Repro

Question 1

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

Answer 1

Question 2

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

Answer 2

• 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

Question 3

Describe the process of spermatogenesis

Answer 3

• 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

Question 4

Describe the maturation and release of spermatozoa

Answer 4

• 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

Question 5

Distinguish between the spermatogenic cycle and spermatogenic wave

Answer 5

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

Question 6

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

Answer 6

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

Question 7

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

Answer 7

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

Question 8

Describe the microscopic structure of the ovary

Answer 8

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

Question 9

Describe the production of oocytes

Answer 9

• 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

Question 10

List the stages of follicular development

Answer 10

1. Pre-antral
2. Antral
3. Pre-ovulatory

Question 11

Describe the pre-antral stageof follicular development

Answer 11

• 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

Question 12

Describe the antral stage of follicular development

Answer 12

• 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

Question 13

Describe the pre-ovulatory stage of follicular development

Answer 13

• 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

Question 14

Describe the formation of the corpus luteum

Answer 14

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

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

Question 15

Describe the stages of the menstrual cycle

Answer 15

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

Question 16

Describe the origin of germ cells

Answer 16

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

Question 17

Describe the formation of the ductal system

Answer 17

• 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

Question 18

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

Answer 18

• 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

Question 19

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

Answer 19

• 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

Question 20

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

Answer 20

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

Question 21

Describe the development of the external male genitalia

Answer 21

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

Question 22

Describe the development of the external female genitalia

Answer 22

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

Question 23

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

Answer 23

Question 24

Describe the control of secretion in the hypothalamus

Answer 24

• 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

Question 25

Describe the control of secretion of gonadotrophs

Answer 25

* 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

Question 26

Describe the action of gonadotrophs in the testes

Answer 26

* 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

Question 27

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

Answer 27

* 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

Question 28

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

Answer 28

* 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

Question 29

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

Answer 29

* 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

Question 30

List the action of testosterone

Answer 30

* 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

Question 31

List the action of oestrogen

Answer 31

* 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

Question 32

List the action of progesterone on oestrogen-primed cells

Answer 32

* Further thickening of endometrium * Thickening and acidification of cervical mucus * Thickening but reduced motility of myometrium * Increased body temperature

Question 33

List the phases of the menstrual cycle

Answer 33

* 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

Question 34

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

Answer 34

* Stimulation and muscular contraction of Fallopian tubes * Growth and motiity and myometrium * Thickening of endometrium * Production and thin and alkaline cervical mucus

Question 35

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

Answer 35

* 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

Question 36

What happens to hormone secretion if conception has occurred?

Answer 36

* 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

Question 37

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

Answer 37

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

Question 38

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

Answer 38

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

Question 39

Discuss the hormonal control of puberty

Answer 39

* 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)

Question 40

Describe some causes of precocious puberty

Answer 40

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

Question 41

Describe the hormonal changes that lead to menopause

Answer 41

* 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

Question 42

List some effects of menopause

Answer 42

* 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

Question 43

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

Answer 43

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

Question 44

Describe the different types of amenorrhea

Answer 44

* 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

Question 45

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

Answer 45

* 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

Question 46

List some hypothalmic/pituitary causes of amenorrhea

Answer 46

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

Question 47

List some gonadal causes of amenorrhea

Answer 47

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

Question 48

How is secondary amenorrhea assessed?

Answer 48

* Menstrual history * Medical history * Pregnancy * Surgery * Medication * Chronic diseases * Lifestyle - weight loss/stress/diet * Family history - thyroid/diabetes/cancer

Question 49

List some outflow causes of amenorrhea

Answer 49

Primary: * Uterine = Mullerian agenesis * Vaginal = Vaginal atresia/ cryptomenorrhea/imperforate hymen Secondary: * Intrauterine adhesions (Asherman's syndrome)

Question 50

How is amenorrhea managed?

Answer 50

* Treat underlying cause * Lifestyle changes * If outflow problem = surgery * If hormonal problem = hormone replacement therapy

Question 51

What is DUB and how is it assessed and treated?

Answer 51

* 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

Question 52

What is menorrhagia and how is it treated?

Answer 52

* 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

Question 53

Define oligomenorrhea

Answer 53

Uterine bleeding occurring at intervals between 35 days and 6 months

Question 54

Define dysmenorrhea

Answer 54

Painful menstruation

Question 55

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

Answer 55

* Young people * Certain ethnicities * Low SES * Higher number of sexual partners * Sexual orientation * Unsafe sexual activity

Question 56

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

Answer 56

Question 57

Describe recent trends in the incidence of sexually transmitted infections

Answer 57

Gradual and sustained increase in number of diagnosed STIs * Increased transmission * Increased GUM clinic attendance * Greater awareness * Improved diagnostic methods

Question 58

Describe the clinical presentation, diagnosis and management of chlamydial infections

Answer 58

* 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)

Question 59

Describe the clinical presentation, diagnosis and management of gonorrhoea

Answer 59

* 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

Question 60

Describe the clinical presentation, diagnosis and management of genital herpes

Answer 60

* 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

Question 61

Describe the clinical presentation, diagnosis and management of genital warts

Answer 61

* 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

Question 62

Describe the organism, detection, presentation and treatment for syphillis

Answer 62

* 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

Question 63

Describe some causes of vaginal discharge

Answer 63

* 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

Question 64

What is Pelvic Inflammatory Disease?

Answer 64

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

Question 65

List some risk factors for Pelvic Inflammatory Disease

Answer 65

* Sexual behaviour * 1st week fo Intrauterine Contraceptive Device * Alcohol/drug use * Smoking

Question 66

What are the clinical features of Pelvic Inflammatory Disease?

Answer 66

* Pyrexia (\>38°C) * Pain * Bilateral lower abdominal * Dyspareunia * Adnexal tenderness * Abnormal vaginal/cervical discharge * Abnormal vaginal bleeding

Question 67

Describe the investigations for Pelvic Inflammatory Disease

Answer 67

* Pregnancy test * Triple Swabs * High vaginal - bacterial vaginosis * Endocervical - chlamydia or gonorrhoea * Urethral - chlamydia in males * MSU * CRP

Question 68

Describe the management of Pelvic Inflammatory Disease

Answer 68

* 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

Question 69

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

Answer 69

* Ectopic pregnancy * Infertility * Chronic pelvic pain * Fitz Hugh Curtis syndrome = RUQ pain and perihepatitis

Question 70

Describe the arterial supply to the female reproductive tract

Answer 70

* 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

Question 71

Describe the venous drainage of the female reproductive system

Answer 71

* 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

Question 72

Describe the innervation of the female reproductive system

Answer 72

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

Question 73

Describe the lymphatic drainage of the female reproductive system

Answer 73

* Ovary = para-aortic nodes * Fundus of uterus = aortic nodes * Body = external iliac nodes * Cervix = external + internal iliac nodes + sacral nodes

Question 74

Briefly describe how the gonads develop

Answer 74

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

Question 75

Describe the position of the uterus

Answer 75

* Anteverted with respect to the vagina * Anteflexed with respect to the cervix

Question 76

Describe the main ligaments of the female reproductive tract

Answer 76

* 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

Question 77

Describe what happens to the uterus during the secretory phase

Answer 77

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

Question 78

Describe what happens to the uterus during the menstrual phase

Answer 78

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

Question 79

Describe some clinical problems of the ovary

Answer 79

* Poycystic ovaries (\> 10 cysts) can lead to infertility * Tumours * Epithelial * Germ cell (teratoma)

Question 80

Describe some clinical problems of the uterus

Answer 80

* 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

Question 81

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

Answer 81

* 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

Question 82

Describe some clinical problems of the vagina

Answer 82

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

Question 83

Describe some properties of a 'good' gynecoid pelvis

Answer 83

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

Question 84

Describe some clinical assessments of the pelvis

Answer 84

* 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

Question 85

Name 2 ligaments of the pelvis

Answer 85

* Sacrospinous * Divides into greater and lesser sciatic foramen * Sacrotuberous

Question 86

Identify the major cell types in the testis

Answer 86

* 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

Question 87

Describe the main histological features of the epidydimis

Answer 87

* 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)

Question 88

Describe the main histological features of the vas deferens

Answer 88

* 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

Question 89

Describe the main histological features of the seminal vesicle

Answer 89

* 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

Question 90

Describe the main histological features of the prostate

Answer 90

* 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

Question 91

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

Answer 91

* 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

Question 92

Describe the main histological features of the ovaries

Answer 92

* 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

Question 93

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

Answer 93

* 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

Question 94

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

Answer 94

* 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

Question 95

Recognise the histological changes that occur prior to and during ovulation

Answer 95

* 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

Question 96

Describe the main histological features of the Fallopian tubes

Answer 96

* 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

Question 97

Describe the main histological features of the uterus

Answer 97

* 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

Question 98

Describe the main histological features of the cervix

Answer 98

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

Question 99

Describe the main histological features of the vagina

Answer 99

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

Question 100

Describe the main histological features of the breast

Answer 100

* 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

Question 101

Describe the histological changes occurring during menstrual cycle

Answer 101

* 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

Question 102

Describe the structure of the pelvic floor

Answer 102

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

Question 103

Describe the function of the pelvic floor

Answer 103

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

Question 104

Name the muscles that levator ani comprises of and innervation

Answer 104

* 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)

Question 105

Describe the coccygeus muscle and innervatio

Answer 105

* Runs posteriorly from ischial spine to coccyx along sacrospinous ligament * Supplied by anterior rami of S4-5

Question 106

Describe the layers of the urogenital perineum

Answer 106

* 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

Question 107

Describe the contents of the urogenital perineum

Answer 107

* 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

Question 108

Describe the contents of the anal perineum

Answer 108

* 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

Question 109

What is the perineal body and its function?

Answer 109

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

Question 110

List some consequences of damage to the pelvic floor

Answer 110

* Stretching pudendal nerve = neuropraxia and muscle weakness * Muscle damage * Rupturing ligaments that support muscles

Question 111

List some risk factors for pelvic floor dysfunction

Answer 111

* Age * Menopause * Atrophy of tissues after oestrogen withdrawal * Obesity * Chronic cough * Intrinsic connective tissue laxity

Question 112

Name the innervation and blood supply to the perineum

Answer 112

* Pudendal nerve (S2-4) * Internal pudendal artery

Question 113

Describe the scrotum and its contents

Answer 113

A cutaneous sac developed from labioscrotal folds * Testis * Epididymis * First part of spermatic cord

Question 114

Describe the structure of the testis and examples of cells

Answer 114

* 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

Question 115

Name the blood supply to the testis

Answer 115

* 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

Question 116

List the contents of the spermatic cord

Answer 116

* 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

Question 117

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

Answer 117

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

Question 118

Describe the innervation to the scrotum and testis

Answer 118

* Anterior = lumbar plexus * Posterior and inferior = sacral plexus

Question 119

Describe the lymphatic drainage to the testis and scrotum

Answer 119

* Testis - paraaortic nodes * Due to embryological origin in abdomen * Important in malignancy spread * Scrotum - superficial inguinal

Question 120

What is the epididymis? Describe its function

Answer 120

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

Question 121

What is the vas deferens? Describe its function

Answer 121

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

Question 122

Name the important anatomical associations with the prostate gland

Answer 122

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

Question 123

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

Answer 123

* 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

Question 124

What is the bulbourethral gland? Describe its function

Answer 124

* Located in urogenital diaphragm * Contains tubular and alveolar glands * Produce a watery secretion that lubricates the urethra

Question 125

Describe the structure of the penis

Answer 125

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

Question 126

Describe the blood supply to the penis

Answer 126

* 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

Question 127

Describe the muscles of the male perineum

Answer 127

* Bulbospongiosus (continues from shaft) * Expels last drop of urine * Maintains erection * Ischiocavernosus (sides of shaft) * Maintains erection by compressing veins

Question 128

Describe some disorders of the scrotum

Answer 128

* 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

Question 129

Describe some disorders of the prostate

Answer 129

* 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

Question 130

List the phases of coitus

Answer 130

* Excitment phase * Plateau phase - sustained period of arousal * Orgasmic phase * Resolution phase (+/- refractory period)

Question 131

List the main constituents of semen

Answer 131

* 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

Question 132

Describe the physiological processes involved in emission

Answer 132

Emission = movement of ejaculate into prostatic urethra before ejaculation * Peristalsis of vas deferens

Question 133

Describe the physiological processes involved in erection of the penis

Answer 133

* 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

Question 134

Describe the role of nitric oxide in erection of the penis

Answer 134

* 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

Question 135

Describe some causes of erectile dysfunction

Answer 135

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

Question 136

How can erectile dysfunction be treated?

Answer 136

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

Question 137

Describe the physiological changes in the female which facilitate coitus

Answer 137

* 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

Question 138

Describe the mechanism of ejaculation

Answer 138

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

Question 139

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

Answer 139

* 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

Question 140

Describe the processes of capacitation of sperm

Answer 140

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

Question 141

Describe the acrosomal reaction

Answer 141

* 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

Question 142

Describe the mechanisms involved in fertilisation of the ovum

Answer 142

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

Question 143

Describe the causes and risks of ectopic pregnancy

Answer 143

* 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

Question 144

List the main types of contraception

Answer 144

* Natural * Vasectomy * Barrier methods * Prevent ovulation * Sterilisation * Inhibit sperm passing through cervix * Inhibit implantation

Question 145

Describe natural contraception including any advantages or disadvantages

Answer 145

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

Question 146

Describe the the vasectomy and any advantages or disadvantages

Answer 146

* Division of vas deferens bilaterally * Need semen analysis after to ensure success

Question 147

Describe barrier methods of contraception and any advantages or disadvantages

Answer 147

* 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

Question 148

Describe hormonal contraception to prevent ovulation and any advantages or disadvantages

Answer 148

* 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)

Question 149

Describe how sperm transport in the Fallopian tubes can be inhibited

Answer 149

* Sterilisation * Clips/rings/ligation * Rarely recanalises

Question 150

Describe how sperm can be prevented from passing through cervix

Answer 150

* POP/implant/COCP/depot progesterone * Produces thick, hostile and cervical mucus plug

Question 151

Describe how contraception can inhibit implantation

Answer 151

* 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

Question 152

Describe why progesterone and oestrogen are used in contraception

Answer 152

* 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

Question 153

Define infertility

Answer 153

The failure to conceive within 1 year * Affects 15% of couples * Primary = no previous pregnancy * Secondary = previous pregnancy (successful or not)

Question 154

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

Answer 154

Male 20-25% Female 45-60% Unknown 20-30%

Question 155

List the main causes of infertility

Answer 155

* Coital problems * Anovulation (15-20%) * Tubal occlusion * Abnormal sperm prodcution

Question 156

Describe the main causes of anovulation

Answer 156

* Hypothalamus - hyperprolactinaemia, weight loss, exercise, stress, anorexia * Pituitary - tumour, nercrosis (sheehan's syndrome) * Ovary - ovarian failure, menopause, radio/chemotherapy, PCOS

Question 157

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

Answer 157

* Sterilisation or scarring from infection/endometriosis * Diagnosed by laparascopy and dye insufflation or hypersalpingogram * Treated with reanastamosis or assisted contraception

Question 158

Describe some reasons for abnormal sperm production

Answer 158

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

Question 159

What is PCOS and main signs and symptoms

Answer 159

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)

Question 160

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

Answer 160

Serum progesterone level in mid-luteal phase (day 21) * Rise if ovulating

Question 161

How can ovulation be induced?

Answer 161

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

Question 162

How can infertility be investigated?

Answer 162

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

Question 163

How can infertility be treated?

Answer 163

* Induce ovulation * Surgery or IVF to overcome tubal occlusion * Sperm donor / intracytoplasmic sperm injection

Question 164

What are the normal values for semen analysis?

Answer 164

NB disputes in morpholgy \> 4%

Question 165

Describe the process of implantation of the conceptus into the endometrium

Answer 165

* 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)

Question 166

What are the aims of implantation?

Answer 166

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

Question 167

Describe the histological changes in implantation

Answer 167

* 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

Question 168

Describe some disorders of implantation

Answer 168

* 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

Question 169

Describe the structure of the placenta

Answer 169

* 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

Question 170

Describe how the placenta develops over time

Answer 170

* 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)

Question 171

Describe the arrangement of fetal blood vessels within the placenta

Answer 171

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

Question 172

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

Answer 172

* Concentration gradient * Barrier to diffusion * Barrier thins throughout pregnancy as foetal need increases * DIffusion distance * Haemomonochorial

Question 173

Identify the major substances which are actively transported across the placenta

Answer 173

* 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

Question 174

Describe some disorders that can arise from transport across the placenta

Answer 174

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

Question 175

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

Answer 175

* 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

Question 176

Describe the hormonal basis of testing for pregnancy

Answer 176

* 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

Question 177

Describe the metabolic functions of the placenta

Answer 177

Synthesis of: * Glycogen * Cholesterol * Fatty acids

Question 178

Describe the hormonal regulation of pregnancy

Answer 178

* 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

Question 179

Describe the metabolic changes during pregnancy

Answer 179

* 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

Question 180

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

Answer 180

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

Question 181

Describe the cardiovascular changes during pregnancy

Answer 181

* 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

Question 182

What is pre-eclampsia?

Answer 182

Defect in placentation where blood vessels develop abnormally * Poor uteroplacental circulation * Vasoconstriction * Plasma-contracted * Proteinuria * Hypertension

Question 183

Describe the respiratory changes during pregnancy

Answer 183

* 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

Question 184

Describe the urinary changes during pregnancy

Answer 184

* 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

Question 185

Describe the GI changes during pregnancy

Answer 185

* 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

Question 186

Describe the haematological changes during pregnancy

Answer 186

* 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

Question 187

Describe changes to thyroid hormones during pregnancy

Answer 187

* 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

Question 188

Define the periods of embryology and important features

Answer 188

* 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

Question 189

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

Answer 189

* 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

Question 190

Describe the important events in the development of the respiratory system

Answer 190

* 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

Question 191

What is threshold of viability?

Answer 191

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

Question 192

Describe the important events in the development of the nervous system

Answer 192

* 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

Question 193

Describe the important events in the development of the cardiovascular system

Answer 193

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

Question 194

Describe the important events in the development of the urinary system

Answer 194

* 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

Question 195

Describe some techniques used to estimate fetal age

Answer 195

* 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

Question 196

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

Answer 196

* \< 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

Question 197

Name some techniques used to assess fetal wellbeing and development

Answer 197

* 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

Question 198

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

Answer 198

* Early = neural tube defects (DiGeorge Syndrome) * Late = Asymmetrical growth restriction * Oligohydramnios

Question 199

Describe the fetal circulation before birth

Answer 199

* 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

Question 200

Describe the changes in fetal circulation after birth

Answer 200

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

Question 201

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

Answer 201

* 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

Question 202

How is volume of amniotic fluid assessed?

Answer 202

Ultrasound * Polyhydramnios can be caused by oesophageal/ duodenal atresia and CNS abnormalities * Oligohydramnios can be caused by poor renal function and pre-clampsia

Question 203

Describe the function of the fetal kidneys

Answer 203

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

Question 204

Describe how bilirubin is dealt with in the fetus

Answer 204

* 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?

Question 205

Describe oxygen transport in the fetus

Answer 205

* 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)

Question 206

Describe oxygen transfer across the placenta

Answer 206

* 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

Question 207

Describe carbon dioxide transfer in the fetus

Answer 207

* 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

Question 208

Define labour and the different stages

Answer 208

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

Question 209

Describe the processes necessary to create a birth canal

Answer 209

* 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

Question 210

Describe the role of prostaglandins in the control of contractions

Answer 210

* 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

Question 211

Describe the role of oxytocin in the control of contractions

Answer 211

* 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

Question 212

What is the Ferguson Reflex?

Answer 212

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

Question 213

What is brachystasis?

Answer 213

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

Question 214

Describe what happens during the 2nd stage of labour

Answer 214

* 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

Question 215

Describe what happens during the 3rd stage of labour

Answer 215

* 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

Question 216

Describe the normal presentation of a fetus during birth

Answer 216

* 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 (

Question 217

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

Answer 217

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

Question 218

Describe the principles of inducing labour

Answer 218

Administering prostaglandins or oxytocin will begin cervical ripening and uterine contractions

Question 219

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

Answer 219

Fetal heart rate assessed using a fetal scalp electrode

Question 220

Describe some interventions in childbirth

Answer 220

* Caesarian section * Suprapubic incision * Forceps delivery * Vacuum extraction

Question 221

Describe the components of the breast

Answer 221

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

Question 222

Describe the function and components of colostrum

Answer 222

* 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 *

Question 223

Describe the function and components of mature milk

Answer 223

* 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)

Question 224

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

Answer 224

* 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

Question 225

Describe the stimulation of prolactin secretion

Answer 225

* 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

Question 226

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

Answer 226

* 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

Question 227

Describe the hormonal control of milk let down

Answer 227

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

Question 228

Describe the mechanisms which produce cessation of lactation

Answer 228

* 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

Question 229

Describe the range of breast conditions

Answer 229

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

Question 230

Describe some physiological breast changes

Answer 230

* 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

Question 231

Describe the clinical presentation of breast conditions

Answer 231

* 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

Question 232

Describe the mammogram and what it is used for

Answer 232

Breast screening programme for women aged 47-73 years * Densities = invasive carcinoma, fibroadenoma, cysts * Calcifications = ductal carcinoma in situ, benign changes

Question 233

Describe the incidence of different breast conditions in relation to age

Answer 233

* Fibroadenomas often \< 30 years * Phyllodes tumour most present in 50s * Breast cancer usually \> 50 years except some familial cases

Question 234

Describe how breast lesions are investigated and diagnosed

Answer 234

Triple approach: * Clinical - history, family history, examination * Radiographic imaging - mammogram, ultrasound * Pathology - fine needle aspiration cytology, biopsy

Question 235

Describe the features and significance of acute mastitis

Answer 235

* Almost always during lactation * Staph aureus * Presents with painful, erythematous breast and pyrexia * Treated by expressing milk and antibiotics

Question 236

What is duct ectasia?

Answer 236

Dilation and inflammation of the lactiferous ducts * Usually during 50s or 60s * Can mimic carcinoma

Question 237

Describe the features of fat necrosis

Answer 237

* Presents as a mass, skin change or mammographic abnormality * Usually due to trauma or surgery * Can mimic carcinoma

Question 238

Describe the features of fibrocystic change

Answer 238

* Benign epithelial lesions * Presents as a mass or mammographic abnormality * Histological findings: * Cyst formation * Fibrosis * Apocrine metaplasia

Question 239

Describe the features and common causes of gynaecomastia

Answer 239

* 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)

Question 240

Describe the main features of fibroadenoma

Answer 240

* 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

Question 241

Describe the main features of Phyllodes tumour including management

Answer 241

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

Question 242

List some risk factors of breast cancer

Answer 242

* 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

Question 243

How is breast cancer classified?

Answer 243

* In situ or invasive * Ductal or lobular

Question 244

Describe the histological findings from an in situ carcinoma

Answer 244

* 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

Question 245

Describe the presentation and histological findings of DCIS

Answer 245

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

Question 246

Describe the presentation, histological findings and examples of invasive carcinoma

Answer 246

* 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

Question 247

Describe the patterns of metastasis in breast carcinomas

Answer 247

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

Question 248

Name some factors determining the prognosis of breast carcinoma

Answer 248

* In situ or invasive * Grade (differentiation) * Staging (TNM) * Gene expression profile * Oestrogen receptor * HER2

Question 249

Describe some therapeutic approaches to managing breast carcinoma

Answer 249

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

Question 250

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

Answer 250

* 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

Question 251

Describe the principles of screening for cervical carcinoma

Answer 251

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

Question 252

Describe the histological features of carcinoma of the cervix

Answer 252

* 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

Question 253

List some risk factors for cervical carcinoma

Answer 253

Caused by HPVs (mainly 16 and 18) * Sexual intercourse * Early 1st pregnancy * Multiple partners * Promiscuity * OCP * Smoking low SES

Question 254

Describe the factors which influence prognosis in carcinoma of the cervix

Answer 254

* Depth of invasion * Size of tumour * Degree of metastases - iliac and aortic lymph nodes etc

Question 255

Describe the pathological features, presentation and prognosis of endometrial adenocarcinoma

Answer 255

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

Question 256

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

Answer 256

* 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

Question 257

Name the classification of ovarian tumours

Answer 257

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)

Question 258

Describe the risk factors and prognosis of ovarian carcinoma

Answer 258

* Nulliparity, BRCA gene mutation, smoking, endometriosis * Poor prognosis due to late presentation and high chance of malignant spread

Question 259

Describe the key features of gestational tumours

Answer 259

* 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