Reproductive AP Flashcards
1
Q
Ovarian and Uterine blood supply?
A
- ovarian artery comes off of the aorta: feeds ovary, fallopian tube, uterus, anastomes with uterine artery
- internal iliac artery feeds uterine, vaginal, middle rectal, and internal pudendal artery
2
Q
Relationship of uterine artery and ureter?
A
- ureter is underneath the uterine artery
3
Q
Anatomic variations in position of the uterus?
A
- mid-position
- anteverted (MC variation)
- anteverted and anteflexed
- retroverted
- retroverted and retroflexed
4
Q
Why are there so many diff uterine anomalies?
A
- b/c in fetal development first mullerian or paramesonephric ducts form fallopian tubes and then fuse caudally to form uterus, cervix, and upper vagina
- usually don’t notice any problems until pregnancy (early labor, miscarriage)
5
Q
What are gartner’s duct and cyst?
A
- remnants of male reproductive system - from : sites of mesonephric duct remnants - epoophoron (by ovaries), cervix, and vagina
6
Q
DES was assoc with what?
A
- b/t 1941-71 given to 3 mill preg ladies to decrease miscarriages
- in 1971 - fetal exposure in daughters assoc with rare clear cell adenocarcinoma vaginal cancers in girls 14-22
- later assoc with uterine anomalies (T shaped uterus) which increased preg. complications and infertility as well as increased risk of cervical and breast cancer
(women now 45 and older) - exposed sons: increased risk of cryptorchidism, hypogonadism, and epidymal cysts
- mothers have modest increase risk of breast cancer
7
Q
Pelvic types?
A
- round = gynecoid
- wedge = android
- oval = platypelloid
- oval-long = anthropoid
8
Q
How many eggs are left at puberty? How many get the chance to develop? How many ovulations are in a lifetime?
A
- 500,000 eggs left at puberty
- only 8,000 have chance to develop
- 400-500 ovulations in a lifetime
9
Q
Where is hypothalamus located? Circulation to anterior pituitary?
A
- located at base of brain, just above junction of optic nerves
- hypothalamic-hypophyseal portal circulation: blood supply of anterior pituitary originates in hypothalamus - no direct nerve connections
10
Q
5 hormones that hypothalamus releases?
A
- GnRH - gonadotropin releasing hormone
- TRH - thyrotropin releasing hormone
- SRIF - somatotropin release inhibiting factor
- CRF - corticotropin releasing factor
- PIF - prolactin release- inhibiting factor = dopamine
11
Q
What are anterior and posterior pituitaty glands derived from? Main fxns?
A
- anterior (adenohypohysis): derived from ectoderm, diff cell types that produce 6 diff hormones
- posterior (neurohypophysis): derived from neural tissue, transports oxytocin and vasopressin
12
Q
Hormones produced by anterior pituitary?
A
- FSH - gonadotrophs (ovaries)
- LH - gonadotrophs (ovaries)
- TSH - thyrotrophs
- prolactin - lactotrophs (breast)
- GH
- ACTH - MSH (melanocyte stim hormone - Addison’s)
13
Q
Effect of secretion of GnRH from (arcuate nucleus) hypothalamus?
A
- stim by NE
- inhibited by dopamine (PIF)
- influenced by endogenous opioids
- low pulse frequency triggers FSH
- high pulse frequency triggers LH
14
Q
How does GnRH reach the anterior pituitary? What does this stimulate?
A
- by hypothalamic pituitary portal vascular system and stimulates secretion of FSH and LH
15
Q
What does low levels of LH stimulate?
A
- stimulate secretion of androgens (testosterone and androstenedione) from theca cells, these androgens are converted to estrogens in granulosa cells
16
Q
What does FSH stimulate?
A
- secretion of estrogens (estradiol and estrone) by granulosa cells of ovarian follicles
17
Q
When does FSH and LH spike?
A
- LH spikes 36 hrs b/f ovulation
18
Q
When does estrogen spike? Progesterone?
A
- estrogen spikes - during end of follicular proliferative phase (the granulosa cells of chosen follicle is making estrogen)
ovulation occurs 36 hrs after LH surge - progesterone spikes during luteal secretory phase
19
Q
Feedback mechanism of estrogen and LH?
A
- initially estrogen creates negative feedback to pituitary to decrease LH and FSH
- in late follicular phase, peak estradiol levels from dominant follicle trigger a midcycle surge of LH needed for ovulation and preparing the ovary to make progesterone
20
Q
What secretes progesterone? What phase of menstrual cycle begins?
A
- with ovulation, dominant follicle becomes a progesterone secreting cyst called corpus luteum and luteal phase of menstrual cycle begins?
21
Q
Negative feedback of progesterone?
A
- negative feedback on pituitray secretion of LH and FSH causes decreasing E and P to be made in corpus luteum
22
Q
What occurs to progesterone levels if there is no conception?
A
- lifespan of corpus luteum is then 9-11 days, and then progesterone levels fall
- menstrual period is triggered
- negative feedback for FSH secretion stops and FSH levels start to rise b/f onset of menses
23
Q
What occurs to progesterone levels if there is implantation?
A
- HCG (human chorionic gonadotropin) from zygote sustains corpus luteum for 6-7 wks until placenta takes over
- this is time when a lot of miscarriages occur, hard to transition with change in hormones
24
Q
Characteristics of follicular (proliferative) phase - what hormone dominates?
A
- estrogen dominates
- development of mature follicle
- culminates with LH surge preceding ovulation (LH surge necessary for ovulation)
25
Q
Characteristics of luteal (secretory) phase - what hormone dominates?
A
- reqrs that ovulation has occurred
- progesterone dominant
- elevated basal body temp
- further prepares uterine lining (endometrium) to receive fertilized egg
26
Q
Importance of estrogen - on diff parts of body?
A
- breast: pubertal development
- endometrium: stim cell growth (proliferative phase)
- cervix: stimulates abundant, clear mucus at mid cycle (helps with motlity of sperm)
- vagina: growth and maturation of epithelium, lubrication
- bone: helps to maintain density, estrogen receptors in osteoblasts
- brain: we don’t really know
27
Q
Importance of progesterone on diff parts of body?
A
- thermogenic effects at level of hypothalamus: increase BBT by 0.5-1.F
- cervical mucus thickens and decreases in amt (prevents sperm from easy travel)
- breasts: stim of ducts, nipple and areola contributes to fullness and tenderness
- fallopian tubes: decrease mucus and causes relaxation to speed transport of ovum
28
Q
What are diff ways to tell if ovulation has occurred?
A
- track length of menstrual cycles
- serial transvaginal US to follow follicular development from dominant follicle to corpus lute
- measure LH surge (OTC urine kits):
ovulation 36 hrs after LH surge, LH shows up in urine 12 hrs after surge - LH also increased with PCOS, POI, and menopause
- BBT rises 0.5-1.0 defree F
- measure serum progesterone at mild luteal phase: expect more than 6 ng/ml
- ovulation to menses: 12-14 days
- menses to ovulation - more variable
29
Q
What is the reproductive physiology of breasts - when does it present, what occurs during pregnancy? What is thelarche?
A
- both males and female infants may have palpable breast tissue at birth. Some will have galactorrhea - an effect of maternal hormones
- by 2-3 months of age, the breast tissue regresses
- thelarche: onset of breast development starts at 12.5 in US in 95% of girls
- growth during pregnancy from hormones including: prolactin, estrogen, progesterone, cortisol, insulin, thyroid hormones, and growth hormone
30
Q
Composition of the breasts?
A
- nipple
- areola
- milk glands (lobules)
- ducts: transport milk from glands
- connective (fibrous) tissue that surrounds the lobules and ducts
- fat
31
Q
What happens to the breasts during pregnancy?
A
- breasts increase in size: increase in lobules= alveoli lined by milk secreting epithelial cells
- the release of estrogen and progesterone from the placenta and prolactin from the anterior pituitary causes breast development
- breast milk production: inhibited during pregnancy by effect of progesterone on prolactin
32
Q
lactation physiology?
A
- colostrum produced first 3-6 days
- milk production stimulated by prolactin, prolactin release stimulated by direct stimulation of the nipple
- milk ejection results from nipple stimulation: neuro endocrine reflex with release of oxytocin
- neuro-endocrine reflex disturbed by maternal tension resulting in problems with nursing
33
Q
What are diff causes of galactorrhea?
A
this is non-physiologic milky d/c from nipples
- idiopathic
- meds: tranquilizers, antidepressants, antiHTN meds, herbal supplements, birth control pills
- hypothyroidism
- pituitary tumors
- stimulation of breasts
- chest surgery, burns, nerve damage from injury
- spinal cord injury
34
Q
Duration of the menstural cycle? Define Menarche and menopause?
A
- majority are b/t 24-35 days and are ovulatory
- about 15% are 28 days
- less than 1% are less than 21 or more than 35 days
- menarche: first menses
- menopause: final menses
35
Q
Diff phases of menstrual cycle?
A
- follicular: begins with onset of menses and ends with LH surge
ovulation occurs w/in 36 hrs of LH surge - luteal phase: begins with LH surge and ends with onset of next menses
- day 1 is 1st day of menses and date used in LMP
36
Q
Usual age of first menses? What is this the onset of?
A
- age of first menses: US median age: 12.5
- one of final events in continuum of puberty: onset of puberty signals reactivation of hypothalamic-pituitary gonadal axis with pulsatile Gn-RH secretions
37
Q
What is puberty?
A
- endocrine process that influences physical, sexual and emotional transition from childhood to adulthood
- triggers for onset not well defined
- US: puberty starting 6-12 months earlier than last century
38
Q
Sequence of events in puberty?
A
sexual maturation extends about 4.5 yrs
- growth acceleration
- breast development (thelarche) - in US by age 12.5 in 95%
- pubic hair development (pubarche): preceded by increased adrenal androgen production (adrenarche), and axillary hair development
- max growth rate
- menarche (further ht limited to about 2.4 in)
- ovulation
39
Q
What is onset of puberty influenced by?
A
- ethnic background: African American earlier, then Mexican American, then white and then Asian American
(black girls begin around 8-9 but can be as early as 6, white girls around 10 but as early as 7 is normal) - BMI: higher the earlier onset - possible effect of leptin (from adipocytes) on pulsatile GnRH secretion
- genetics
- possible role of enviro toxins acting as endocrine disruptors (pesticides, fertilizers)
40
Q
Role of estrogens in puberty?
A
- augments accrual of bone during puberty. 2 estrogen receptors (alpha and beta) mediate the actions of estrogen, and presence of both has been demonstrated in growth plate
- contributes to growth plate fusion at end of puberty
- stimulates breast development
41
Q
What hormone causes pubertal growth spurt?
A
- Growth Hormone
- pulsatile release from pituitary
- both GH and sex steroids contribute to growth and epiphyseal fusion
- stimulates secretion of IGF-1
42
Q
What is delayed puberty?
A
- absent or incomplete seual maturation by age at which 95% of girls started pubertal development:
- absence of secondary sexual characteristics by age 13
- absence of menarche by 15-16
- no menarche 5 yrs after onset of thelarche (breast development)
43
Q
Causes of delayed puberty?
A
- hypergonadotrophic hypogonadism: FSH greater than 35 - gonadal dysgenesis (turner’s syndrome)
- hypogonadotropic hypogonadism: FSH and LH less than 10 -
constitutional (physiologic delay) of HPO. Suppression of HPO axis by illness, malnutrition or excessive exercise
Elevated prolactin (certain drugs, pituitary tumors)
Kallman syndrome (genetic) - anatomic:
Imperforate hymen/transverse vaginal septum
Mullerian agenesis: absence of uterus, cervix, and upper vagina
44
Q
What is precocious puberty? What is this caused by?
A
- onset of secondary sexual characteristics b/f age 6 in black girls and prior to 7 in white girls (or more than 2 SD from normal)
- caused by early sex hormone production
45
Q
Evaluation goals of precocious puberty?
A
- define cause, determine if tx is necessary and minimize psychosocial impact
- hx and exam (tanner staging)
- xray of non-dominate wrist and hand for bone age: premature closure of epiphyseal plates limits stature
- lab
- pelvic sono
- MRI of brain
46
Q
Causes of GnRH-dependent (central) precocious puberty?
A
early activation of HPO with both breast and pubic hair development
- 90% idiopathic (dx of exclusion: MRI)
- CNS lesions (tumor, hydrocephalus), trauma, inflammatory disease
- severe hypothyroidism: high TSH activates FSH receptor
- generally tx with GnRH agonist
47
Q
Causes of Gn-RH independent (peripheral) precocious puberty?
A
- autonomous fxnl ovarian cysts
- McCune-Albright syndrome (rare genetic disorder)
- adrenal pathology: nonclassical congenital adrenal hyperplasia (CAH). May mimic PCOS due to accompanying hyperadrogenism, adrenal tumors
- exposure to exogenous estrogens or xenoestrogens (endocrine disruptors which mimic estradiol)
48
Q
What is menopause? Median age?
A
- permanent cessation of menses: retrospective dx: no period for 12 months w/o other explanation = post menopause
- median age: 51.4, primary ovarian insufficiency (premature ovarian failure): cessation of menses prior to 40, confirmation of infertility is a common concern
49
Q
What is happening with the hormones in menopause?
A
- ovaries are no longer listening to brain - the oocytes are resistant to FSH:
this represents depletion (or near depletion) of follicles
FSH, although elevated is seldom needed for dx unless confirmation of infertility is a concern
50
Q
What occurs secondarily to estrogen loss in postmenopause?
A
- urogenital atrophy
- increase in LDL and decrease in HDL
- decrease in bone density: estrogen acts to maintain the appropriate ratio b/t bone-forming osteoblasts and bone-resorbing osteoclasts in part through the induction of osteoclast apoptosis
- vasomotor sxs (hot flashes)
