
  • Secretion increased by high levels of oestrogen
  • Secretion decreased by moderate levels of oestrogen and testosterone
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26
Q

Describe the action of gonadotrophs in the testes

A
  • FSH binds to Sertoli cells to promote inhibin secretion and spermatogenesis
  • LH binds to Leydig cells to secrete testosterone
    • Enhanced by prolactin
  • Testosterone promotes spermatogenesis and maintains internal genitalia
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27
Q

Describe the action of gonadotrophs on the ovaries in the antral phase

A
  • LH binds to thecal cells to produce androgens
  • FSH binds to granulosa cells to produce enzymes that convert androgens into oestrogens
  • Oestrogen negatively feedbacks onto the hypothalamus and the anterior pituitary
  • As the follicle grows, more oestrogen is produced per concentration of gonadotroph
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28
Q

Describe the action of gonadotrophs on the ovaries in the ovulatory phase

A
  • LH receptors develop in the outer thecal layer
  • High oestrogen levels positively feedbacks onto the hypothalamus and the anterior pituitary
  • LH surge stimulates ovulation
  • FSH is inhibited by inhibin from granulosa cells does not increase as much as LH
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29
Q

Describe the action of gonadotrophs on the ovaries in the luteal phase

A
  • Remains of follicle reorganise into a corpus luteum
  • LH stimulates the corpus luteum to secrete oestrogen and progesterone
  • Progesterone stops positive feedback of oestrogen
  • Prevents new follicles from developing by decreasing FSH levels
  • Corpus luteum grows so secretes more steroids
    • Until day 14 when it spontaneously regresses in the abscence of a conceptus
    • Low oestrogen levels stimulate new cycle
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30
Q

List the action of testosterone

A
  • Determinative
    • Increase size and mass of muscles, bones and vocal cords
    • Deepening of the voice
    • Body hair
  • Regulatory
    • Maintenance of internal genitalia
    • Anabolic effect
    • Aggression
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31
Q

List the action of oestrogen

A
  • Stimulates Fallopian tube activity
  • Thickening of endometrium
  • Growth and motility of myometrium
  • Production of thin and acidic cervical mucus
  • Changes in skin, hair and metabolism
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32
Q

List the action of progesterone on oestrogen-primed cells

A
  • Further thickening of endometrium
  • Thickening and acidification of cervical mucus
  • Thickening but reduced motility of myometrium
  • Increased body temperature
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33
Q

List the phases of the menstrual cycle

A
  • Follicular (0-12 days)
    • Stimulation and growth of follicle
    • Uterus is prepared for sperm transport
  • Ovulatory (12-14 days)
    • Stimulated by LH surge
    • Formation of corpus luteum
  • Luteal phase (14-28 days)
    • LH maintains corpus luteum
    • Waiting for signals from conceptus
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34
Q

Describe the changes to the ovary and endometrium during the follicular phase

A
  • Stimulation and muscular contraction of Fallopian tubes
  • Growth and motiity and myometrium
  • Thickening of endometrium
  • Production and thin and alkaline cervical mucus
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35
Q

Describe the changes to the ovary and endometrium during the luteal phase

A
  • Action of progesterone on oestrogen-primed cells
  • Reduced Fallopian tube motility, secretion and cilia activity
  • Further thickening of myometrium but reduced motility
  • Thickening and acidification of cervical mucus to block sperm transport
  • Elevation of body transport
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36
Q

What happens to hormone secretion if conception has occurred?

A
  • Placenta develops which secretes hCG
  • hCG prevents regression of corpus luteum which continues to secrete oestrogen and progesterone
  • This maintains the suppression of the ovarian cycle
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37
Q

Describe the sequence of physiological and anatomical changes that occur in the male during puberty

A
  • From ages 9-14
  • Genital development
  • Pubic hair growth (adrenarche)
  • Beginning of spermatogenesis
  • Growth spurt (10cm/year)
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38
Q

Describe the sequence of physiological and anatomical changes that occur in the female during puberty

A
  • Ages 8-13
  • Breast bud development (thelarche)
  • Pubic hair growth (adrenarche)
  • Growth spurt (9cm/year)
  • Onset of menstrual cycle (menarche)
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39
Q

Discuss the hormonal control of puberty

A
  • Steady rise in LH and FSH
    • Due to rise in GnRH secretion
  • Adrenarche due androgens
    • From adrenals in girls
  • Breast development stimulated by oestrogen
  • Growth spurt stimulated by GH and steroids
    • Presence of oestrogen closes epiphyses earlier in girls
    • NB: weight also determines whether puberty begins or not (girls = 47 kg and boys = 55kg)
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40
Q

Describe some causes of precocious puberty

A
  • Before ages 8
  • Neurological = early stimulation of central maturation causes inappropriate GnRH secretion
    • Pineal tumours
    • Meningitis
  • Uncontrolled gonadotrophin or steroid secretion
    • Hormone secreting tumours
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41
Q

Describe the hormonal changes that lead to menopause

A
  • Pre-menopause (40 years)
    • Follicular phase shortens - ovulation is early or absent
    • Less oestrogen secreted
    • More and LH and (significantly) FSH due to reduced feedback
  • Menopuase (49-50 years)
    • Cessation of menstruation due to absence of follicles
    • Oestrogen falls dramatically
    • FSH and LH rises (FSH more due to lack of inhibin)
  • Post menopause
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42
Q

List some effects of menopause

A
  • Vascular changes - hot flushes
    • Transient rises in skin temperature and flushing
    • Relieved by oestrogen treatment
  • Endometrium regresses
  • Myometrium shrinks
  • Cervix thins
  • Vaginal rugae lost
  • Bone mass reduces by 2.5% per year
    • Increased reabsorption due to less osteoclast inhibition from oestrogen
    • Lead to osteoporosis and fractures
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43
Q

List the advantages and disadvantages of hormone replacement therapy in the post-menopausal woman

A

Advantages:

  • Relives menopausal symptoms
  • Can be given orally or topically
  • Can limit osteoporosis

Disadvantages:

  • Increased risk of stroke
  • Increased risk of breast and endometrial cancer
  • Increases blood pressure
  • Increased risk of clots
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44
Q

Describe the different types of amenorrhea

A
  • Primary = absence of menses by age 14 with absence of secondary sexual characteristics
  • Secondary = where an established menstruation has ceased:
    • 3 months if history of regular periods
    • 9 months if history of irregular periods
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45
Q

Describe an overview of the causes of amenorrhea and how to distinguish between them

A
  • Outflow problem = FSH is normal as there is no issue with HPO axis
  • Gonadal problem = FSH is high due to low oestrogen
  • Pituitary/hypothalmic problem = FSH is low
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46
Q

List some hypothalmic/pituitary causes of amenorrhea

A

Inadequate levels of FSH = less stimulation to ovaries = less oestrogen = no endometrium stimulation

Primary:

  • Kallman’s syndrome = inability to produce GnRH

Secondary:

  • Exercise/stress/eating disorders
  • Hyperprolactinaemia/haemochromatosis
  • Hypo/hyperthyroidism
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47
Q

List some gonadal causes of amenorrhea

A

Ovary does not respond to pituitary stimulation = low oestrogen = high FSH

Primary:

  • Gonadal dysgenesis (Turner’s syndrome)
  • FSH and LH receptor abnormalities
  • Androgen insensitivity syndrome

Secondary:

  • Pregnancy
  • Menopause
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48
Q

How is secondary amenorrhea assessed?

A
  • Menstrual history
  • Medical history
    • Pregnancy
    • Surgery
    • Medication
    • Chronic diseases
  • Lifestyle - weight loss/stress/diet
  • Family history - thyroid/diabetes/cancer
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49
Q

List some outflow causes of amenorrhea

A

Primary:

  • Uterine = Mullerian agenesis
  • Vaginal = Vaginal atresia/ cryptomenorrhea/imperforate hymen

Secondary:

  • Intrauterine adhesions (Asherman’s syndrome)
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50
Q

How is amenorrhea managed?

A
  • Treat underlying cause
  • Lifestyle changes
  • If outflow problem = surgery
  • If hormonal problem = hormone replacement therapy
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51
Q

What is DUB and how is it assessed and treated?

A
  • Dysfunctionial Uterine Bleeding = excessively heavy, prolonged or frequent bleeding not due to pregnancy, pelvic or systemic disease
  • Caused by a disturbance in HPO axis
    • Irregular endometrium shedding due ot low oestrogen and prolonged progesterone
  • Assessed by ruling out other conditions - blood test, smear, endometrium sample
  • Treated with oestrogen/progesterone replacement therapy
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52
Q

What is menorrhagia and how is it treated?

A
  • Heavy vaginal bleeding that isn’t DUB
  • Secondary to distortion of uterine cavity
    • Uterus unable to contract down on open venous sinuses
  • Can be caused by endocrine, haemostatic or iatrogenic factors
  • Treat with progesterone
    • Or NSAIDs
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53
Q

Define oligomenorrhea

A

Uterine bleeding occurring at intervals between 35 days and 6 months

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54
Q

Define dysmenorrhea

A

Painful menstruation

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55
Q

What are the risk factors for developing a genital tract infection?

A
  • Young people
  • Certain ethnicities
  • Low SES
  • Higher number of sexual partners
  • Sexual orientation
  • Unsafe sexual activity
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56
Q

List the most common sexually transmitted infections, identifying the infecting organism in each case

A
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57
Q

Describe recent trends in the incidence of sexually transmitted infections

A

Gradual and sustained increase in number of diagnosed STIs

  • Increased transmission
  • Increased GUM clinic attendance
  • Greater awareness
  • Improved diagnostic methods
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58
Q

Describe the clinical presentation, diagnosis and management of chlamydial infections

A
  • Infection by chlamydia trachomatis
    • Obligate gram -ve intra-cellular bacterium
  • Males = urethritis, epididymitis, prostatitis, proctitis
  • Females = urethritis, cervicitis, salpingitis, perihepatitis
  • Diagnosed using endocervical and urethral swabs
    • Nucleid Acid Amplification test
  • Treated with doxycycline or azithromycin
    • Erythromycin in children (conjunctivitis)
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59
Q

Describe the clinical presentation, diagnosis and management of gonorrhoea

A
  • Infection by neisseria gonorrhoea
    • Gram -ve intracellular diplococcus
  • Males = urethritis, epididymitis, prostatitis, proctitis, pharyngitis
  • Females = can be asymptomatic, endocervicitis, urethritis, pelvic inflammatory disease
  • Diagnosed by swab from urethra or cervix or urine
    • Gram stain (requires special medium)
  • Treated with IM ceftriaxone
    • Also treat chlamydia with azithromycin
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60
Q

Describe the clinical presentation, diagnosis and management of genital herpes

A
  • Infection by Herpes Simplex Virus 2
    • Encapsulated, double stranded DNA virus
  • Presents with painful genital ulceration, dysuria, inguinal lymphadenopathy and fever
  • Can be recurrent - latent infection in dorsal root ganglia
  • Diagnosed using PCR of vesicle fluid or ulcer base
  • Treated with aciclovir
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61
Q

Describe the clinical presentation, diagnosis and management of genital warts

A
  • Infection by human papillomavirus
    • Double stranded DNA virus
  • Presents with cutaneous, mucosal and anogenital warts
    • Benign, painless, verrucous or mucosal outgrowths
  • Oncogenic types = 16 and 18
  • Diagnosis from clinical, biopsy and genome analysis
    • Hybrid capture
  • Treated with topical podophyllin, cryotherapy or surgery (if hasn’t spontaneously resolved)
  • Screened using a cervical pap smear
  • Vaccine offered to girls aged 12-13
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62
Q

Describe the organism, detection, presentation and treatment for syphillis

A
  • Infection from treponema pallidum (spirochaete)
    • Mainly in MSM
  • Detected using dark-field microscopy or EIA antibody test
  • Multi-stage disease
    • Primary = painless ulcers (chancres)
    • Secondary = fever, rash, lymphadenopathy, mucosal lesions (6-8 weeks)
    • Tertiary = neurosyphilis, cardiovascular syphilis, gummas (local destruction)
  • Treated with penicillin
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63
Q

Describe some causes of vaginal discharge

A
  • Trichomonas vaginalis = flagellated protozoan
    • Thin, frothy, offensive discharge with irritation and dysuria
    • Treated with metronidazole
  • Vulvovaginal candidiasis (thrush) = candida albicans
    • Risk factors = antibiotics, COCP, pregnancy, steroids, obesity, diabetes
    • Profuse, white, itchy, curd-like discharge
    • Treated with topical azoles
  • Bacterial vaginosis = unsettled normal flora
    • Scanty but offensive discharge
    • Vaginal pH > 5
    • Treated with metronidazole
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64
Q

What is Pelvic Inflammatory Disease?

A

The result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscesses and/or pelvic peritonitis

  • Disease of sexually active women
  • Mainly caused by chlamydia and gonorrhoea
  • Inflammation causes adhesions and tubal epithelium damage
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65
Q

List some risk factors for Pelvic Inflammatory Disease

A
  • Sexual behaviour
  • 1st week fo Intrauterine Contraceptive Device
  • Alcohol/drug use
  • Smoking
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66
Q

What are the clinical features of Pelvic Inflammatory Disease?

A
  • Pyrexia (>38°C)
  • Pain
    • Bilateral lower abdominal
    • Dyspareunia
    • Adnexal tenderness
  • Abnormal vaginal/cervical discharge
  • Abnormal vaginal bleeding
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67
Q

Describe the investigations for Pelvic Inflammatory Disease

A
  • Pregnancy test
  • Triple Swabs
    • High vaginal - bacterial vaginosis
    • Endocervical - chlamydia or gonorrhoea
    • Urethral - chlamydia in males
  • MSU
  • CRP
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68
Q

Describe the management of Pelvic Inflammatory Disease

A
  • Analgesia
  • Antibiotics
    • IM ceftriaxone + PO doxycyline + PO metronidazole
  • Laparoscopy/laparotomy if no response to antibiotics or tubo-ovarian abscess
  • Ultra sound-guided aspiration to remove pelvic fluid accumulation
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69
Q

What does Pelvic Inflammatory Disease increase the risk of in the future?

A
  • Ectopic pregnancy
  • Infertility
  • Chronic pelvic pain
  • Fitz Hugh Curtis syndrome = RUQ pain and perihepatitis
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70
Q

Describe the arterial supply to the female reproductive tract

A
  • Uterine artery (via internal iliac)
  • Ovarian artery (via abdominal aorta)
    • Just below renal arteries
  • Vaginal and internal pudendal artery (via internal iliac) supply the middle and inferior vagina
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71
Q

Describe the venous drainage of the female reproductive system

A
  • Ovarian veins
    • Right vein directly into inferior Vena Cava
    • Left vein into left renal vein
  • Uterine venus plexus → uterine veins → internal iliac
  • Vaginal venus plexus → vaginal vein → uterine veins → internal iliac
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72
Q

Describe the innervation of the female reproductive system

A
  • Inferior 1/5 vagina = pudendal nerve (S2-4)
  • Superior 4/5 vagina and uterus = uterovaginal plexus
  • Perineum = pudendal + ilioinguinal nerves
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73
Q

Describe the lymphatic drainage of the female reproductive system

A
  • Ovary = para-aortic nodes
  • Fundus of uterus = aortic nodes
  • Body = external iliac nodes
  • Cervix = external + internal iliac nodes + sacral nodes
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74
Q

Briefly describe how the gonads develop

A
  • Within mesonephric ridge (L2/3)
  • Descend through abdomen into pelvis
  • Following the path of the round ligament of the uterus (embrylogically gubernaculum)
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75
Q

Describe the position of the uterus

A
  • Anteverted with respect to the vagina
  • Anteflexed with respect to the cervix
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76
Q

Describe the main ligaments of the female reproductive tract

A
  • Broad ligament = a peritoneal fold in the pelvis that acts as a mesentery of the uterus, uterine tube and ovary
  • Round ligament = attaches ovary to labia majoris via the inguinal canal
    • Embryologically = gubernaculum
  • Transverse cervical = contributes to lateral stability of the cervix
  • Uterosacral = opposes anterior pull of round ligament
  • Suspensory = a fold of peritoneum that connects the ovary to the wall of the pelvis
    • Contains ovarian artery, vein, nerve plexus and lymph nodes
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77
Q

Describe what happens to the uterus during the secretory phase

A

After ovulation, the newly formed corpus luteum secretes progesterone, which stimulates the endometrial glands to secrete glycogen and causes their extensive coiling, enriching the vascular supply to the mucous membrane

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78
Q

Describe what happens to the uterus during the menstrual phase

A
  • Withdrawal of hormonal support due to degeneration of corpus luteum
  • Breakdown of endometrium (stratum functionalis)
  • Bleeding and shedding of dead tissue
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79
Q

Describe some clinical problems of the ovary

A
  • Poycystic ovaries (> 10 cysts) can lead to infertility
  • Tumours
    • Epithelial
    • Germ cell (teratoma)
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80
Q

Describe some clinical problems of the uterus

A
  • Salpingitis = inflammation of the uterine tube
    • Can cause fusions/lesions of the mucosa which can lead to blockage = infertility
  • Endometriosis = ectopic endometrial tissue is dispersed along the peritoneal cavity
    • Associated with dysmenorrhea and infertility
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81
Q

Describe some clinical problems of the cervix and examinations of the cervix

A
  • Endometrial carcinoma
    • Mainly post menopausal
    • Usually at squamocolumnar junction - change of simple columnar epithelium of endocervix into stratified squamous at exocervix
    • Causes abnormal uterine bleeding

Examinations:

  • Bimanual examination
  • Cervical examination using a speculum
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82
Q

Describe some clinical problems of the vagina

A
  • Barthinolitis
  • Bartholin Gland cysts
  • Vaginitis = inflammation of the vagina
  • Vaginismus = reflex that makes penetration extremely painful or impossible
    • Pubococcygeus muscle
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83
Q

Describe some properties of a ‘good’ gynecoid pelvis

A
  • Round inlet
  • Straight side walls
  • Small (and not prominent) ischial spines
  • Round greater sciatic notch
  • Curved sacrum
  • Sub-pubic arch > 90 degrees
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84
Q

Describe some clinical assessments of the pelvis

A
  • Pelvic inlet - anteroposterior diameter
    • Obstetric conjugate = measured from sacral promontory to midpoint of pubic symphisis
    • Diagonal conjugate = from sacral promontory to inferior border of pubic symphisis
  • Mid-pelvis
    • Straight side walls
    • Bispinous diameter
  • Pelvic outlet
    • Infrapubic angle
    • Distance between ischial tuberosities
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85
Q

Name 2 ligaments of the pelvis

A
  • Sacrospinous
    • Divides into greater and lesser sciatic foramen
  • Sacrotuberous
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86
Q

Identify the major cell types in the testis

A
  • Leydig cells lie in islands between seminiferous tubules
    • Secrete testosterone
  • Sertoli cells extedn through the seminiferous epithelium
  • Seminiferous epithelium = contain developing male gametes
    • Spermatagonia (deepest) → spermatocytes → spermatids
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87
Q

Describe the main histological features of the epidydimis

A
  • Single coiled tube
  • Pseudostratified columnar epithelium with stereocilia
  • Outside layer contains thickening smooth muscle
  • Contains basal cells
  • First part is absorptive (residual bodies lost from sperm)
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88
Q

Describe the main histological features of the vas deferens

A
  • Transports germ cells to ejaculatory duct (union of terminal VD and seminal vescile duct)
  • 3 layers = epithelium, lamina propria and 3 layers of smooth muscle
    • Inner and outer SM is longitudinal and middle is circular
  • Pseudostratified columnar epithelium with few stereocilia
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89
Q

Describe the main histological features of the seminal vesicle

A
  • Paired and coiled tubulosaccular gland
  • Highly foled mucosa = epithelium + lamina propria
  • Glandular element surrounded by a muscular coat
    • Activated by sympathetic stimulation during ejaculation
  • Pseudostratified columnar epithelium
    • Produces secretion rich in fructose
  • Contains basal cells
    • Can mature into epithelium
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90
Q

Describe the main histological features of the prostate

A
  • Tubuloalveolar glands arranged in 3 groups:
    • Mucosal, submucosal and main glands
    • Each group drains separately into urethra
  • Surrounded by a fibromuscular capsule
    • Septae divide gland into lobules
  • Secretory elements sit in fibromuscular connective tissue
    • Secrete acid phosphatase and PSA
  • Heterogenous epithelia
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91
Q

Explain why benign prostatic hyperplasia usually presents with symptoms earlier than a prostatic carcinoma

A
  • BPH usually occurs in muscosal zone (closer to urethra)
    • Compression of urethra causes symptoms
  • Prostatic carcinoma occurs in the main gland zone
    • Doesn’t compress the urethra for a longer time
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92
Q

Describe the main histological features of the ovaries

A
  • Divided into cortex and medulla
  • Medulla contains nerves, blood vessels, connective tissue, stromal cells and germ cells in various developmental stages
  • Covered by squamous epithelium
  • Hilum = where nerves and blood vessels enter/leave
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93
Q

Recognise the histological changes that occur to the primordial follicle during puberty

A
  • Primordial follicle = oocyte + single layer of granulosa cells
  • FSH begins maturation
  • Granulosa cells change from squamous to cuboidal = unilaminar primary follicle
  • Granulosa cells divide to become stratified
  • Zona pellucida develops between oocyte and granulosa cells
  • Stromal cells differentiate into theca folliculi
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94
Q

Recognise the histological changes that occur that produces the secondary, ternary and Graafian follicles

A
  • Fluid filled spaces appear between granulosa cells = secondary follicle
  • Theca folliculi cells divide into theca interna (secrete androgens) and theca externa (vascular connective tissue)
  • Fluid filled spaces forms an antrum = ternary follicle
    • Oocyte is pushed to one side of the follicle where it sits on the cumulus oophorus
  • Antrum develops to form the Graafian follicle
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95
Q

Recognise the histological changes that occur prior to and during ovulation

A
  • Cumulus oophorus breaks down to allow oocyte to float freely
  • Surrounding tissue becomes ischaemic so follicle ruptures
  • After LH surge, corpus luteum forms from the remnants of the follicle
    • Granulosa cells → granulosa lutein cells (secrete progesterone)
    • Theca interna cells → theca lutein cells (secrete oestrogen)
  • In the absence of fertilisation, the corpus luteum then degenerates into white connective tissue within 2 weeks = corpus albicans
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96
Q

Describe the main histological features of the Fallopian tubes

A
  • Tube collects released ova and provide a site for fertilisation
  • Contain fimbriae that capture ovum
  • Fimbriae attach to infundibulum (bell-shaped)
  • Structure consists of an inner mucosa, a muscular layer and a serosal covering
    • 2 layers of muscle in ampulla
    • 3 layers in isthmus
  • Simple columnar epithelium
    • With cilia in ampulla region
    • Towards uterus, contains peg cells that secrete mucus
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97
Q

Describe the main histological features of the uterus

A
  • Innermost layer = endometrium
    • Simple columnar epithelium
  • Endometrium has 2 layers:
    • Stratum functionalis (coiled arcuate arteries) = shed completely during menstruation
    • Stratum basalis (straight arcuate arteries)
  • Outer layer = myometrium
    • 4 layers of smooth muscle
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98
Q

Describe the main histological features of the cervix

A

Connects uterine cavity and vagina

  • Simple columnar epithelium at external os
    • Changes to stratified squamous during reproductive life
  • Many mucus-secreting glands
  • Squamocolumnar junction at any point across cervix
    • Majority of neoplasms
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99
Q

Describe the main histological features of the vagina

A

Fibromuscular tube connecting the cervix to the exterior

  • Non-keratinised stratified squamous epithelium
    • Accumulates glycogen for lactobacilli under oestrogen influence
  • Structure consists of mucoa, submucosa and muscular (smooth and skeletal) layers
  • Lubricated by mucus from cervical and vestibular glands
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100
Q

Describe the main histological features of the breast

A
  • Consists of a duct system, nipple and areola
  • Puberty causes enlargement - deposition of fat
  • Ducts linedby cuboidal to columnar epithelium
    • Changes to stratified squamous at lactiferous sinuses
  • Ducts surrounded by myoepithelial cells
  • Compound tubuloacinar gland
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101
Q

Describe the histological changes occurring during menstrual cycle

A
  • Proliferative - stratum functionalis regenerates from the stratum basalis
    • Under oestrogen control
  • Secretory = growth and coiling of endometrial glands and formation of decidual cells from stromal cells
    • Under progesterone control
    • Decidual cells form the placenta and secrete prolactin
  • Menstrual = shedding of endometrium due to spasm of spiral arteries (necrosis)
    • Due to lack of androgens
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102
Q

Describe the structure of the pelvic floor

A
  • Pelvic diaphragm within lesser pelvis = levator ani, coccygeus + fascia
    • Separates pelvic cavity from perineum
  • Superficial muscles
    • Anterior (urogenital) perineum
    • Posterior (anal) perineum
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103
Q

Describe the function of the pelvic floor

A
  • Sphincter action on rectum and vagina
  • Resists increase in intra-abdominal pressure
    • Coughing, defaecation, heavy lifting
  • Supports pelvic viscera
    *
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104
Q

Name the muscles that levator ani comprises of and innervation

A
  • Puborectalis = U shaped sling around anal canal
    • Maintains faecal conteinence
    • Maintains anorectal flexure
  • Pubococcygeus = around urogenital hiatus, attaching at coccyx
    • Divided into levator prostatae or pubovaginalis
  • Iliococcygeus = from ischial spines to coccyx
  • Supplied by pudendal nerve (S2-4)
105
Q

Describe the coccygeus muscle and innervatio

A
  • Runs posteriorly from ischial spine to coccyx along sacrospinous ligament
  • Supplied by anterior rami of S4-5
106
Q

Describe the layers of the urogenital perineum

A
  • Deep perineal pouch
  • Perineal membrane
  • Superficial perineal pouch
    • Site of urine collection if urethra is ruptured below perineal membrane
  • Deep perineal fascia
  • Superficial perineal fascia
  • Skin
107
Q

Describe the contents of the urogenital perineum

A
  • Bounded by pubic symphysis, ischiopubic rami and line between ischial tuberosities
  • External genitalia
  • Urethra
  • Bartholin glands = maintains a moist vagina
  • Muscles:
    • Sphincter urethrae - between superior and superficial fascia
    • Bulbospongiosus - below perineal membrane
108
Q

Describe the contents of the anal perineum

A
  • Bounded by coccyx, sacrotuberous ligaments and line between ischial tuberosities
  • Anal aperture
  • Levator ani
  • External anal sphincter
  • Two ischiorectal fossa - laterally to anus
    • Aid expansion of anal canal during defaecation
109
Q

What is the perineal body and its function?

A

A fibromuscular mass between the urogenital and anal triangles

  • Point of attachment for pelvic floor and perineal muscles
  • Acts as a tear resistant body between the vagina and anus
  • Supports posterior part of vaginal wall against prolapse
  • Can be damaged during childbirth
    • Episiotomy avoids this
110
Q

List some consequences of damage to the pelvic floor

A
  • Stretching pudendal nerve = neuropraxia and muscle weakness
  • Muscle damage
  • Rupturing ligaments that support muscles
111
Q

List some risk factors for pelvic floor dysfunction

A
  • Age
  • Menopause
    • Atrophy of tissues after oestrogen withdrawal
  • Obesity
  • Chronic cough
  • Intrinsic connective tissue laxity
112
Q

Name the innervation and blood supply to the perineum

A
  • Pudendal nerve (S2-4)
  • Internal pudendal artery
113
Q

Describe the scrotum and its contents

A

A cutaneous sac developed from labioscrotal folds

  • Testis
  • Epididymis
  • First part of spermatic cord
114
Q

Describe the structure of the testis and examples of cells

A
  • Surrounded by tunica vaginalis
  • Enclosed by tunica albuginea
  • Organised into lobules by fibrous spetae
    • Contain seminiferous tubules
  • Suspended in scrotum by the spermatic cord
  • Seminiferous tubules converge into rete testis in mediastinum of testis
  • Cells:
    • Sertoli - in seminiferous tubules and produce sperm
    • Leydig - in interstitium and secrete testosterone
115
Q

Name the blood supply to the testis

A
  • Testicular arteries (from abdominal aorta)
    • Inferior to renal arteries
  • Venous drainage = pampiniform plexus then converge into testicular veins
    • right testicular vein into IVC
    • left testicular vein into left renal vein
116
Q

List the contents of the spermatic cord

A
  • 3 arteries:
    • Testicular
    • Cremasteric
    • Artery to vas deferens
  • Pampiniform plexus - draws heat away from testicular artery for ideal temperature in spermatogenesis
  • Nerves:
    • Genital branch of genitofemoral nerve
    • Sympathetic
    • Ilioinguinal
  • Lymphatics
  • Processus vaginalis
117
Q

Name the fascial coverings of the spermatic cord and where they arise from

A

Testis pick up anterolateral abdominal wall fascia as they descend into abdomen

  • External spermatic fascia from aponeurosis of external oblique
  • Cremestaric muscle and fascia from internal oblique
  • Internal spermatic fascia from transversalis fascia
118
Q

Describe the innervation to the scrotum and testis

A
  • Anterior = lumbar plexus
  • Posterior and inferior = sacral plexus
119
Q

Describe the lymphatic drainage to the testis and scrotum

A
  • Testis - paraaortic nodes
    • Due to embryological origin in abdomen
    • Important in malignancy spread
  • Scrotum - superficial inguinal
120
Q

What is the epididymis? Describe its function

A

Connects the seminiferous tubules to the vas deferens via efferent ductules and the rete testis. It has a head, body and tail.

  • Storage of sperm
  • Maturation of Sperm
    • Become motile
  • Transport of sperm
121
Q

What is the vas deferens? Describe its function

A

A straight muscular tube that connect the epididymis to the prostatic urethra.

  • Rapid transport of sperm into the urethra
    • Rapid contractions allowed by rich autonomic innervation to smooth muscle
  • Contained in spermatic cord through the inguinal canal
  • Dilates into ampulla and then opens into ejaculatory duct
122
Q

Name the important anatomical associations with the prostate gland

A
  • Apex = urethral sphincter and deep perineal muscles
  • Base = neck of bladder
  • Posterior = ampulla of rectum (DRE)
  • Inferiolateral = levator ani muscles
123
Q

Describe the structure of the prostate gland and the components of secretions

A
  • Surrounded by fibromuscular capsule
  • Branching septae divide it into compound alveolar glands
    • Where excretory ducts originate
  • Secretions contain prostaglandins, proteolytic enzymes and citric acid
    • Makes up 30% of ejaculate
124
Q

What is the bulbourethral gland? Describe its function

A
  • Located in urogenital diaphragm
  • Contains tubular and alveolar glands
  • Produce a watery secretion that lubricates the urethra
125
Q

Describe the structure of the penis

A
  • Root, body and glans
  • 2 corpora cavernosa dorsally = erectile tissue
  • 1 corpus spongisus ventrally = stops obstructions to urethra during an erection
126
Q

Describe the blood supply to the penis

A
  • Branches of internal pudendal artery
    • From internal iliac (anterior)
  • Drained by the deep dorsal vein of the penis
    • Into prostatic venous plexus
      • Into internal iliac veins
127
Q

Describe the muscles of the male perineum

A
  • Bulbospongiosus (continues from shaft)
    • Expels last drop of urine
    • Maintains erection
  • Ischiocavernosus (sides of shaft)
    • Maintains erection by compressing veins
128
Q

Describe some disorders of the scrotum

A
  • Hydrocoele = serous fluid in tunica vaginalis
  • Haematocoele = blood in tunica vaginalis
  • Varcicocoele = varicosities of pampiniform plexus
  • Spermatocoele = retention cyst within epididymis
  • Testicular torsion = twisting of spermatic cord which cuts off the blood supply and can cause necrosis
  • Inguinal hernias
  • Indirect hernias = reopening of processus vaginalis
129
Q

Describe some disorders of the prostate

A
  • Benign hyperplastic prostate
    • Occurs in central zone
    • Compresses urethra - presents early with dysuria, nocturia and urgency
  • Prostatic malignancies
    • Occurs in peripheral zone
    • Only presents with urinary symptoms later on
    • Metastatise via lymph (internal iliac) or venous (internal vertebral plexus) routes
  • PSA raised in prostate disorders
130
Q

List the phases of coitus

A
  • Excitment phase
  • Plateau phase - sustained period of arousal
  • Orgasmic phase
  • Resolution phase (+/- refractory period)
131
Q

List the main constituents of semen

A
  • 2-4 ml
  • 20-200 x 10^6 sperm per ml (2-5%)
  • Seminal vesicles - alkaline fluid that contains fructose, prostaglandins and clotting factors
  • Prostate - slightly acidic fluid containing proteolytic enzymes to breakdown clotting factors
  • Bulbourethral glands - small volume of alkaline fluid
    • Lubrication of urethra and end of penis
132
Q

Describe the physiological processes involved in emission

A

Emission = movement of ejaculate into prostatic urethra before ejaculation

  • Peristalsis of vas deferens
133
Q

Describe the physiological processes involved in erection of the penis

A
  • Psychogenic or tactile (sensory) stimuli
  • Stimulates somatic and autonomic efferents
    • Pelvic nerve (PNS)
    • Pudendal nerve (somatic)
  • Activation of parasympathetic NS and non-adrenergic, non-cholinergic nerves
    • Release NO
  • ​Central arteries of corpora cavernosa vasodilate
    • ​Inhibition of sympathetic vasoconstrictor nerves
  • Intracellular calcium in smooth muscle decreases
  • Contraction of ischiocavernosus to compress veins
134
Q

Describe the role of nitric oxide in erection of the penis

A
  • Post-ganglionic PNS fibres release Ach
  • Ach binds to M3 receptors on endothelial cells
  • Stimulates a rise in intracellular calcium and NOS
    • Formation of NO
  • NO diffuses into vascular smooth muscle to cause relaxtion and vasodilation
    • Forms cyclic GMP
    • Calcium taken into stores

NB: Can also be directly released from non-a, non-c, autonomic nerves

135
Q

Describe some causes of erectile dysfunction

A
  • Psychological
    • Descending inhibition of spinal reflexes
  • Fibrous tissue damage in corpora cavernosa
  • Vascular
  • Drugs (block NO)
    • Alcohol, anti-hypertensives, diabetes, anti-histamines
136
Q

How can erectile dysfunction be treated?

A

Viagra

  • Inhibits cGMP breakdown
  • Increased cGMP = increased cGMP protein kinase
  • More calcium taken into stores (less intracellular)
  • Increase in vasodilation
137
Q

Describe the physiological changes in the female which facilitate coitus

A
  • Swelling and engorgement of external genitalia
  • Glandular activity = increased mucus
    • Vaginal lubrication
  • Cervical mucus under oestrogen control
    • Clear, non-viscous mucus
  • Internal enlargement of the vagina
138
Q

Describe the mechanism of ejaculation

A

Under sympathetic control (L1-L2)

  1. Contractions of gland and ducts (smooth muscle)
  2. Contraction of internal urethral sphincter - prevent entry of semen into bladder
  3. Rhythmic striatal muscle contractions
  • Pelvic floor
  • Ischiocavernosus (pudendal S2-S4)
  • Bulbospongiosus (pudendal S2-S4)
  • Hip and anal muscles
139
Q

Describe the process involved in sperm transport through the cervix and uterus

A
  • Immediate coagulation to prevent loss from vagina
  • Re-liquefies 20 mins later by action of proteolytic enzymes from prostate
  • Travel 15-20 cm up uterus and into Fallopian tubes
    • Ciliated cells in uterine tract
    • Own propulsive capacity
140
Q

Describe the processes of capacitation of sperm

A

Capacitation = the maturation of sperm in the female reproductive tract

  • Cell membrane changes to allow oocyte fusion
    • Removal of glycoprotein coat
  • Tail movement changes from beating to whip-like
  • Sperm becomes responsive to signals from oocyte
  • Takes 6-8 hours
141
Q

Describe the acrosomal reaction

A
  • Sperm pushes through granulosa cells
  • Binds to ZP3 proteins on zona pellucida
  • Membranes fuse
  • Acrosome swells and liberates its contents by exocytosis
  • Hydrolysing enzymes digest path through zona pellucida
142
Q

Describe the mechanisms involved in fertilisation of the ovum

A
  1. Sperm penetrates cytoplasm and the nuclei fuse = zygote
  2. Cortical granules disintegrate to harden the zona pellucida against polyspermy
  3. Egg completes meiosis II = pronuclei
  4. Pronuclei fusion = diploid zygote
  5. Cleavage (mitotic divisions) = morula
  6. Further divisions = blastocyst
  7. Implantation in posterior uterine wall (6th day)
    1. Endometrium primed by progesterone
143
Q

Describe the causes and risks of ectopic pregnancy

A
  • Failure of transport of egg into uterine cavity
  • Implants in Fallopian tube, ovary or abdomen
  • Embryo dies due to lack of blood supply (6-8 weeks)
  • Growth puts pressure of vasculature and can cause maternal haemorrhage
144
Q

List the main types of contraception

A
  • Natural
  • Vasectomy
  • Barrier methods
  • Prevent ovulation
  • Sterilisation
  • Inhibit sperm passing through cervix
  • Inhibit implantation
145
Q

Describe natural contraception including any advantages or disadvantages

A
  • Abstinence
  • Coitus interruptus
    • Sperm could be in pre-ejaculate
  • Rhythm method = avoid intercourse during fertile phase (usually day 7-16 of cycle)
146
Q

Describe the the vasectomy and any advantages or disadvantages

A
  • Division of vas deferens bilaterally
  • Need semen analysis after to ensure success
147
Q

Describe barrier methods of contraception and any advantages or disadvantages

A
  • Condoms
    • Readily available
    • Also prevent STIs
  • Diaphragm = lies diagonally across cervix
    • Needs correct fitting
    • Holds sperm in acid environment of vagina to decrease survival time
  • Cap = fits across cervix
148
Q

Describe hormonal contraception to prevent ovulation and any advantages or disadvantages

A
  • Combined Oral Contraceptive Pill = oestrogen and progesterone
    • Negative feedback to hypothalamus/pituitary
    • Less LH/FSH = inhibition of follicular development
    • Loss of positive feedback midcycle from oestrogen = no LH surge
  • Depot progesterone = 3 monthly injections
    • Negative feedback inhibits ovulation (above)
  • Progesterone-Only Pill (low dose progesterone)
    • May inhbit ovulation
  • Progesterone implants (subcutaneous)
149
Q

Describe how sperm transport in the Fallopian tubes can be inhibited

A
  • Sterilisation
    • Clips/rings/ligation
    • Rarely recanalises
150
Q

Describe how sperm can be prevented from passing through cervix

A
  • POP/implant/COCP/depot progesterone
  • Produces thick, hostile and cervical mucus plug
151
Q

Describe how contraception can inhibit implantation

A
  • COCP/POP/other progesterones
    • Affects receptivity of endometrium
  • Post-coital contraception = high dose oestrogen and progesterone
    • up to 72 hours after intercourse
    • Disrupts ovulation, blocks implantation and impairs luteal function
  • Intra-uterine device (coil) = inert copper impregnanted with progesterone
    • Interferes with endometrial enzymes, sperm transport and implantation
152
Q

Describe why progesterone and oestrogen are used in contraception

A
  • Progesterone creates a thick and hostile cervical mucus plug to inhibit sperm transport
    • Negative feedback to hypothalamus to reduce GnRH pulses and inhibit follicular development
  • Oestrogen negatively feedbacks on anterior pituitary
    • Loss of positive feedback mid-cycle
    • No LH surge
153
Q

Define infertility

A

The failure to conceive within 1 year

  • Affects 15% of couples
  • Primary = no previous pregnancy
  • Secondary = previous pregnancy (successful or not)
154
Q

What are the ratios of male:female:unknown of causes of infertility

A

Male 20-25%

Female 45-60%

Unknown 20-30%

155
Q

List the main causes of infertility

A
  • Coital problems
  • Anovulation (15-20%)
  • Tubal occlusion
  • Abnormal sperm prodcution
156
Q

Describe the main causes of anovulation

A
  • Hypothalamus - hyperprolactinaemia, weight loss, exercise, stress, anorexia
  • Pituitary - tumour, nercrosis (sheehan’s syndrome)
  • Ovary - ovarian failure, menopause, radio/chemotherapy, PCOS
157
Q

Describe the main causes of tubal occlusion and how to diagnose and treat this

A
  • Sterilisation or scarring from infection/endometriosis
    • Diagnosed by laparascopy and dye insufflation or hypersalpingogram
    • Treated with reanastamosis or assisted contraception
158
Q

Describe some reasons for abnormal sperm production

A
  • Testicular disease (cancer - radiotherapy)
  • Obstruction of ducts - vasectomy, infection
  • Hypothalmic/pituiatary - tumours, hypergonadotropism
    • Can be treated
159
Q

What is PCOS and main signs and symptoms

A

Appearance of multiple small ovarian cysts (primordial follicles) which produce the pearl necklace presentation

  • Hyperandrogenism
    • Hirsutism, acne, menstrual disorders
  • Insulin resistance
  • Amenorrhoea
  • Raised LH/FSH ratio (feedback from hypothalamus)
160
Q

How is anovulation diagnosed? What are the hormone levels for each different type?

A

Serum progesterone level in mid-luteal phase (day 21)

  • Rise if ovulating
161
Q

How can ovulation be induced?

A
  • Anti-oestrogen (tamoxifen) = reduces negative feedback to hypothalamus/pituitary to increase GnRH and FSH
    • Increased FSH = follicular development
  • Administer synthetic FSH
  • GnRH agonists (pulsatile)
162
Q

How can infertility be investigated?

A
  • Do they have regular unprotected intercourse?
    • Investigate coitus problems
  • Normal ovulation? Day 21 progesterone
  • Tubes - sterlisation or infection?
  • Sperm count
163
Q

How can infertility be treated?

A
  • Induce ovulation
  • Surgery or IVF to overcome tubal occlusion
  • Sperm donor / intracytoplasmic sperm injection
164
Q

What are the normal values for semen analysis?

A

NB disputes in morpholgy > 4%

165
Q

Describe the process of implantation of the conceptus into the endometrium

A
  • Blastocyst arrives in uterine cavity at day 4-5
  • Trophoblast invades into endometrium to implant the conceptus within the stroma
  • Implantation is complete by day 10
    • Placental membrane becomes thinner
    • Also becomes haemomonochorial (1 layer of trophoblast separates maternal and foetal blood flow)
166
Q

What are the aims of implantation?

A
  • Establish basic unit of exchange
    • Primary, secondary and teriary villi
  • Anchor placenta and establish the cytotrophoblast shell
  • Establish maternal blood flow within the placenta
167
Q

Describe the histological changes in implantation

A
  • Decidualisation = the reaction that balances the invasive force of the trophoblast
    • Pre-decidual cells
    • Stimulated by progesterone
    • Otherwise haemorrhage occurs (ectopic pregnancy)
  • Spiral arteries remodel to meet foetal demand
    • Low resistance
    • High flow
168
Q

Describe some disorders of implantation

A
  • Ectopic pregnancy = implantation at a site other than the uterine body (perineal, ovaries, Fallopian tubes)
    • Haemorrhages and aborts
  • Placenta praevia = implantation in lower uterine segment
    • Can haemorrhage
    • Requires C section
  • Incomplete invasion can lead to pre-eclampsia and placental insufficiency
169
Q

Describe the structure of the placenta

A
  • Foetal portion - formed by chorion frondosum
    • Bordered by chorionic plate
  • Maternal portion - formed by decidua basalis
  • Intervillous spaces filled with maternal blood between chorionic and decidual plate
  • Decidua form decidual septa which divides the placenta into cotyledons
170
Q

Describe how the placenta develops over time

A
  • 1st trimester
    • Barrier still relatively thick
    • Complete cytotrophoblast layer beneath the syncytiotrophoblast layer
  • Term pregnancy
    • Barrier now thin
    • Surface area increases dramatically
    • Cytotrophoblast layer disappears (week 38)
171
Q

Describe the arrangement of fetal blood vessels within the placenta

A

Umbilical arteries and veins project into tertiary villi

  • 2 umbilical arteries carry deoxygenated blood from the foetus to the placenta
  • 1 umbilical vein carry oxygenated blood from the placenta to the foetus
  • Cotyledons receive blood from spiral arteries that pierce the decidua
    • Pressure in these arteries force oxygenated blood into the intervillous spaces
172
Q

Describe the factors influencing the passive diffusion of substances across the placenta

A
  • Concentration gradient
  • Barrier to diffusion
    • Barrier thins throughout pregnancy as foetal need increases
  • DIffusion distance
    • Haemomonochorial
173
Q

Identify the major substances which are actively transported across the placenta

A
  • Simple diffusion (down concentration gradient)
    • Water, electrolytes, urea, gases
    • Gases require adequate uteroplacental circulation
  • Faciliatated diffusion = glucose
  • Active transport (via specific transporters in syncytiotrophoblast)
    • Amino acids, iron, vitamins
  • Passive immunity (receptor mediated endocytosis)
    • IgG
174
Q

Describe some disorders that can arise from transport across the placenta

A

Teratogens can access the foetus via the placenta (not a true barrier)

  • Drugs - thalidomide, alcohol, therapeutic drugs
  • Maternal smoking
  • Antibody transport = haemolytic disease of the baby
    • Screening for Rh positive baby to prevent attack of baby’s RBC by mothers antibodies
  • Infectious agents - varicella zoster, cytomegalovirus, toxoplasma gondii, rubella
175
Q

Describe the role of the placenta as an endocrine organ supporting pregnancy

A
  • Steroid hormones = progesterone and oestrogen maintain pregnant state
    • Progesterone also increases appetite to lay down fat for later on in the pregnancy
  • Protein hormones
    • hCG by syncytiotrophoblasts during first 2 months to prevent regression of the corpus luteum
    • Human chorionic somatomammotrophin increases glucose availabilty to the foetus
176
Q

Describe the hormonal basis of testing for pregnancy

A
  • Human chorionic gonadotrophin
  • Secreted by syncytiotrophoblasts to support the secretory function of the corpus luteum
  • During first 2 months of pregnancy
  • Pregnancy specific (syncytiotrophoblast)
  • Excreted in maternal urine
177
Q

Describe the metabolic functions of the placenta

A

Synthesis of:

  • Glycogen
  • Cholesterol
  • Fatty acids
178
Q

Describe the hormonal regulation of pregnancy

A
  • hCG released from syncytiotrophoblasts mimic the action of LH on the corpus luteum to prevent regression
    • Also reduces maternal IgA, IgG and IgM to prevent rejection of the foetus
  • Corpus luteum secretes oestrogen and progesterone
    • Negative feedback suppresses further secretion of FSH and stops maturation of further follicles (along with inhibin)
    • Stimulates breast growth (with prolactin)
    • Progesterone relaxes smooth muscle
179
Q

Describe the metabolic changes during pregnancy

A
  • Progesterone increases appetite to lay down fat to meet metabolic needs to foetus as it grows
    • Diverts glucose into fat synthesis
  • Maternal responsiveness to insulin decreases
  • Increases release of insulin after a meal
    • Less uptake into cells so increased gluconeogenesis
    • Stimulated by human placental lactogen (hPL)
  • Increase in lipolysis to increases fatty acids
    • Risk of ketoacidosis
180
Q

Why can pregnant women suffer from gestational diabetes? If this is poorly controlled, what consequences can occur to the foetus?

A

Carbohydrate intolerance during pregnancy that does not persist after delivery

  • Increased resistance to insulin
  • Pancreas fails to respond to metabolic demands of pregnancy

Consequences of poor control:

  • Macrosomic foetus
  • Stillbirth
  • Increased risk of congenital defects
181
Q

Describe the cardiovascular changes during pregnancy

A
  • Increase in blood volume
  • Increase in cardiac output, stroke volume and heart rate to meet increasing demand of foetus
  • Progesterone causes vasodilation
    • Blood pressure decreases then returns to normal (T3)
  • Growing foetus presses on IVC = venous distension and engorgement
182
Q

What is pre-eclampsia?

A

Defect in placentation where blood vessels develop abnormally

  • Poor uteroplacental circulation
  • Vasoconstriction
  • Plasma-contracted
  • Proteinuria
  • Hypertension
183
Q

Describe the respiratory changes during pregnancy

A
  • Progesterone acts on respiratory centre to increase respiratory effort and reduce pCO2
    • Sensitises chemoreceptors to CO2 changes
  • Results in respiratory alkalosis which is compensated for by increasing renal bicarbonate excretion
  • Physiological hypreventilation → physiological dyspnoea
    • BUT resp rate, vital capacity and FEV1 unchanged
184
Q

Describe the urinary changes during pregnancy

A
  • Increased renal blood flow increases GFR
    • This increases stimulation of RAAS to compensate for sodium loss
  • Expanding foetus presses of bladder
  • Progesterone relaxes smooth muscles in ureters (hydroureter)
    • Risk of stasis and obstruction → UTI/pyelonephritis
  • Increased protein excretion
  • Decreased urea, bicarbonate and creatinine
185
Q

Describe the GI changes during pregnancy

A
  • Alterations in disposition of viscera (appendix → RUQ)
  • Progesterone relaxes smooth muscle
    • Delayed emptying of bowels
    • Stasis in biliary tract → Gall stones
    • Increased risk of pancreatitis
186
Q

Describe the haematological changes during pregnancy

A
  • Pro-thrombotic state
  • Increased fibrinogen and clotting factors
  • Decreased fibrinolysis
  • Increased risk of thromboembolic disease
    • Cannot use warfarin to treat as it is teratogenic
  • Physiological anaemia = mismatch between increased blood volume and haemocrit
187
Q

Describe changes to thyroid hormones during pregnancy

A
  • hCG stimulates the thyroid to secrete more T3 and T4
    • TSH decreased due to negative feedback
  • Thyroid binding globulin also increased
    • Free T4 in normal range (even though it also increases) due to binding
188
Q

Define the periods of embryology and important features

A
  • Pre-embryonic (1-2 weeks) = mitotic division and location of cells
  • Embryonic (2-8 weeks) = morphogenesis
  • Fetal = growth and physiological maturation
    • Preparation for independent life after birth
189
Q

Describe the pattern of increase of fetal size, weight and body proportion during pregnancy

A
  • Crown rump length increases rapidly in pre-embryonic, embryonic and early fetal periods
  • Weight gain increases rapidly during the mid and late fetal period
    • Protein gain during early fetal
    • Adipose gain during late fetal
  • Body proportion - body and lower limb growth develop after 9 weeks
190
Q

Describe the important events in the development of the respiratory system

A
  • Bronchopulmonary tree develops in the embryonic period
  • Functional specialism during fetal period
  1. Pseudoglandular stage (weeks 8-16) - duct system (bronchioles) form within bronchopulmonary tree
  2. Canalicular stage (weeks 16-26) - budding of bronchioles forms respiratory bronchioles
    1. Crosses threshold of viability
  3. Terminal sac stage (weeks 26+) - terminal sacs forms and Type I and II pneumocytes differentiate to produce surfactant
  4. Alveolar period (up to 8 years) - Formation of alveoli
191
Q

What is threshold of viability?

A

The time when the lungs have entered the terminal sac stage and are able to produce surfactant to sustain life

  • Above 24 weeks
  • If
  • Can be prevented with glucocorticoid treatment of mother to increase surfactant production
  • Also affected by maturity of brain - needs to control body functions such as breathing
192
Q

Describe the important events in the development of the nervous system

A
  • Corticospinal tracts develop in 4th month - coordinate voluntary muscle movements
  • Myelination of brain in 9th month
    • Still incomplete after birth
  • Movement begins in 8th week - ‘practicing’ for post-natal life (suckling, breathing)
  • Quickening = maternal awareness of fetal movements from week 17
  • Hearing (5 months) and taste mature before vision
193
Q

Describe the important events in the development of the cardiovascular system

A
  • Oxygenated blood from umbilical vein at placenta circulated around fetus
  • Definitive fetal heart rate achieved at 15 weeks
    • 120-160 bpm
194
Q

Describe the important events in the development of the urinary system

A
  • Fetal kidney (metanephros) function beings in week 10
    • Without function = oligohydramnios
  • Histological differentation of cortex and medulla by 8 months
  • Fetal urine contributes to amniotic fluid
195
Q

Describe some techniques used to estimate fetal age

A
  • Last Menstrual Period
    • Prone to inaccuracy (recollection, implantation)
  • Crown-rump length - between 7 and 12 weeks
  • Biparietal diameter = distance between parietal bones of skull
    • Measured in T2 to T3
  • Abdominal circumference
  • Femur length
  • Symphysis-fundal height
    • Depends on number of fetuses, amniotic fluid, position and location of fetus
196
Q

Describe the boundaries of baby weight and some causes of growth restriction

A
  • < 2500g
  • Premature
    • Constitutionally small
    • Nutritional deprivation
  • > 4500g suggests macrosomia
    • Maternal diabetes
  • Asymmetrical - abdominal growth lags due to oxygen or nutritional deficit
  • Symmetrical - Proportional growth restriction
197
Q

Name some techniques used to assess fetal wellbeing and development

A
  • Fetal movements (after 17 weeks)
  • Uterine expansion
    • Symphysis-fundal height
  • Ultrasound scan
    • 20 weeks
    • Assess growth, detect anomalies, calculate age
    • Detect location and number of fetuses
  • Non-stress tests (monitor heart rate)
  • Biophysical profiles
198
Q

Describe the effects on the fetus of poor nutrition during early and late pregnancy

A
  • Early = neural tube defects (DiGeorge Syndrome)
  • Late = Asymmetrical growth restriction
    • Oligohydramnios
199
Q

Describe the fetal circulation before birth

A
  • Oxygenated blood enters via umbilical vein at placenta
  • Bypasses the liver via ductus venosus into IVC
  • Passes from right atrium to left atrium via foramen ovale and crista dividens
    • SVC flow directly into right ventricle
  • Blood passes from the Pulmonary Trunk to the Aorta via the ductus arteriosus to avoid non-functioning and fluid-filled lungs
  • Deoxygenated blood returns to placenta via 2 umbilical arteries
200
Q

Describe the changes in fetal circulation after birth

A
  1. Expansion of lungs decreases resistance to blood flow through the lungs
  2. This increases return into left atrium and increases pressure to force the foramen ovale shut
  3. The increases in oxygen and decrease in prostaglandins stimulates the smooth muscle in wall of ductus arteriosus to constrict and shut
  4. Stasis and clotting of blood in umbilical vein and ductus venosus cause closure due to fibrosis
201
Q

Describe the processes involved in the control of amniotic fluid volume and composition

A
  • Offers mechanical protection and moist environment
  • Early pregnancy - dialysis of fetal and maternal extracellular compartments and some exchange across non-keratinised fetal skin
  • Late pregnancy - fetal urine
202
Q

How is volume of amniotic fluid assessed?

A

Ultrasound

  • Polyhydramnios can be caused by oesophageal/ duodenal atresia and CNS abnormalities
  • Oligohydramnios can be caused by poor renal function and pre-clampsia
203
Q

Describe the function of the fetal kidneys

A
  • Metanephros - produces fetal urine
    • 500ml at term
  • fetus swallows amniotic fluid
    • Absorbs water and electrolytes
    • Debris accumulates in gut = meconium
204
Q

Describe how bilirubin is dealt with in the fetus

A
  • Fetal liver cannot conjugate bilirubin
  • Crosses placenta and conjugated and excreted by the mother
  • Can persist after birth to causes jaundice
    • Liver stimulated by light?
205
Q

Describe oxygen transport in the fetus

A
  • Diffuses across placenta (haemomonochorial) from maternal blood
  • Maternal pO2 increases by hyperventilation to increase the partial pressure gradient
  • Fetus has different haemoglobin
    • No beta chains = different shape causes increased affinity (70% at 4kPa)
    • Does not readily bind to 2,3 DPG
  • Fetus has more haemoglobin (18-20g/dl-1)
  • So fetal blood contains similar levels of oxygen to adults (7.5 mmol of O2/l)
206
Q

Describe oxygen transfer across the placenta

A
  • Low diffusion resistance (thin barrier)
  • Large partial pressure gradient
  • High affinity to fetal haemoglobin
  • Double Bohr effect
  • Rate determined by umbilical arterial pO2
  • Fetal oxygen stores low
    • During labour, myometrium compresses blood vessels and compromises flow to fetus
207
Q

Describe carbon dioxide transfer in the fetus

A
  • Cannot tolerate high pCO2 as kidneys cannot neutralise acidic blood by excreting HCO3-
  • CO2 transfer possible due to lower maternal pCO2
    • Hyperventilation stimulated by progesterone
208
Q

Define labour and the different stages

A

Labour = expulsion of products of conception after 24 weeks

  1. Creation of brith canal
    • Latent phase = onset to 4cm cervical dilation
    • Active phase = more regular uterine contraction
  2. Expulsion of fetus
  3. Expulsion of placenta and contraction of uterus
209
Q

Describe the processes necessary to create a birth canal

A
  • Cervical ripening triggered by prostaglandins PGE2/F2x
    • Reduction in collagen
    • Increase in gylcosaminoglycans
    • Reduction in aggregation of collagen fibres
  • Generation of force by myometrium
    • Smooth muscle thickens during pregnancy
    • Contracts due to increases intracellular Ca2+ due to spontaneous action potentials
210
Q

Describe the role of prostaglandins in the control of contractions

A
  • Local hormones produced in endometrium
  • Production stimulated by high oestrogen : progesterone ratio
  • Increase the force of contractions by increasing the amount of Ca2+ per action potential
  • Also contributes to cervical ripening
211
Q

Describe the role of oxytocin in the control of contractions

A
  • Produced in the posterior pituitary in response to signals from the hypothalamus
  • Secretion increased by afferent impulses from stretch receptors in the cervix and vagina
  • Ferguson Reflex
  • Acts on smooth muscle receptors to decrease the threshold of action potentials, increasing the frequency
212
Q

What is the Ferguson Reflex?

A

The positive feedback mechanism where pressure on the cervix and vaginal walls releases oxytocin. This stimulates further contractions and increases pressure which releases more oxytocin etc

213
Q

What is brachystasis?

A

The uterus relaxes less than it contracts to shorten the fibres in the body of the uterus and drives the presenting part of the fetus into the cervix

214
Q

Describe what happens during the 2nd stage of labour

A
  • Urge to ‘bear down’ = abdominal muscles increaseintra abdominal pressure
  • Babies head flexes and rotates internally
  • Head stretches vagina and perineum
    • Risk of tearing
  • Head delivered - rotates and extends back again
215
Q

Describe what happens during the 3rd stage of labour

A
  • Uterus contracts hard after expulsion of fetus
  • Placenta is sheared off
  • The contraction of the uterus (interlacing muscle fibres) constrict blood vessles in the myometrium to prevent haemorrhage
    • This can be enhanced by giving an oxytocic drug
216
Q

Describe the normal presentation of a fetus during birth

A
  • Lie = relationship to long axis of uterus
    • Normally longitudinal and flexed
    • Can be transverse
  • Presentation = which part is adjacent to pelvic inlet
    • Normally cephalic
    • Can be podalic (breach position)
  • Position = orientation of presenting part
    • Vertex to pelvic inlet at minimum diameter (
217
Q

Describe the 3 reasons as to why labour may not progress properly

A
  1. Power - assessment of uterine contractions in terms of frequency, amplitude and duration
  2. Passage
    • Pelvic inlet - 10.5cm
    • Pelvic cavity - 12cm
    • Pelvic outlet - 11cm
    • Or insufficient cervical ripening
  3. Passenger
    • Size/number of fetuses
    • Presentation/position
218
Q

Describe the principles of inducing labour

A

Administering prostaglandins or oxytocin will begin cervical ripening and uterine contractions

219
Q

Describe how the physiological state of the fetus can be monitored during labour

A

Fetal heart rate assessed using a fetal scalp electrode

220
Q

Describe some interventions in childbirth

A
  • Caesarian section
    • Suprapubic incision
  • Forceps delivery
  • Vacuum extraction
221
Q

Describe the components of the breast

A

Mammary glands consist of:

  • 15-20 lobulated masses of tissue
  • Fibrous and adipose tissue inbetween
  • Lobe:
    • lobule
    • alveoli - produce milk
    • blood vessels
    • lactiferous ducts - drain into lactiferous sinus
  • Myoepithelial cells for let down
222
Q

Describe the function and components of colostrum

A
  • 40 ml produced per day soon after birth
  • Contains less water, fat and sugar than maturemilk
  • Contains more proteins
    • Immunoglobulins to provide passive immunity
    • Absorbed whole by ‘open’ gut of the baby
      *
223
Q

Describe the function and components of mature milk

A
  • 2 weeks after birth
  • Stimulated by suckling (prolactin secretion)
  • Provides nutrition to the baby
    • 90% water
    • 7% sugar
    • 2% fats
    • Proteins
    • Minerals and vitamins (calcium)
224
Q

Describe the synthesis of mature milk in the alveolar cells and how this is stimulated

A
  • Fat produced in smooth endoplasmic reticulum
  • Protein secrete via Golgi Apparatus

Stimulated by prolactin, which increases due to a fall in steroid hormones after birth

225
Q

Describe the stimulation of prolactin secretion

A
  • Fall in oestrogen and progesterone allow the breast to become responsive to prolactin
  • Suckling triggers a neuroendocrine reflex in the hypothalamus
  • Decreases secretion of dopamine
  • Which promotes secretion of prolactin from the anterior pituitary
  • This stimulates the production of milk for the next feed
    • Accumulates in alveoli and ducts
226
Q

Describe the hormonal control of growth of the mammary tissue in the breast

A
  • At puberty - oestrogen causes the ducts to sprout and branch and alveoli to develop
  • During pregnancy - the increase in progesterone:oestrogen ratio stimulate growth of the alveoli but NOT secretion of milk
    • Hypertrophy of the ductular-lobular-alveolar system
227
Q

Describe the hormonal control of milk let down

A
  • Suckling also stimulates secretion of oxytocin from the posterior pituitary
  • This contracts the myoepithelial cells surrounding the alveoli
  • Ejects milk out of breast
228
Q

Describe the mechanisms which produce cessation of lactation

A
  • If suckling stops, prolactin will stop being secreted by the pituitary
  • This stops production of milk due to low prolactin and turgor-induced damage to the breast
229
Q

Describe the range of breast conditions

A
  • Disorders of development (polythelia)
  • Inflammatory conditions
    • Acute mastitis
    • Fat necrosis
  • Benign epithelial lesions
    • Fibrocystic change
    • Epithelial hyperplasia
  • Stromal tumours
  • Breast carcinoma
230
Q

Describe some physiological breast changes

A
  • Puberty - increase in number of lobules and stroma during puberty
  • Ovulation - cell proliferation and stromal oedema
  • Pregnancy - increase in size and number of lobules but decrease in stroma
  • Increasing age - decrease in terminal duct lobular units and replacement of stroma with adipose tissue
231
Q

Describe the clinical presentation of breast conditions

A
  • Pain
    • Non-cylical and focal = ruptured cysts, inflammation
  • Palpable mass = invasive carcinoma, fibroadenoma, cysts
    • Hard, craggy and fixed = carcinoma
  • Nipple discharge
    • Milky = endocrine disorder (pituitary, drugs)
    • Bloody or serous = benign lesions (papilloma)
  • Skin changes
  • Mammographic abnormalities
232
Q

Describe the mammogram and what it is used for

A

Breast screening programme for women aged 47-73 years

  • Densities = invasive carcinoma, fibroadenoma, cysts
  • Calcifications = ductal carcinoma in situ, benign changes
233
Q

Describe the incidence of different breast conditions in relation to age

A
  • Fibroadenomas often < 30 years
  • Phyllodes tumour most present in 50s
  • Breast cancer usually > 50 years except some familial cases
234
Q

Describe how breast lesions are investigated and diagnosed

A

Triple approach:

  • Clinical - history, family history, examination
  • Radiographic imaging - mammogram, ultrasound
  • Pathology - fine needle aspiration cytology, biopsy
235
Q

Describe the features and significance of acute mastitis

A
  • Almost always during lactation
  • Staph aureus
  • Presents with painful, erythematous breast and pyrexia
  • Treated by expressing milk and antibiotics
236
Q

What is duct ectasia?

A

Dilation and inflammation of the lactiferous ducts

  • Usually during 50s or 60s
  • Can mimic carcinoma
237
Q

Describe the features of fat necrosis

A
  • Presents as a mass, skin change or mammographic abnormality
  • Usually due to trauma or surgery
  • Can mimic carcinoma
238
Q

Describe the features of fibrocystic change

A
  • Benign epithelial lesions
  • Presents as a mass or mammographic abnormality
  • Histological findings:
    • Cyst formation
    • Fibrosis
    • Apocrine metaplasia
239
Q

Describe the features and common causes of gynaecomastia

A
  • Enlargement of the male breast (usually seen at puberty or in the elderly)
  • Caused by relative decrease in androgen effect or increase in oestrogen effect
    • Klinefelters Syndrome (XXY)
    • Liver cirrhosis (oestrogen not metabolised properly)
    • Gonadotrophin excess (germ cell tumours)
    • Drugs (alcohol, steroids, spironolactone)
240
Q

Describe the main features of fibroadenoma

A
  • Stromal tumour
  • Mobile and elusive mass (breast mouse)
  • Mixture of stromal and epithelial elements
  • Well circumscribed, rubbery and grey/white
  • Local hyperplasia rather than true neoplasm
241
Q

Describe the main features of Phyllodes tumour including management

A
  • Stromal tumour
  • Mainly benign mass
  • Nodules of proliferating stroma covered by epithelium
    • Leaf histology
  • Needs to be excised with wide margin or may recur
242
Q

List some risk factors of breast cancer

A
  • Age
  • Gender
  • Uninterrupted menses
  • Early menarche and late menopause
  • Obesity/high fat diet - hyperoestrogenic
  • Radiation
  • Previous breast cancer
  • Exogenous oestrogen - HRT, OCP
  • Familial - BRCA1/2 or p53 genes
243
Q

How is breast cancer classified?

A
  • In situ or invasive
  • Ductal or lobular
244
Q

Describe the histological findings from an in situ carcinoma

A
  • Neoplastic cells limited to lobules and ducts by the basement membrane
  • Myoepithelial cells are preserved
  • Cannot spread into blood vessels so doesn’t metastasise
  • Can extend to nipple skin without crossing basement membrane = Paget’s disease
245
Q

Describe the presentation and histological findings of DCIS

A

Ductal Carcinoma In Situ

  • Presents as a mass or mammographic calcifications
  • Spreads through ducts and lobules only
  • Central necrosis with calcification
  • Can progress to invasive carcinoma
246
Q

Describe the presentation, histological findings and examples of invasive carcinoma

A
  • Neoplastic cells have invaded through the basement membrane into stroma
  • Invades into vessels and metastasises
  • Presents as a mass or mammographic abnormality

Types:

  • Invasive ductal
  • Invasive lobular - infiltrating cells in a single file
    • cells lack cohesion
247
Q

Describe the patterns of metastasis in breast carcinomas

A
  • Lymph nodes (ipsilateral axilla) via lymphatics
  • Bones, lung, liver and brain via blood vessels
  • Peritoneum, leptomeninges and GI tract in invasive lobular
248
Q

Name some factors determining the prognosis of breast carcinoma

A
  • In situ or invasive
  • Grade (differentiation)
  • Staging (TNM)
  • Gene expression profile
    • Oestrogen receptor
    • HER2
249
Q

Describe some therapeutic approaches to managing breast carcinoma

A
  • Surgery - mastectomy/breast conserving surgery
  • Sentinel node biopsy
    • Determination of axillary dissection
  • Chemotherapy
  • Hormonal treatment (Tamoxifen for oestrogen receptor +ve)
  • Herceptin (if Her2 +ve)
250
Q

Describe the pathological features, potential aetiology, presentation, spread and treatment of tumours of the vulva

A
  • Mainly squamous cell carcinoma
  • Causes = HPV (young) chronic irritation (post-menopausal) lichen sclerosis
  • Presents with Vulval Intraepithelial Neoplasia (VIN) by patient or through examination
  • Spreads to inguinal lymph nodes, lungs and liver
  • Treated with vulvectomy and lymphadenectomy
251
Q

Describe the principles of screening for cervical carcinoma

A

Pap test detects precursor lesions (enlarged nuclei and abnormal chromatin) by using a Papnicolau stain and examining microscopically

  • Age 25 until 50-65
  • If abnormal, referred for colposcopy or biopsy
252
Q

Describe the histological features of carcinoma of the cervix

A
  • Mainly squamous cell carcinoma
  • Arise from Cervical Intraepithelial Neoplasia (CIN) = dysplasia of squamous cells within the cervical epithelium (transofrmation zone) due to HPVs
  • Micro invasive - treat with cervical cone excision
  • Invasive - hysterectomy, lymph node dissection, radiation, chemotherapy
253
Q

List some risk factors for cervical carcinoma

A

Caused by HPVs (mainly 16 and 18)

  • Sexual intercourse
  • Early 1st pregnancy
  • Multiple partners
  • Promiscuity
  • OCP
  • Smoking low SES
254
Q

Describe the factors which influence prognosis in carcinoma of the cervix

A
  • Depth of invasion
  • Size of tumour
  • Degree of metastases - iliac and aortic lymph nodes etc
255
Q

Describe the pathological features, presentation and prognosis of endometrial adenocarcinoma

A

Presents with post-menopausal vaginal bleeding

  1. Endometrioid - arises from endometrial hyperplasia
    • Mimics proliferative glands
    • Mainly due to excess oestrogen and obesity
  2. Serous
    • Poorly differentiated, aggressive
    • Worse prognosis
    • Exfoliates to Fallopian tubes and peritoneum via papilla
256
Q

Describe the pathological features, presentation and prognosis of tumours of the myometrium

A
  • Leiomyoma = benign tumours of uterine smooth muscle
  • Presents with heavy/painful periods, urinary frequency, pain and infertility
  • Ranges from tiny to filling the pelvis
  • Very rarely progresses to leiomyosarcoma - good prognosis
257
Q

Name the classification of ovarian tumours

A
  1. Epithelial Tumours
    • Serous
    • Mucinous
    • Endometrioid
  2. Germ Cell Tumours (teratomas)
    • Mature (benign)
    • Immature (malignant)
    • Monodermal (specialised)
  3. Sex Cord-Stromal Tumour
    • Granulosa Cell
    • Sertoli-Leydig Cell
  4. Metastases (Mullerian, GI, breast)
258
Q

Describe the risk factors and prognosis of ovarian carcinoma

A
  • Nulliparity, BRCA gene mutation, smoking, endometriosis
  • Poor prognosis due to late presentation and high chance of malignant spread
259
Q

Describe the key features of gestational tumours

A
  • Proliferation of placental tissue
  • Raised hCG
  1. Hydratidiform mole = cystic swelling of chorionic villi
  2. Invasive mole = penetrates and perforates uterine wall
    • Locally destructive
  3. Gestational choriocarcinoma = malignancy of trophoblastic cells derived from pregnancy
    • Rapidly invasive
    • Metastasises widely

ESA 4 (3 decks)

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