Reproductive Flashcards
Venous drainage in reproductive anatomy
Left gonadal vein takes the Longest way
Left ovary/testis –> left gonadal vein –> left renal vein –> IVC
right ovary/testis –> right gonadal vein –> IVC
Why are varicoceles more common on the left side?
because the left spermatic vein enters the left renal vein at a 90 degree angle .
flow is less laminar on left than on right –> left venous pressure >right venous pressure
results in varicocele more common on left
lymphatic drainage: ovaries/testes
para-aortic lymph nodes
lymphatic drainage: body of uterus/superior bladder
external iliac nodes
lymphatic drainage: prostate/cervix/corpus cavernosum/proximal vagina
internal iliac nodes
lymphatic drainage: distal vagina/vulva/scrotum/distal anus
superficial inguinal nodes
lymphatic drainage: glands penis
deep inguinal nodes
This ligament connects the ovaries to the lateral pelvic wall. Which ligament is it and what structures does it contain
Infundibulopelvic ligament or suspensory ligament
contains ovarian vessels
What do you want to ligate during an oophorectomy
suspensory ligament or infundibulopelvic ligament because it has the ovarian vessels
avoid bleeding
Ureter courses ______ close to the gonadal vessels. It is at risk of injury during ligation of _____ and _____ vessels
retroperitoneally
ovarian
and uterine vessels
This ligament connects the cervix to side wall of pelvis. What ligament? what does it contain?
cardinal ligament
contains the uterine vessels
This ligament connects the uterine horn to labia majora
round ligament of the uterus
derivative of gubernaculum
travels through round inguinal canal above the artery of sampson
This ligament connects the uterus, fallopian tubes, and ovaries to pelvic side walls
Broad ligament
contains the ovaries, fallopian tubes, round ligaments of uterus
Mesosalpinx - tube portion
Mesometrium - uterus
Mesovarium - ovaries
What ligament connects the medial pole of ovary to uterine horn
ovarian ligament
derivative of gubernaculum
What is the most common area for cervical cancer
transformation zone that is squamocolumnar junction
The vagina and endocervix are (histology)
stratified squamous epithelium , non keratinized
Endocervix,uterus, and fallopian tubes are (histology)
simple columnar epithelium
uterus is SCE with long tubular glands in proliferative phase and coiled glands in secretory phase
fallopian tube is ciliated
Ovary, outer surface is (histology)
simple cuboidal epithelium (germinal epithelium covering surface of ovary)
Pathway of sperm
Seminiferous tubules Epididymis Vas deferens Ejaculatory duct (after seminal vesicle and ampulla join) Urethra Penis
Patient has blood at the urethral meatus and a scrotal hematoma
Anterior urethral injury at the bulbar (spongy) urethra
blood is accumulating in scrotum and if bucks fascia is also torn then it escapes into perineal sapce
due to perineal straddle injury
Patient has blood at urethral meatus and a high riding prostate
Posterior urethral injury at the membranous urethra
urine leaks into retropubic space
due to pelvic fracture
Erection is due to ______ nervous system
parasympathetic NS
pelvic splanchnic nerves (S2-S4)
NO effect on erection
proerectile
it increases cGMP which causes smooth muscle relaxation –> vasodilation –> proerectile
PDE5 inhibitors like sildenafil effect on erection
decrease cGMP breakdown therefore proerectile
Norepinephrine effect on erection
increases calcium which causes smooth muscle contraction and vasoconstriction –> antierectile
Emission (release of semen from reproductive glands and contraction of reproductive duct) is controlled by the _____ system
sympathetic nervous system
hypogastric nerve T11-L2
Ejaculation (release from urethra) is controlled by _____ nerves
visceral and somatic nerves
pudendal nerves
Cells in the seminiferous tubules
Spermatogonia
Sertoli cells
Leydig cells
Spermatogonia
cells in seminiferous tubules that maintain germ cell pool and produce primary spermatocytes
Sertoli cells
cells in seminiferous tubules
- Stimulated by FSH
- Secrete inhibin B which feedback inhibits FSH
- Secrete androgen binding protein to maintain local levels of testosterone
- Support and nourish developing spermatozoa
- Regulate spermatogenesis
- Temperature sensitive
How do sertoli cells protect gametes from autoimmune attack
tight junctions between adjacent sertoli cells form the blood testis barrier
How does temperature impact sertoli cells
causes decreased sperm production and decreased inhibin B (important for feedback inhibiting FSH)
What enzyme converts testosterone and androstenedione to estrogen in the sertoli cells
aromatase
sertoli cells are the homolog of female ___
granulosa cells
Leydig cells
secrete testosterone in the presence of LH
unaffected by temperature
leydig cells are the homolog of female
theca interna cells
Source of estrogen
ovary (17beta-estradiol)
placenta (estriol)
adipose (estrone via aromatization)
estradiol>estrone> estriol
Estrogen functions to upregulate
estrogen, LH, and progesterone receptors
feedback inhibition of FSH and LH, then LH surge
Stimulates prolactin secretion
increases transport proteins like sex hormone binding globulin
Increases HDL and decreases LDL
estrogen levels during pregnancy
50 fold increase in estradiol and estrone
1000 fold increase in estriol which is an indicator of fetal wellbeing
pathway for converting cholesterol to estrogen
1) LH binds LHR on theca cells and causes cAMP + of desmolase
2) desmolase converts cholesterol to androstenedione
3) androstenedione enters granulosa cells
4) FSH binds FSHR on granulosa cells and causes cAMP + of aromatase
5) aromatase converts androstenedione to estrone
6) estrone estradiol
7) Estradiol –> estrogen which leaves the franulosa cells
Source of progesterone
corpus luteum, placenta, adrenal cortex, testes
Function of progesterone
- Stimulation of endometrial glandular secretions and spiral artery development
- Maintains pregnancy
- Reduces myometrial excitability
- Thick cervical mucus to prevent sperm entry
- Increase body temperature
- Inhibition of gonadotropins (LH and FSH)
- Uterine smooth muscle relaxation (preventing contractions)
- Decrease estrogen receptor expression
- Prevent endometrial hyperplasia
Progesterone is _____
PROGESTation
Fall in progesterone after delivery disinhibits ____ and allows for lactation
prolactin
primary oocytes are arrested in _____ until ovulation
prophase I
secondary oocytes are arrested in _____ until fertilization
metaphase II
“an egg met a sperm”
degenerates if egg does not meet sperm in 1 day
product of complete oogenesis
1 ovum
3 polar bodies
hormone changes during ovulation
increase estrogen
increase GnRH receptors on anterior pituitary
estrogen surge causes LH release –> ovulation (rupture of follicle)
increase in temperature is due to progesterone
Mittelschmerz
transient mid cycle ovulatory pain
peritoneal irritation
can mimic appendicitis
phases of menstrual cycle
Follicular phase (Varies in length)
Ovulation
Luteal phase
ovulation + 14 days= menstruation
Follicular growth is fastest during ____ week of the _____ phase because ____ stimulates endometrial proliferation. _________ maintains the endometrium to support implantation during the _____ phase.
2nd week of the follicular phase because estrogen stimulates endometrial proliferation
Progesterone maintains the endometrium to support implantation during the luteal phase of the ovarian cycle
effect of low progesterone on fertility?
decreases fertility
menstrual cycle: ___ and ___ release from the ____ pituitary stimulates the developing follicle to release ______. This is around the time of _____
LH and FSH
anterior pituitary
estrogen
menses in uterine cycle (early follicular phase in ovary)
menstrual cycle: As estrogen levels increase we get a ______ surge and also ___ increase. This causes ____
LH surge and FSH increase
ovulation ( at the end of proliferative phase of the uterine cycle )
menstrual cycle: as LH and FSH decrease during the ___ phase, so does ________ and ______. But then the ______ produces _____ and _____. This is the ____ phase of the uterine cycle
luteal phase (ovarian cycle)
so does the estrogen and progesterone levels
corpus luteum produces estrogen and progesterone (important for endometrial proliferation and maintaining implantation)
This is the secretory phase of the uterine cycle (luteal phase of ovarian cycle)
ovarian cycle
follicular phase
Luteal phase
Uterine cycle
menses –> proliferative –> ovulation –> secretory –> menses
corpus luteum degrades into the
corpus albicans
Abnormal uterine bleeding due to structural causes
PALM
polyp
adenomyosis
leiomyoma
malignancy/hyperplasia
abnormal uterine bleeding due to non structural causes
COEIN
coagulopathy ovulatory endometrial iatrogenic not yet classified
Where does fertilization most commonly occur
ampulla (upper end of fallopian tube)
_________ secretes hCG
syncytiotrophoblasts
hCG peaks at ________ then decreases. All other placental hormones increase in secretion till end of pregnancy
8-10 weeks
detectable in urine at 2 weeks
in blood at 1 week
gestational age
date of last menstrual period
embryonic age
gestational age - 2 weeks
date of cenception
physiological adaptations during pregnancy
increased CO
increased HR
Anemia due to higher increase in plasma compared to RBC
hypercoagulability to decrease blood loss during pregnancy
hyperventilation to eliminate fetal CO2
hCG functions to maintain _____ for first 8-10 weeks of pregnancy by acting like _____. After 8-10 weeks, placenta synthesizes its own estriol and progesterone and the ______ degenerates
corpus luteum and thus prgesterone
acts like LH (identical alpha subunit to LH, FSH, and TSH)
corpus luteum degerates
Why can an increase in hCG cause hyperthyroidism
because hCG has a similar alpha subunit as TSH
____ subunit of hCG is unique and thus is used for pregnancy tests
beta
Other causes of high hCG
multiple gestations
hydatidiform moles
choriocarcinomas
down syndrome
Causes of decrease in hCG
ectopic/failing pregnancy
edwards
patau syndrome
Human placental lactogen/ chorionic somatomammotropin
secreted by syncytiotrophoblasts of the placenta
stimulates insulin production and overall increase insulin resistance. This causes maternal hypoglycemia –> lipolysis. This preserves available glucose and AA for fetus
gestational diabetes
occurs when maternal pancreatic function cannot overcome the insulin resistance
APGAR score
Appearance Pulse Grimace Activity Respiration
Score each 2-0 for a 10 point scale evaluated at 1 minute and 5 minutes
<7 score requires further evaluation
low score after later time points there is a risk the child will develop long term neurologic damage
Appearance scoring for APGAR
2 if pink
1 if extremities blue
0 if pale or blue
Pulse scoring for APGAR
2 if >100 bpm
1 <100 bpm
0 no pulse
Grimace scoring for APGAR
2 if cries and pulls away
1 if grimaces or weak cry
0 if no response to stimulation
Activity scoring for APGAR
2 if active movement
1 if arms and legs flexed
0 if no movement
Respiration scoring fo APGAR
2 if strong cry
1 if slow, irregular
0 no breathing
Motor milestones for 0-12 months : primitive reflexes (moro, rooting, palmar, babinski)
Moro reflex disappears by 3 months
Rooting reflex disappears by 4 months
Palmar reflex disappears by 6 months
Babinski reflex disappears by 12 months
Motor milestones for 0-12 months: posture and picks
lifts head up prone by 1 month rolls, sits, and passes toys hand to hand by 6 months crawls by 8 months stands and has pincer grasp by 10 months Points to objects by 10 months walks by 12-18 months
Social milestones for 0-12 months
social smile by 2 months
stranger anxiety by 6 months
separation anxiety by 9 months
Verbal/cognitive milestones for 0-12 months
orients to voice by 4 months
orients to name and gesture by 9 months
object permanence by 9 months
says mama and dada by 10 months
Motor milestones for 12-36 months (toddler)
Takes first steps by 12 months Climbs stairs by 18 months Cubes stacked number = age x 3 Feeds self by fork and spoon by 20 months Kicks ball by 24 months
Social milestones for 12-36 months (toddler)
Parallel play by 24-26 months
Moves away from and returns to mother by 24 months
Core gender identity formed by 36 months
verbal/cognitive milestones by 12-36 months (toddler)
200 words by age 2 (2 zeros)
2 word sentences
Motor milestones for 3-5 yrs (preschool)
Tricycle by 3 years
Copies line or circle, stick figures by 4 years
Hops on one foot by 4 years
Uses buttons or zippers, grooms self by 5 years
social milestones for 3-5 yrs (preschool)
Comfortably spends part of day away from mother by 3 years
Cooperative play and has imaginary friends by 4 years
verbal/cognitive milestones by 3-5 yrs (preschool)
1000 words by age 3 (3 zeros)
Complete sentences and prepositions by 4 years
Can tell detailed stories by 4 years
Low birth weight
defined as <2500 g
increased risk of SIDS and increased overall mortality
Rapid decrease in _______ disinhibits and initiates lactation
progesterone
Suckinling causes increased nerve stimulation and increase in _____ and _____
oxytocin and prolactin
prolactin
induces and maintains lactation and decreases reproductive function
oxytocin
assists in milk let down and promotes uterine contractions
breast feading decreases risk for child to develop
asthma, allergies, diabetes mellitus, and obesity
what do you need to supplement in children who are exclusively breast fed
vitamin D and iron supplementation
what benefit does breast feeding have for a mother
decreases risk of breast and ovarian cancer
Where do you get estrogen after menopause
peripheral conversion of androgens
increasing androgens causes hirsutism
hormonal changes in menopause:
drop in estrogen drastic increase in FSH increase in LH no LH surge increase GnRH
Androstenedione is from the
adrenal glands
androgen potency
DHT>testosterone>androstenedione
Testosterone is converted to DHT by
5alpha reductase
In men androgens are converted to estrogen by
cytochrome P450 aromatase
adipose tissue and testis
Giving exogenous testosterone causes azoospermia. Why?
exogenous testosterone causes inhibition of hypothalamic-pituitary-gonadal axis
this decreases intratesticular testosterone
this decreases testicular size
causing azoospermia
Testosterone function
- Differentiation of epididymis, vas deferens, seminal vesicles (internal genitalia except prostate)
- Growth spurt: penis, seminal vesicles, sperm, muscle, RBCs
- Deepening of voice
- Closing of epiphyseal plates (via estrogen converted from testosterone)
- Libido
DHT
early: differentiation of penis, scrotum, prostate
late: prostate growth, balding, sebaceous gland activity
Spermatids undergo spermiogenesis which involves
losing cytoplasmic contents and gaining a acrosomal cap to form mature spermatozoon
“spermatogonium is going to be a sperm”
“spermatozoon is zoomng to the egg”
Impaired tail mobility in mature spermatozoon can lead to infertility. This is linked to what syndrome
Kartagener syndrome or ciliary dyskinesia
Tanner stages
stage the genitalia, pubic hair, and breast separately
Tanner stage 1 (genitalia, pubic hair, and breast)
- no sexual hair
- flat appearing chest with raised nipple
“prepubertal”
Tanner stage 2 (genitalia, pubic hair, and breast)
- pubarche
- testicular enlargement in boys
- Therache/breast bud formation in girls
8-11.5 years
Tanner stage 3 ((genitalia, pubic hair, and breast)
- coarsening of pubic hair
- penile size/length increases in boys
- breast enlarges and mound forms in girls
Tanner stage 4 (genitalia, pubic hair, and breast)
- coarse pubic hair across pubis but sparing thigh
- penis width/glans increases in boys
- breast enlarges, raised areola, mound on mound in girls
13-15 yo
Tanner stage 5 ((genitalia, pubic hair, and breast))
- coarse hair across pubis and medial thigh
- penis and testis enlarge to adult size in men
- adult breast contour, areola flattens in women
> 15 yo
Patient is a male thathas testicular atrophy, a eunuchoid body shape, is tall, has long extremities, gynecomastia, and female hair distribution.
Klinefelter syndrome
Male ,47,XXY (inactivated X chromosome or Barr body)
Patients with klinefelter syndrome have dysgenesis of seminiferous tubules which results in decreased _____ and thus increased _____
decreased inhibin B
Increased FSH
Patients with klinefelter syndrome have abnormal leydig cell function which causes a decrease in ______ which causes an increase in LH and then increase in estrogen
testosterone
Common problems associated with turners syndrome
Shield chest
Bicuspid aortic valve
Coarctation (femoral pulse < brachial pulse)
Lymphatic defects causing the webbed neck or cystic hygroma
Lymphedema in feet and hands
Horseshoe kidney
Amenorrhea
Turner syndrome estrogen, LH, and FSH levels
Female, 45, XO
Low estrogen levels result in increased LH and FSH. This is because estrogen and progesterone together are important for producing negative feedback at hypothalamus. Without this negative feedback, the GnRH increases and ultimately so does LH and FSH
These patients are phenotypically normal males that are very tall. They have normal fertility and may have severe acne, learning disability, or autism
Double Y males
47,XYY
Ovotesticular disorder of sex development
46,XX > 46, XY
Both ovarian and testicular tissue present (ovotestis)
Ambiguous genitalia
used to be called true hermaphorditism
Patient has high testosterone and high LH
Defective androgen receptor
Patient has high testosterone and low LH
Testosterone secreting tumor
Exogenous steroids
Patient has low testosterone and high LH. Give example of syndrome
Hypergonadotropic hypogonadism (primary)
ex) turners syndrome
Patient has low testosterone and low LH. Give example of syndrome
hypogonadotropic hypogonadism (secondary)
ex) kallman syndrome
Patient has ovaries but their external genitalia are virilized or ambiguous
46,XX disorder of sexual development
can be due to congenital adrenal hyperplasia or exogenous administration of androgens during pregnancy
Patient has test present but external genitalia are female or ambigious
46,XY disorder of sexual development
most common form is androgen insensitivity syndrome resulting in testicular feminization
phenotypic sex
external genitalia
influenced by hormone levels
Gonadal sex
internal genitalia (ovaries vs testes)
influenced by y chromosome
If patient has a uterus but no breasts
hypergonadotropic hypogonadism
or
hypergonadotropic hypogonadism
If patient has no uterus but has breasts
uterovaginal agenesis in genotypic female
or
androgen insensitivity in genotypic male
if patient has no uterus or breasts
male genotype with insufficient production of testosterone
placental aromatase deficiency
inability to synthesize estrogens from androgens. Results in an increase in testosterone and androstenedione
results in masculinization of female (46, XX DSD) infants –> ambiguous genitalia
can present with mother being virilized during pregnancy due to fetal androgens crossing the placenta
female external genitalia with rudimentary vagina
no uterus or fallopian tubes
Normal functioning testes that are found in labia majora
androgen insensitivity syndrome - defect in androgen receptor resulting in normal appearing female (46,XY DSD)
high testosterone, estrogen, LH
Patient presented with ambiguous genitalia until puberty. Then the rise in testosterone causes masculinization and growth of external genitalia
5α-Reductase deficiency
autosomal recessive
genetic males (46,XY DSD)
unable to convert testosterone to DHT
Testosterone and estrogen levels are normal
LH can be normal or high
Internal genitalia normal
This patient failed to complete puberty due to defective migration of GnRH releasing neurons and subsequent failure of GnRH releasing olfactory bulbs to develop. There is a decrease in synthesis of GnRH in the hypothalamus
kallman syndrome
hypogondotropic hypogonadism
hyposmia/anosmia, low GnRH, FSH, LH and testosterone
infertility (low sperm in males and amenorrhea in females)
Cystic swelling of chorionic villi and proliferation of chorionic epithelium (only trophoblast)
hydatidiform mole
presents with vaginal bleeding, uterine enlargement more than expected, pelvic pressure/pain, early preeclampsia, theca-lutein cysts, hyperemesis gravidarum, hyperthyroidism
hCG mediated sequelae
Complete hydatidiform mole
karyotype: 46,XX or 46,XY
most commonly enucleated egg + single sperm
no fetal parts present uterine size increased very high increase in hCG "honeycombed"uterus or "cluster of gapes" "snowstorm" on ultrasound
complete has a greater risk of malignancy (15-20%)
Partial hydatiform mole
karyotype: 69,XXX; 69, XXY; 69 XYY
due to 2 sperm + 1 egg
there are some fetal parts present
normal uterine size
increase in hCG
Imaging shows fetal parts
Malignancy of trophoblastic tissue (cytotrophoblasts, syncytiotrophoblasts)
choriocarcinoma
- No chorionic villi present
- Increase frequency of bilateral/multiple theca-lutein cysts
- Abnormal increase in beta hCG (pregnancy)
- Shortness of breath
- Hemoptysis
- Hematogenous spread to lungs causing “cannonball” metastases
Abruptio placentae
premature separation (partial or complete) of placenta from uterine wall before delivery of infant
patient presents with abrupt painful bleeding in third trimester.The bleeding can be concealed or apparent.
complications: DIC, maternal shock, fetal distress, life threatening for mother and baby
Morbidly adherent placenta
Defective decidual layer resulting in abnormal attachment and separation after delivery.
often detected on ultrasound prior to delivery. No separation of placenta after delivery results in postpartum bleeding and possible sheehan syndrome
Sheehan’s syndrome, also known as postpartum pituitary gland necrosis, is hypopituitarism (decreased functioning of the pituitary gland), caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth
Three types of morbidly adherent placenta
1) placenta accreta
2) placenta increta
3) placenta percreta
Placenta accreta
most common type of morbidly adherent placenta
placenta attaches to myometrium without penetrating it
thing accreta or “attaches”
Placenta increta
type of morbidly adherent placenta
placenta penetrates into the myometrium
think increta “into”
Placenta percreta
placenta penetrates/perforates through myometrium and into uterine serosa (invades the uterine wall)
placental attachment to rectum or bladder can cause hematuria
think percreta “ perforates”
Placenta previa
attachment of placenta to lower uterine segment over (or <2 cm from) internal cervical os
painless third trimester bleeding
a “preview” of the placenta is visible through cervix
partial - only part of placenta over internal cervical os
complete- all of internal cervical os is covered by placenta
Vasa previa
fetal vessels run over or in close proximity to cervical os
may result in vessel rupture, exsanguination, fetal death.
associated with velamentous umbilical cord insertion (Cord inserts in chorioamniotic membrane rather than placenta) and thus fetal vessels travel to placenta unprotected by wharton jelly
patient presents with membrane rupture, painless vaginal bleeding and fetal bradycardia (<110 beats/min). What is the next step?
patient has vasa previa
emergency C section
4 Ts of postpartum hemorrhage
Tone (uterine atony is most common cause)
Trauma
Thrombin
Tissue (retained products of conception)
Ectopic pregnancies commonly occur at?
ampulla of the fallopian tube
hCG seen with ectopic pregnancy
lower than expected rise in hCG based on dates
can often be msitake with appendicitis
polyhydramnios
too much amiotic fluid
due to inability to swallow amniotic fluid (esophageal/duodenal atresia, anencephaly),
maternal diabetes, fetal anemia, multiple gestations
Oligohydramnios
too little amniotic fluid
associated with placental insufficiency, bilateral renal agenesis, posterior urethral valves (in males) and resultant inability to excrete urine
can cause potter sequence
potter sequence
Potter sequence is the atypical physical appearance of a baby due to oligohydramnios experienced when in the uterus. It includes clubbed feet, pulmonary hypoplasia and cranial anomalies related to the oligohydramnios.
Gestational hypertension
BP > 140/90 after 20th week of gestation
no preexisting hypertension
no proteinuria
no end organ damage
treat: antihypertensives (hydralazine, α-methyldopa, labetalol, nifedipine)
preeclampsia
new-onset hypertension with either proteinuria or end organ dysfunction after 20th week of gestation ( <20 wks suggests a molar pregnancy)
caused by abnormal placental spiral arteries –> endometrial dysfunction, vasoconstriction, ischemia
treat: antihypertensives, IV magnesium sulfate (to prevent seizure), definitive is delivery of fetus
eclampsia
preeclampsia + maternal seizures
maternal death due to stroke, intracranial hemorrhage, or ARDS
treat: IV magnesium sulfate, antihypertensives, immediate delivery
HELLP syndrome
Hemolysis
Elevated Liver enzymes
Low Platelet
due to severe preeclampsia
treat with immediate delivery
can lead to DIC and hepatic subcapsular hematomas –> rupture –> severe hypotension
incidence of gyn tumors
in us: endometrial > ovarian > cervical
worldwide: cervical is more common
prognosis? Cervical> endometrial > ovarian
bartholin cyst and abscess is related to what kind of infection
N gonorrhoeae
Lichen sclerosus
thinning of epidermis with fibrosis/sclerosis of dermis
postmenopausal women
benign but slightly increased risk of SCC
Lichen simplex chronicus
hyperplasia of vulvar squamous epithelium
benign
no risk of SCC
presents with leathery, thick vulvar skin with enhanced skin markings due to chronic rubbing or scratching
HPV related vulvar carcinoma
HPV types 16 and 18
Non HPV related vulvar carcinoma
related to long standing lichen sclerosus in females >70 yo
Vaginal SCC is usually secondary to
cervical SCC
What type of vaginal tumor are women at risk for after exposure to DES in utero
clear cell adenocarcinoma
patient is a 3 yo girl with clear, grape like, polypoid mass emerging from vagina
sarcoma botryoides
spindle shaped cells
Desmin +
embryonal rhabdomyosarcoma variant
Dysplasia and carcinoma in situ
begins at basal layer of squamocolumnar jnction (transformation zone) and extends outward
classified as CIN1,CIN2,CIN3 (severe, irreversible dysplasia or carcinoma in situ) depending on extent of dysplasia
HPV 16 and 18
how does HPV 16 and 18 cause dysplasia
both produce the E6 gene product that inhibits p53 and the E7 gene product that inhibits pRb
______ are pathognomonic of HPV infection
koilocytes
primary ovarian insufficiency
signs of menopause after puberty but before age 40
decrease estrogen, increase LH and FSH
Polycystic ovarian syndrome or Stein-leventhal syndrome
- enlarged bilateral cystic ovaries
- hyperinsulinemia and or insulin resistance hypothesized to alter hypothalamic hormonal feedback response that causes increase in LH:FSH
- increase in androgens from theca interna cells
- decreases rate of follicular maturation –> unruptured follicles (cysts) + anovulation. Repeated anovulatory cycles results in an increased risk of endometrial cancer secondary to unopposed estrogen
Most common ovarian mass in young women
follicular cyst due to distention of unruptured graafian follicle
Theca-lutein cysts
bilateral and multiple
due to gonadotropin stimulation
associated with choriocarcinoma and hydatidiform moles
Most common adnexal mass in women >55 yo
ovarian neoplasms
risk decreases with previous pregnancy
Majority of malignant ovarian neoplasms are
epithelial (serous cystadenocarcinoma is most common)
What marker is helpful in monitoring response to therapy for ovarian neoplasms
CA 125
Surface epithelial tumors - ovarian neoplasms
Benign
1) serous cystadenoma - bilateral, fallopian tube like epithelium
2) Mucinous cystadenoma -lined by mucus secreting epithelium
3) endometrioma - endometriosis within ovary with cyst formation
Chocolate cyst is related to what kind of tumor
endometrioma filled with dark, reddish brown blood
endometriosis within ovary with cyst formation
Germ cell tumors - ovarian neoplasms
Mature cystic teratoma (dermoid cyst)
Benign
most common ovarian tumor in females 10-30 yo
cystic mass with elements of all 3 germ layers
monodermal form with thyroid tissue (struma ovarii) uncommonly presents with hyperthyroidism
Sex cord stromal tumors - ovarian neoplasms
Benign
1) Fibroma - bundles of spindle shaped fibroblasts causing Meigs syndrome.
2) Thecoma - granulosa cell tumors that may produce estrogen
Patient presents with pulling sensation in groin. Also has the triad of ovarian fibroma, ascites, hydrothorax
Meigs syndrome
Patient presents with abnormal uterine bleeding and is postmenopausal. What ovarian tumor are you worried about
thecoma - a sex cord stromal tumor
benign
Brenner tumor
resembles bladder epithelium (transitional cell tumor)
pale yellow tan and appears encapsulated
coffee bean nuclei on H&E stain
usually benign
Most common malignant ovarian neoplasm
surface epithelium tumor : serous cystadenocarcinoma
bilateral
psammoma bodies
Surface epithelium ovarian tumors that are malignant
1) serous cystadenocarcinoma
2) mucinous cystadenocarcinoma
What is a complication associated with mucinous cystadenocarcinoma
pseudomyxoma peritonei- intraperitoneal accumulation of mucinous material
Germ cell ovarian tumors that are malignant
1) dysgerminoma
2) Immature teratoma
3) tolk sac tumor
dysgerminoma
most common in adolescents
equivalent to male seminoma
sheets of uniform “fried egg” cells
hCG and LDH= tumor markers
Immature teratoma
aggressive, contains fetal tissue, neuroectoderm
dx before 20 yo
Yolk sac tumor
ovarian endodermal sinus tumor
aggressive
in ovaries or testes and sacrococcygeal area in young children
yellow, friable (hemorrhagic), solid mass
50% have schiller duval bodies that resemble glomeruli
AFP=tumor marker
most common germ cell tumor in male infants
yolk sac tumor
most common malignant sex cord stromal tumor
granulosa cell tumor
women in 50s
often produces estrogen and progesterone and causes postmenopausal bleeding, sexual precocity (in preadolescents) , breast tenderness
Call-exner bodies - granulosa cells arranged haphazardly around collections of eosinophilic fluid, resembling primordial follicles
krukenberg tumor
Gi malignancy that metastasizes to ovaries –> mucin secreting signet cell adenocarcinoma
commonly presents as bilateral ovarian masses
Patient presents with dysmenorrhea, menorrhagia, uniformly enlarges soft globular uterus
adenomyosis
extension of endometrial tissue (glandular) into uterine myometrium
caused by hyperplasia of basal layer of endometrium
Patient presents with decreased fertility, recurrent pregnancy loss, abnormal uterine bleeding, pelvic pain
Asherman syndrome
adhesions and or fibrosis of endometrium
Most common tumor in females
Leiomyoma (fibroid)
Leiomyoma (fibroid)
multiple discrete smooth mm tumors
estorgen sensitive therefore tumor size increases with pregnancy and decreases with menopause
20-40 yo
severe bleeding may lead to iron deficiency anemia
whorled pattern of smooth mm bundles with well demarcated borders on histology
Most common gynecologic malignancy
endometrial carcinoma
55-65 yo
preceded by endometrial hyperplasia
risk factors: prolonged use of estrogen without progestins, nulliparity, late menopause, early menarche, lynch syndrome etc
chronic endometritis characterized by presence of ____ on histology
plasma cells
tx with gentamicin + clindamycin +/- ampicillin
Fibrocystic breast changes
common in women < 35 yo
premenstrual breast pain or lumps
1) sclerosing adenosis - acini and stromal fibrosis associated with calcifications
2) epithelial hyperplasia - cells in terminal ductal or lobular epithelium. Increased risk of carcinoma with atypical cells
Fat necrosis in breast
Inflammatory process
benign usually painless lump due to injury to breast tissue
mammography: calcified oil cyst
Biopsy: necrotic fat and giant cells
Lactational mastitis
occurs during breastfeeding and increases risk of bacterial infection through cracks in nipple
treat with antibiotics and continue breast feeding
inflammatory process
most common pathogen in lactational mastiitis
S. aureus is most common pathogen
FIbroadenoma in breast
women < 35 yo
benign - no increased risk of cancer
small, well defines, mobile mass
increase size and tenderness with increased estrogen
Intraductal papilloma
benign - small fibroepithelial tumor within lactiferous ducts typically beneath areola
most common cause of nipple discharge (serous or bloody)
slight increased risk of cancer
Phyllodes tumor
benign
large mass of connective tissue and cysts with leaf like lobuations
most common in 5th decade
some may be malignant
drugs that commonly cause gynecomastia
spironolactone
cimetidine
finasteride
ketoconazole
Malignant breast tumors
postmenopausal common
usually arise from terminal duct lobular unit
axillary lymph node involvement indicating metastasis is the most important prognostic factor in early stage disease
most often located in upper outer quadrant of breast
genetics behind malignant breast tumors
amplification/overexpression of estrogen/progesterone receptors or c-erbB2 (HER-2 an EGF receptor) is common
triple negative (ER -, PR - , Her2/Neu - ) are more aggressive
Ductal carcinoma in situ
fills ductal lumen
Arises from ductal atypia. often seen early as microcalcifications on mammography
early malignancy without basement membrane penetration
Comedocarcinoma
ductal, central necrosis
subtype of ductal carcinoma in situ
Paget disease results from
results from underlying ductal carcinoma in situ or invasive breast cancer
Patient notices a firm, fibrous, rock hard mass with sharp margins and small glandular duct like cells in her breast. What tumor is she most likely to have?
Invasive ductal carcinoma - most common and is 75% of breast cancers
tumor can deform suspensory ligament and cause dimpling of skin
classic morphology of stellate infiltration
invasive lobular carcinoma of breast
orderly row of cells “single file” due to decreased E-cadherin
invasive
often bilateral with multiple lesions in the same location
medullary carcinoma of breast
invasive
fleshy cellular lymphocytic infilrate
good prognosis
inflammatory breast cancer
dermal lymphatic invasion of breast carcinoma
poor prognosis
Patient has a peau d’ orange sign , what kind of breast cancer does this indicate
inflammatory breast cancer due to dermal lymphatic invasion by breast carcinoma
skin texture change due to edema leading to tightening of coopers suspensory ligament
neoplastic cells block lymphatic drainage
Patient presents with abnormal curvature of penis due to fibrous plaque within the tunica albuginea
peyronie disease
Penile fracture is due to rupture of ______ due to forced bending
corpora cavernosa
Painful sustained erection lasting >4 hours
ischemic priapism
due to meds and sickle cell disease (block venous drainage)
SCC in the penis is due to many precursor in situ lesions
Bowen disease - leukoplakia
Erythroplasia of Queyrat - erythroplakia
Bowenoid papulosis - present as red papules
Sperm develops best at what temperature
37 celcius
why do patients with cryptorchidism have normal testosterone levels
because leydig cells are unaffected by the rise in temperature
only low if bilateral
what labs do you see in a patient with cryptorchidism
low inhibin B
high FSH and LH
testicular torsion involves the rotation of testicle around _____ and _____. Commonly present with an absent ____ reflex
spermatic cord and vascular pedicle
cremasteric reflex
Surgical procedure used to treat testicular torsion
Orchiopexy - move testicle into scrotum and permanently fix it there
do it to other testicle too because it is susceptible
Varicocele is due to dilated veins in the ________ plexus due to increased venous pressure
pampiniform plexus
Varicocele is diagnosed by
standing clinical exam / valsalva maneuver
doppler
does not transilluminate
Extragonadal germ cell tumors
arise in midline locations
in adults most commonly in retroperitoneum, mediastinum, pineal, and suprasellar regions
congenital hydrocele (scrotum) is due to
incomplete obliteration of processus vaginalis
spontaneously resolve by 1 yo
spermatocele
cyst due to dilated epididymal duct or rete testis
paratesticular fluctuant nodule
95% of all testicular tumors are ______ cell tumors
germ cell tumors
young men
risk factors: cryptorchidism and klinefelter syndrome
do not transilluminate
How do you test/treat testicular germ cell tumors
do not biopsy because it can seed
removed via radical orchiectomy
seminoma
most common testicular tumor
malignant germ cell tumor of testicle
painless, homogenous testicular enlargement
large cells in lobules with watery cytoplasm and fried egg appearance
increase placental ALP
similar to dysgerminoma in females. late metastasis. excellent prognosis
yolk sac tumor or testicular endodermal sinus tumor
Testicular germ cell tumor
yellow mucinous aggressive malignancy of testes
analogous to ovarian yolk sac tumor
schiller duval bodies resemble primitive flomeruli
increased AFP is highly characteristic
most common testicular tumor in boys <3 yo
yolk sac tumor or testicular endodermal sinus tumor
Choriocarcinoma
malignant
increased hCG
disorder syncytiotrophoblastic and cytotrophoblastic elements
hematogenous metastases to lungs and brain
may produce gynecomastia, hyperthyroidism due to alpha subunit of hCG being similar to TSH
Mature teratoma in males vs children
may be malignant but benign in children
testicular germ cell tumor
Embryonal carcinoma
testicular germ cell tumor
malignant hemorrhagic mass with necrosis
painful, worse prognosis than seminoma
often glandular/papillary morphology and usually mixed tumor types
increased AFP if mixed
normal AFP if pure
Testicular non germ cell tumors are mostly _____
benign
Leydig cell tumor
testicular non germ cell tumor
golden brown color that contains Reinke crystals (eosinophilic cytoplasmic inclusions)
produces androgens or estrogens –> gynecomastia in men and precocious puberty in boys
sertoli cell tumor
testicular non germ cell tumor
androblastoma from sex cord stroma
testicular lymphoma
testicular non germ cell tumor
most common testicular cancer in older men
arises from metastatic lymphoma to testes
aggressive
benign prostatic hyperplasia involves enlargement of waht lobes of the prostate
periurethral lobes
increased PSA
treatment for benign prostatic hyperplasia
alpha1-antagonists to relax urethra smoothmm
5alpha reductase inhiitors
PDE5 inhibitors
surgical resection
prostatitis
dysuria frequency urgency low back pain warm, tender, enlarged prostate
acute bacterial prostatitis in older men (pathogen)
E. Coli
acute bacterial prostatitis in younger men (pathogen)
C trachomatis
N gonorrhoeae
Chronic prostatitis
either bacterial or nonbacterial
prostatic adenocarcinoma
men > 50 yo
posterior lobe more common (peripheral zone)
diagnosed with increased PSA and subsequent needle core biopsy
osteoblastic metastases in bone may develop in late stages as indicated by lower back pain and icnreased serum ALP and PSA
Useful markers in prostatic adenocarcinoma
prostatic acid phosphatase (PAP)
and PSA
increase in total PSA
decrease fraction of free PSA
