Reproduction - PATHO Flashcards

1
Q

2 functions of the testicles

A
  1. Testosterone production
    - Leydig cells
    - line seminiferous tubules
    - production testosterone and androgens
  2. spermatogenesis
    - sertoli cells
    - line seminiferous tubules
    - production sperm
    - mature in epididymis and stored in vas deferens
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2
Q

Testicular descent occurs when in utero

A

Descent from abdomen -> inguinal canal -> scrotum
last 3 months of development

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3
Q

Control of blood flow to Leydig Cells

A

Autonomic adrenergic neurons

Blood flow to surface of testicles
cools to 4 degrees
temperature for spermatogenesis

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4
Q

Function of the Epididymis

A
  1. Structural
    - posterior testicle
    - 5-7cm
    - connection seminiferous tubules to vas deferens
  2. Functional
    - matruation sperm
    - 12 days to swim across
    - testosterone, nutrients
    A. motility
  3. maturation
  4. fertility
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5
Q

Function of the vas deferens

A
  • storage of mature sperm
  • muscular peristalsis for ejactulation
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6
Q

Anatomy and function of the prostate

A
  1. Seminal fluid
    - high pH (alkaline)
    - survival and motility of sperm
    - secreted from the seminal vesicle

Size of walnut
- surrounds urethra
- common duct for sperm and urine

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7
Q

Brief summary Embryonic Male Development

A

Chromosome Y expression SRY signalling

TDF - testes determining factor

MIF - mullerian inhihitory factor (inhibition internal female genitalia)

Leydig cells secrete testosterone - testicle development (wolfian duct)

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8
Q

Male Hormones Gonad development
Definition

A

GnRH
- gonadotropin releasing hormone
- hypothalamus
- stimulates release of anterior pituitary gonadotrophins

LH
- leutinizing hormone
- Leydig cells
- production androgens and testosterone
- primary and secondary sexual characteristics (testicular development)

FSH
- follicle stimulating hormone
- Sertoli cells
- production sperm (spermatogenesis)

Testosterone
- produced by Leydig cells (testicles)
- produced by adrenal glands
- primary and secondary sexual characteristics
- anabolic (muscle, bone buildnig)
- libido
- hair, acne, sebaceous glands, etc.

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9
Q

List Structural Disorders
Penis

A

Cryptorchidism
- undescended testicle

Ectopic testicle

Phimosis
- unable to retract prepuce

Paraphimosis
- unable to reduce prepuce

Hypospadias
- uretra on the ventral side of the shaft

Peyronie’s disease
- fibrosis of penis results in bend

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10
Q

Cryptorchidism
Definition

A

Testicles do not descend to scrotum from abdomen

Unilateral > bilateral (high sterility)

Found anywhere along ectopic, abdomen, inguinal canal, suprapubic

palpable and non-palpable

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11
Q

Cryptorchidism
Incidence and Complications

A

3-4% at birth
1% remain undescended at 1 year

Complications
- infertility
- 50x increase risk of testicular cancer in adulthood (contralateral testicle)

Co-morbidities: anatomy
- vas deferens
- epididymis
- urethra, upper genital tract
- hypospadias
- mixed sex: both cryptorchidism + hypospadias

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12
Q

Cryptorchidism
Etiology

A

genetics x environment (hormones x structure x maternal age)

  1. Structural
    - adhesions
    - fibrosis
    - narrowing inguinal canal
    - no gubernaculum (cord that pulls them through)
  2. Hormonal (environmental)
    - insensitive to gonadotrophic hormones, maternal hormones
  3. Maternal age
    - advanced maternal age
  4. Heredity (genetics)
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13
Q

When is physiological cryptorchidism normal
Retractile Testicle

A
  • involuntary retraction of testes into inguinal canal (can be repositioned) in response to ANS activation
  • cold, physical excitement
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14
Q

Cryptorchidism
Treatment

A
  1. Monitor for first month
    - 50% descend in first month
  2. Referral to urology MD
    - 6 months
    - Rx. Testicular ultrasound
    - assess gonads and genitals (comorbidities)
  3. Surgical intervention
    - 6-18 months

Orchiopexy
- surgical descent of testicles
- 20% remain infertile
- retain 50x increase risk for testicular cancer

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15
Q

Phimosis
Definition

A

Inability to retract the prepuce (foreskin)

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16
Q

Two Types phimosis

A
  1. Congenital phimosis
    - normal
    - up to age 3 years should not retract the foreskin to clean
  2. Poor hygiene
    - not usually STI (can be)
    - poor hygiene
    - poor diabetic control (immunocompromised)
    - secondary infection
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17
Q

Phimosis
Pathophysiology

A

Most commonly from poor hygiene

  • inflammation
  • swelling
  • erythema
  • edema
  • pain
  • discharge
    –> cannot retract the foreskin
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18
Q

phimosis
Complications

A
  1. blanitis
    - inflammation glans of penis
  2. posthitis
    - inflammation prepuce
  3. paraphimosis
    - inability to reduce the forskin
    - cuts off circulation to glans of penis
    - medical emergency
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19
Q

Phimosis
Treatment

A
  1. Treat infection and inflammation
  • if infection, treat infection
  • corticosteroid cream for inflammation
  • control blood sugars if diabetic
  1. MD referral
    - surgical release or circumcision
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20
Q

Phimosis
Incidence and risk factors

A
  • can occur at any time, any age
  • poor hygiene
  • poor diabetic control
  • not usually STIs
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21
Q

Paraphimosis
Definition

A

Inability to reduce the prepuce over the glans of the penis

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22
Q

Paraphimosis
Pathophysiology

A

Inflammation prepuce or glans
inability to reduce foreskin over
restriction blood flow to glans
MEDICAL EMERGENCY

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23
Q

Paraphimosis
Treatment

A

Surgical release or circumcision

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24
Q

Hypospadias
Definition

A

Urethral opening is on the ventral side of the penis (glans, shaft, base, penoscrotal junction, perineum)

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25
Medical management hypospadias
Referral to urology for surgical repair and assessment Co-morbidities - mixed, intersexed - cryptorchidism
26
Peyronie's Disease Definition
"bent nail" disease Inealstic fibrous scar/plaque in the tunica albuginea of the corpus cavernosa
27
Peyronie's Disease Risk factors
Age 40-65 years collagen loss Dupuytren contractures beta blockers diabetes penile trauma
28
Peyronie's Disease Pathophysiology
Trauma to tunica albuginea / corpus cavernosa Bleeding --> inflammation --> fibrosis
29
Peyronie's Disease Clinical Signs and Symptoms
- palpable fibrous lump - bend when erect - +/- pain on erection - +/- erection / penetration
30
Peyronie's Disease Treatment
1. Urology MD consult - 50% will resolve in 12 monts 2. Pharmacological management - L carnitine - potassium aminobenzoate - Q10 - Colchicine - Collagenase clostridium histolyticum (CCH) * more successful for early lesions 3. Surgical management - suture - Nesbit patch
31
List of Examples Masses and Swelling of Testicles
1. Testicular torsion 2. Hydrocele 3. Varicocele 4. Spermatocele
32
Hypospadias Etiology
Multifactoria - genetic - endocrine - advanced maternal age - low birth weight
33
Hypospadias Complications
- Chordee (penile torsion) - skin tethering - penis bows/bends ventrally or to right/left side
34
Varicocele Definition
Dilation of testicular veins, pampiniform plexus, resulting in backflow of blood into testicles
35
Varicocele Pathophysiology and incidence
1. Increase blood flow to testes - adolescents (increased testosterone) - 10% adolescents - hot weather, exercise 2. Dysfunction of valves leads to backflow of blood into testes - congenital defect 3. Tumor/thrombus leads to increase venous pressure - Right sided varicocele - older age 4. Dysfunction testes - decreased spermatogenesis - decreased androgen production - atrophy of testicle (smaller size) - low testosterone - high FSH and LH
36
Varicocele Clinical Signs and Symptoms
1. symptomatic 2. asymptomatic Asymptomatic - detected through infertility testing - low sperm count - low testosterone - high FSH, high LH Symptomatic - Dull ache - heaviness - worse with exercise, warm weather, prolonged standing - palpable spaghetti like cords - small testicle on inspection
37
Varicocele Right or Left Interventions
Left 90% Right 10% - BAD - compression inferior vena cava 1. tumor 2. thrombus - emergency referral
38
Varicocele Treatment Pathways
1. Referral to Urology MD - Mild (left side only) - watch - Moderate/severe - varicocelectomy 2. Retroperitoneal US (moderate/severe, or right side) - order to have prepared for referral - R/O tumor, infarct 3. Doppler US of testes - visualization venous distention of pampiniform plexus
39
Hydrocele Definition
Most common cause of scrotal swelling Fluid accumulation between tunica vaginalis (visceral and parietal) layers Not usually associated with infertility
40
Hydrocele Etiology
1. Congenital hydrocele - 6% infants - majority resolves by 12 months 2. Vascular - abnormal fluid secretion/asboprtion 3. Trauma - trauma, torsion, surgery 4. Infection - epididymitis -orchitis
41
Hydrocele Treatment pathways
1. Non-communicating hydrocele - watch and wait - not usually associated with infertility - majority congenital hydroceles resolve 12 months 2. communicating hydrocele - urology MD referral - aspriation - sclerotherapy 3. Severity of symptoms - asymptomatic/mild (watch and wait) - moderate/severe (treatment) 4. Age - < 2 years, watch and wait
42
Hydrocele Clinical Signs and Symptoms
- painless swollen testicle - unilateral or bilateral - "swollen water balloon" - worsens throughout day - large swelling -> compression blood supply -> pain (communicating hydrogcele) - infection = pain
43
Hydrocele Diagnosis
1. Transillumination 2. Ultrasound
44
Spermatocele Definition
Diverticulum of the epididymis - fluid filled cyst located between epididymis and testicle
45
Spermatocele Clinical Signs and Symptoms
- usually not painful - asymptomatic - palpable, freely movable mass (outside tunica vaginalis) - cyst - filled with milky fluid, sperm - not associated with infertility - heaviness of testicle
46
Spermatocele Treatment
- scrotal support - removal if associated with pain
47
Painful vs. Non-painful Testicular masses
non-painful - testicular cancer - hydrocele - varicocele - spermatocele Painful - epididymitis - testicular torsion - orchitis
48
Testicular Torsion Definition
Torsion of the blood vessels (arteries, veins) supplying the testicles resulting in decrease blood flow and ischemia Medical emergency Needs to be treated within 4 hours
49
TWIST Score Testicular Torsion
1. Hard testicle / 2 2. swelling /2 3. N/V /1 4. Cremasteric reflex absent /1 5. riding high testicles / 1 Score 0-2 differential diagnosis 3-4 intermediate risk, referral, US >5 emergency consult, immediate US
50
Clinical Signs and Symptoms Testicular Torsion
- Hard testicles - edema - nausea and vomiting - absent cremasteric reflex - riding high testicle - unilateral pain - Prehn sign (not relieved by support of testicle)
51
Pathophysiology Testicular Torsion
Etiology - spontaneous (wake up in severe pain) - trauma - > incidence < 25 years of age - any age - Torsion of the vascular supply to testicles - cut off blood flow - ischemia, inflammation, necrosis
52
Testicular Torsion Treatment
Surgical intervention within 6 hours 90% testicles saved; 12 hours 50% testicles saved 24 hours 10% testicles saved
53
Balanitis Definition and pathophysiology
Inflammation of the glans (head) of the penis *non-circumcized > circumcized Accumulation: - smegma (glandular secretions) - epithelial cells - mycobacterium (acid-fast bacterium) - Candidiasis (yeast)
54
Balanitis Etiology
1. Non-infectious - poor hygiene (pre-pubescence) - trauma - skin condition (psoriasis, eczema, lichen plantus) - drug reaction 2. Infectious - Mycobacterium - STD - Candidias *R/O with culture and sensitivity swab
55
Balanitis Complications
Posthitis - inflammation of the prepuce Paraphimosis - inability to reduce the prepuce Phimosis - inability to retract foreskin Blanoposthitis - inflammaiton both prepuce and gland of penis
56
Blanoposthitis Definition
Co-occurance of posthitis (inflammation prepuce) + balanitis (inflammation glans of penis) *usually occur together
57
Risk factors Balanitis
- Immunocompromised - Poorly controlled diabetes - non-circumcized - pre-pubescent males - poor hygiene
58
Treatment Balanitis
1. Hygiene Education - Clean daily, lukewarm water - avoid soaps, lubricants, baby wipes - retract foreskin > 3 years of age vs. clean under foreskin 2. Treat inflammation and/or infection - Inflammation: Hydrocortisone 1% maximum 14 days - Yeast infection: Azole cream + hydrocortisone 1% for maximum 14 days - Mycobacterial infection: PO cloxacillin/cephalexin/clarithromycin 7 days, hydrocortisone cream 1% for 14 days 3. Referrals - Urology/dermatology - circumcision for refractory cases -*investigate immunocompromised conditions (diabetes, HIV, etc.)
59
Urethritis Definition
Inflammation of the urethra *Most commonly STD
60
Urethritis Etiology
1. Infectious 2. Non infectious Most common STDs Clinical signs and symptoms after 1 week: Neisseria gonorrhea - gram negative cocci - symptoms develop in 1 week after contraction Clinical signs and symptoms 1-5 weeks after: Chlamydia trachomatis (gram negative) mycoplasma genitalium (gram negative) ureaplasma urealyticum (gram negative) Trichomonas (protozoan) candidia albicans (yeast) herpes simplex virus adenovirus
61
Clinical Signs and Symptom Urethritis
- Asymptomatic (males > females) - dysuria - burning - pruritis - erythema - +/- discharge (mucopurulent/mucoid/purulent/bleeding) - obstruciton/urgency/retention
62
Urethritis Empirical Treatment
Empirical treatment treats for BOTH N. gonorrhea and C. trachomatis (co-occurring infections) Ceftriaxone 250mg IM once + Azithromycin 1g PO once OR doxycycline 100mg BID for 7 days *Non-gonococcal (asymptomatic, culture and sensitivity swab) Azithromycin 1g PO once OR Doxycycline 100mg BID for 7 days
63
Patient Education Urethritis
1. All partners in last 60 days to be treated 2. Reported to public health 3. Test for cure for 1-2 weeks after infection (*if alternative regime used) 4. Symptom resolution 7-14 days post antibiotics
64
Urethritis Treatment Special populations
1. Pregnancy & Children Ceftriaxone Azithromycin *Doxycycline is contraindicated in pregnancy and children 2. Allergy to penicillin Ciprofloxacin + Azithromycin OR Azithromycin + gentamicin *Test for cure > 1-2 weeks after therapy (3-4 weeks if NAAT being used)
65
Non-infectious causes Urethritis
- inflammation - trauma - urological procedure - foreign bodies - autoimmune reactive arthritis (Reiter syndrome - shigella, campylobacter, chlamydia)
66
Epididymitis Definition
Inflammation of the epididymis
67
Epididymitis Etiology
Most commonly sexually active males < 35 years (rare before puberty) 1. Sexually transmitted infection (Individuals < 35 years) 2. Non-sexually transmitted infections (Individuals > 35 years) 3. Sterile STI Causes: - Neisseria gonorrhea - Chlamydia trachomatis - Enterobactericeae (unprotected anal sex) Non-sexually transmitted infection - Cloriform - Pseudomonas aeruginosa - E. coli - *hematogenous spread from genitourinary tract or chronic prostatitis Sterile - urine - structural reflux urine into epididymis - drug - amiodarone therapy - vasculitis (Behcet disease, henoch-schonlein purpura, polyarteritis nodosa) - idiopathic - urology procedure
68
Chemical epididymitis
- reflux of urine into the epididymis - Heavy lifting - sterile form of epididymitis
69
Clinical Signs and Symptoms Epididymitis
- Acute unilateral testicular pain - Palpable swelling and pain (spermatic cord, testicles, epididymus (lower pole -> head)) - testicular erythema and swelling - hydrocele (fluid between tunica vaginalis) - Fever, malaise, fatigue (infection) - +/- discharge (discharge = STI) - Relief of pain with testicular support (Prehn Sign) - UTI symptoms - urethritis - prostitis symptoms *infection ascends the urether
70
Complication Epididymitis
- abscess - infarcts (testicles, prostate) - chronic epididymis and scaring (antibiotics cannot reach the site of infection) - infertility
71
Co-morbidities Epididymitis
If the epididymitis is infectious: - Prostitis - urethritis - urinary tract infections *infectious organism ascends the urethra --> prostate --> vas deferens / bladder
72
Differential diagnosis Epididymitis
1. Testicular torsion - sudden pain - TWIST score: N/V, hard testicle, swelling testicle, riding high testicle, no cremasteric reflex, no prehn sign, unilateral 2. Testicular cancer - progresses over weeks, not acute - low grade pain
73
Treatment Epididymitis
1. Etiology: STI (N. gonorrhea / C. trachomatis) - Ceftriaxone 250mg IM once AND - Azithromycin 1g PO once - doxycycline 100mg BID for 10-14 days 2. Etiology: non-STI or enteric organisms - Ciprofloxacin 500mg BID for 10-14 days - Levofloxacin 500mg once daily for 10-14 days
74
Special populations Epididymitis
Penicillin Allergy Ciprofloxacin/Levofloxacin 500mg ONCE Azithromycin 1g PO ONCE Doxycycline 100mg BID for 10-14 days
75
Causative organism Epididymitis incidence
< 35 years of age OR multiple sexual partners OR purulent discharge STI N. gonorrhea / C. trachomatis Empirical treatment ceftriaxone 250mg IM once azithromycin 1g PO once doxycycline 100mg BID 10-14 days > 35 years of age Assume non-STI and gram negative enterococci Empirical treatment ciprofloxacin 500mg BID /levofloxacin 500mg OD for 10-14 days *Re-assess if symptoms persist after 3 days
76
Patient Education Epididymitis
- return to doctor if symptoms do not resolve in 3 days (re-assess empiric treatment) - public health reportable - all partners treated within 60 days
77
Duration of therapy Epididymitis
Minimum 10-14 days *secondary to chronic prostatitis up to 6 weeks of antibiotic therapy
78
Prostatitis Definition and types
Inflammation of the prostate 1. Acute prostatitis 2. Chronic prostatitis 1. Bacterial prostatitis 2. non-bacterial prostatitis 3. Idiopathic
79
Acute Prostatitis Clinical Signs and Symptoms
*Similar to UTI - Fever, chills, malaise - perineal, rectal, lower back pain - irritative/obstructive voiding - Pain worse when standing (pelvic floor contracts prostate) - palpation prostate enlarged, swollen, tender, indurated, warm
80
Diagnostic and laboratory tests Prostatitis
obtain urine sample before empiric treatment
81
Acute Prostatitis Treatment
MUM's Guideline 10-14 days re-assess - Ciprofloxacin 500mg BID for 3-4 weeks - Levofloxacin 500mg OD for 3-4 weeks - Norfloxacin 400mg BID for 3-4 weeks - TMP/SMX Additional 2-4 weeks needed after symptoms have resolved to prevent chronic prostatitis
82
Acute Prostatitis Unable to void Treatment
Hospitalization 1. IV antibiotics 2. Suprapubic catheterization (foley contraindicated) Ampicillin IV OR Ceftriaxone IV + Gentamicin IV OR tobramycin IV
83
Chronic Prostatitis Clinical Signs and Symptoms
*Relapsing UTI suspect chronic prostatitis - urinary frequency, urgency - urinary retention - dysuria - ejactulatory pain - pelvic or genital pain - hemospermia * some patients are asymptomatic - prostate exam is usually normal
84
Chronic Prostatitis Incidence
Incidence increases with age
85
Chronic Prostatitis Diagnostics and treatment
1. Urine culture and sensitivity Syndrome approach (cultures may be negative) 2. Antibiotic treatment - Levofloxacin 500mg once for 4-6 weeks - Ciprofloxacin 500mg BID for 4-6 weeks SECOND LINE - TMP/SMX 3. Alpha blockers - TeraZOSIN - block alpha receptors, relaxation smooth muscles 3. Referral to urology MD - no resolution 4-6 weeks
86
Non-pharmacological treatment Prostatitis
1. Anti-inflammatories 2. hot sitz bath 3. bedrest (relaxation pelvic floor muscles)
87
Complication Prostatitis
1. Prostatic caliculi - stones in the prostate - infected with bacteria - hard to eradicate - Rx. surgical removal 2. Inflammatory chronic pelvic pain syndrome - chronic pain - perineal, testicular, penile, lower abdomen, ejactulatory - dysuria, hesitancy, interrupted flow - exacerbated by sexual activity 3. Chronic prostatitis 4. Abscesses 5. Bacteremia 6. Epididymitis
88
Orchitis Definition
Inflammation of the testicles and scrotal sac secondary to epididymis infection or secondary to systemic illness (Ex. Mumps, COVID19)
89
Orchitis Clinical Signs and Symptoms
- Secondary to infection: Fever, WBC - Inflammation: swelling, erythema to testicles, pain - unilateral or bilateral - +/- hydrocele - prostration (doubled over in pain)
90
Orchitis Pharmacological and Non-pharmacological Treatment
Pharmacological - Treat infection - COVID19 antivirals - Bacterial epididymitis - No pharmacological treatment for mumps Non-pharmacological - bed rest - support testicles - ice - anti-inflammatories
91
Complications Orchitis
Infertility
92
menarch
menstruation occurs 2.5 years after thelarche in females
93
Thelarch
emergence of breast buds approximately 8 years-12 years females = gonadarche for females stage 2 tanner
94
pubarche
pubic hair appearance 8 years of age stage 2 tanner
95
gonadarche
formation testes males and ovaries females stage 2 tanner development corresponding to thelarche in females Stage 2 tanner
96
Pre-puberty hypothalamus-pituitary axis
GnRH gonadotropin releasing hormone LH leutinizing hormone FSH follicle stimulating hormone low levels of all hormones FSH > LH
97
Puberty Hypothalamus- pituitary axis
surges of FSH and LH at night time during REM sleep small release GnRH results in large release FSH and LH LH > FSH
98
Male Secondary sexual characteristics are controlled by what hormone?
LH leutinizing hormone results in release of testosterone from leydig cells secondary sexual characteristics - hair, growth, muscles, testicles FSH follicle stimulating hormone results in spermatogenesis from sertoli cells in the seminiferous tubules in the testicles
99
Female secondary sexual characteristics, controlled by what hormones
LH leutinizing hormone results in release of estrogen from the theca cells in the ovaries Estrogen receptors in ovaries, placenta, breast tissue FSH follicle stimulating hormone promotes development of the ovarian follicle and stimulates estrogen secretion FSH and LH spike occurs on day 14 of the cycle
100
Female hormones during ovulation
LH and FSH spike promote ovulation Estrogen and LH highest during ovulation progesterone is highest post-ovulation
101
Effect of estrogen Non-reproductive
- bone density - liver: decrease LDL, increase HDL - CNS: memory, cognition - Skin: collagen, elasticity, healing - Kidney: protective against CKD - CVS: prevents atheroscelerosis, platelet adhesion
102
Effects of estrogen Reproductive
Vaginal mucosa: growth squamous epithelium cervical mucosa: fluid secretions, motility sperm increased and survival increased fallopian tubes: motility and cillia action inrease Uterine muscles: increase blood flow, contraction, oxytocin sensors Endometrium: growth, increase progesterone receptors breasts: ducts, prolactin increase
103
Effects of progesterone Reproductive
vaginal mucosa: thinning squamous epithelium Cervical mucosa: thickening, plug cervix Fallopian tube: decrease ciliary motility Uterine muscles: relaxation, decrease sensation oxytocin endometirum: decrease estrogen receptors, activate glands, blood vessels breasts: growth lobules, alveoli, inhibition prolactin