Things I don't know: Ob/gyn Flashcards
1
Q
When and from what to germ cells originate?
A
4th week of embryonic life
endoderm of yolk sac
2
Q
When/how do germ cells form primitive gonad?
A
6th week embryonic life
germ cells migrate to genital ridge and associate with somatic cells
3
Q
What type of errors occur in older men vs. older women?
A
men: mitotic errors
women: chromosome errors
4
Q
How does the number of sperm produced differ from the number of ova?
A
sperm: many millions, ongoing process after puberty
eggs: 2.5 million at birth (already have all you will make at this point), most degenerate, left with about 400 ova in reproductive years
5
Q
When do oogonia
- begin meiosis I
- what phase does meiosis I arrest
- when is meiosis I complete
- what phase does meiosis II arrest
- when is meiosis II complete
A
- month 3 of embryonic development
- prophase: diakinesis stage (as primary oocyte)
- ovulation
- metaphase (as secondary oocyte)
- fertilization
6
Q
What separates?
Are the products identical or different (ignoring recombination)?
What would be the chromosome result be if nondisjunction occurred and a trisomy child was born?
1. Meiosis I
2. Meiosis II
A
- homologs; different; all 3 chromosomes are different
- sister chromatids; identical; 2 chromosomes match (look at centromeric DNA that is not involved in crossing over), 1 is different
7
Q
order of mitosis/meiosis
A
Prophase
Metaphase
Anaphase
Telophase
8
Q
leptotene
A
1st stage prophase
chromosomes have replicated but lie on top of each other
9
Q
zygotene
A
2nd stage prophase
homologous pairs move together and pair or synapse
10
Q
pachytene
A
3rd stage prophase
first time you can see bivalent chromosome: CHEERLEADER pose
2 homologous chromosomes now look like a tetrad
11
Q
diplotene
A
4th stage prophase
CROSSING OVER occurs at CHIASMATA
12
Q
diakinesis
A
5th stage prophase
oogenesis is frozen here until ovulation
13
Q
chiasmata
A
areas of contact between homologs allowing crossing over
14
Q
metaphase
A
nuclear membrane disappears
spindles appear
pairs align on metaphase plate
15
Q
anaphase
A
homologs/sister chromatids pulled apart by spindles attached to centromeres
16
Q
telophase/cytokinesis
A
cell division
17
Q
When does nondisjunction occur?
What will be the status of the chromosomes if a trisomy child is born of it?
A
Meiosis I
all chromosomes are different
18
Q
Insl-3 (insulin-like substance 3)
A
produced by gonad
play role in testicular descent
19
Q
If a child has streak gonads or no SRY gene (regardless if XX or XY), what will they look like?
A
no AMH: uterus, fallopian tubes
presents at female with no breasts or periods
20
Q
Common findings in people with mullein duct abnormalities (MDA)
A
infertility
endometriosis
renal anomalies
21
Q
When does the uterovaginal septum resorb?
A
9-12 weeks gestation
22
Q
unicornate uterus
- uterus
- ovaries
- kidneys
- pregnancy considerations
A
- development of only one horn of uterus
- two
- ipsilateral (same side) renal anomalies
- pregnancy: normal outcome, preterm labor, malpresentation
23
Q
uterus didelphys
- uterus
- ovaries
- kidneys
- pregnancy considerations
A
complete failure of duct fusion
- two: separate uteri, upper vagina (lower may be separated by septum), cervizes
- two
- renal AGENESIS
- normal, preterm
24
Q
T shaped uterus
A
DES exposure in utero
risk for clear cell carcinoma of vagina and pregnancy loss
25
Rokitansky Kunster Hauser syndrome
1. uterus
2. ovaries
3. kidneys
4. pregnancy considerations
complete agencies of Mullerian structures
present: amenorrhea
1. NO upper vagina, cervix, uterus or tubes
2. 2 (has breast development)
3. anomalies, skeletal anomalies (bifid vertebra)
4. infertility
Tx: create neovagina
26
imperforate hymen
failure of reabsorption of uterovaginal septum
presentation: amenorrhea, cyclic pain, abdominal mass
Tx: hymenotomy (sew it open)
27
Risk factors you wouldn't think of for ectopic
IVF
| endometriosis
28
Dx and Tx unstable ectopic
Dx: blood in abdomen, acute abdomen, blood loss (tachycardia, hypotension, anemia)
Tx: blood type and laparotomy
29
Dx and Tx stable ectopic
counsel about rupture
1. quantitative hCG: normally would double in 48 hours
2. progesterone: less than 5 means failed pregnancy
48 hours later
3. curette uterus: products of conception mean SAB; none mean ectopic
Tx: laparoscopy or METHOTREXATE
30
progesterone less than 5
FAILED pregnancy
| ectopic of spontaneous abortion
31
When is methotrexate appropriate to Tx ectopic? What do you need to do after Tx?
1. mass smaller than 5cm
2. no cardiac activity
must follow up with hCG to see if it was effective
32
What is important to advise ectopic patients of?
RECURRENCE
usually other tube is damaged too
discuss contraception, infertility
33
heterotopic pregnancy
RARE
| ectopic and IUP at same time
34
anovulatory cycle
plenty of estrogen, insufficient progesterone
most common: peripubertal, perimenopausal
Sx: irregular sometimes heavy bleeding
35
menstrual irregularity peripubertal
REASSURE
no need for exam
Tx: OCs, cyclic progesterone, depo-provera
36
menstrual irregularity in perimenopausal
likely anovulatory bleeding: reassurance (near menopause), progestin replacement
must RULE OUT CA
37
string of pearls on ovary US
PCOS
38
Tx of PCOS
1. general
2. want regular periods
3. decrease unwanted hair
4. get pregnant
1. LOSE WEIGHT
2. OCs
3. OCs, dipilatories
4. ovulatory agents, metformin
39
Other causes of irregular bleeding
1. pregnant: ALWAYS get pregnancy test
2. anorexia
3. premature ovarian insufficiency
4. hypothyroid
5. hyperprolactinemia
6. cervical/endometrial CA/polyp
7. cervicitis
40
Tx of irregular bleeding in perimenopausal
1. replace hormone: progestin (OCPs, medroxyprogesterone, mirena IUD)
2. when medicine fails: endometrial ablation, hysterectomy
41
Tx of leimyomata
1. asymptomatic
2. menorrhagia, anemia
3. Sx of pressure or infertility and want to preserve fertility
4. severe bleeding, pain, child-bearing over
1. no Tx
2. NSAIDs, hormones
3. myomectomy
4. hysterectomy
42
indications that irregular bleeding might be CA
1. menometrorrhagia, any post-menopausal bleeding
| 2. older than 45 (sooner if Hx of anovulatory cycles)
43
ruling out CA as cause of irregular bleeding
1. PAP
2. endometrial biopsy: simple hyperplasia give progestins, atypia: hysterectomy
3. US
44
PGF2alpha
elevated in dysmenorrhea
45
PGE2
elevated in dysmenorrhea
46
What happens upon infusion of PG to the uterus?
uterine contractions and pain
47
dysmenorrhea
due to elevated PGs due to fall in progesterone after luteal phase
Tx: NSAIDs, OCs (prevent ovulation and progesterone interactions)
48
what is the level of PG in women who do not ovulate and have no dysmenorrhea
low
49
causes of secondary dysmenorrhea
PID
endometriosis
ovarian cysts
Tx: tx cause
50
Tx of endometriosis
1. first
2. if no relief
3. large endometrioma
4. pain/infertility
5. mild IVF with difficulties getting pregnant
1. OCPs/depo-provera, NSAIDs started 2 days before menses
2. laproscopy for Dx: REQUIRES a biopsy
3. laparotomy and mass removal; hysterectomy if done child bearing
4. laparoscopy to fulgarate lesions with cautery or laser
5. IVF
51
How often do infertile couples present with signs of endometriosis?
30-40%
52
premenstrual syndrome (PMS)
cause is unclear, Tx Sx
only occurs in OVULATORY women
Sx regularly occur during the same phase of menstrual cycle and regress rest of cycle
Sx: dysmenorrhea, bloat, weight gain, irritable, difficulty concentrating, tired, moody
Dx: menstrual and Sx diary
Tx: NSAID (dysmenorrhea), diuretics (bloat), OCs, reduce salt, SSRI (mood)
53
Premenstrual dysphoric disorder (PMDD)
extreme PMS: likely an UNDERLYING BEHAVIORAL HEALTH ISSUE that worsens in premenstrual period
PMS Sx plus one of the following: sadness or hopelessness, anxiety or tension, extreme moodiness, marked irritability or anger
Tx: SSRI, OCPs, regular exercise and proper diet, nutritional supplements, avoid stressors
54
What percentage of pregnancy ends in loss?
When is pregnancy loss more likely to occur?
What percentage is lost after heartbeat is found on US?
25% end in loss; most sporadic
earlier pregnancy is at higher risk
once heartbeat is seen: greater than 90% chance of successful pregnancy
55
most common cause of sporadic pregnancy loss
most common: chromosomal abnormalities
most common type of chromosome abnormality: aneuploidy: trisomy 16 followed by 21
single most common abnormality: 45,X
56
causes and Tx of recurrent pregnancy loss
1. insufficient cervix; cerclage
2. uterine anomalies; Sx
3. Ab syndrome; heparin through pregnancy
4. parent carrier of balanced translocation; prenatal Dx or PGD
57
insufficient cervix
cervical integrity compromised
2nd trimester loss, painless bleeding not associated with contractions
Tx: cerclage placed during first trimester (stitch to keep cervix closed)
treat all subsequent pregnancies after first occurrence
58
Normal pregnancy presentation
1. is it normal to bless in 1st trimester
2. US: transabdominal
3. US: transvaginal
4. progesterone level
5. hCG level
1. 1/4 experience; bleeding with cramping is worrisome
2. detect gestations when hCG reaches 2000
3. detects gestational sac when hCG is 1000
4. progesterone greater than 5
5. double every 48 hours
59
prenatal care
1. family Hx questionnaire
2. discussion of age, medical, medication and drug risks
3. offer screens
4. US recommended
5. further counseling, referrals, tests if indicated
60
types of congenital anomalies
1. chromosomal: associated with maternal age
2. single gene: sickle cell, CF
3. structural: sporadic or teratogen associated
61
When should all women have an US for detection of congenital anomalies?
18-20 weeks
62
1. two things that increase chance of multiple gestations
2. other risk factors
3. do these apply to monozygotic twinning
1. IVF, advanced maternal age
2. black, maternal family Hx, young maternal age
3. only IVF
63
complications with twins
1. premature: avg. delivery 36 weeks
2. birth defects
3. c-section needed for some
4. maternal DM, hemorrhage
64
malpresentation
requires c-section
| includes presentation of any of these first: breech, face, foot, arm, cord, placenta
65
Dx of IUGR
cause:
1. symmetrical
2. asymmetrical
serial US: small for gestational age
1. chromosomal
2. smoking, maternal disease causing placental insufficiency
66
causes for large for gestational age (LGA)
maternal DM
| also: some birth defects (Beckwith-Weideman)
67
maternal DM effects on fetus
1. at risk for at birth
2. complications
LGA (glucose moves across placenta: babies become big)
1. birth injury: shoulder dystocia
2. hypoglycemia, polycythemia, hypocalcemia, hyperbilirubinemia
68
twin twin transfusion
monochorionic/diamniotic (MONOZYGOTIC)
one twin receives more nutrients and often one dies
recipient twin: struggle more than donor (CHF, polycythemia)
69
Whose blood is lost
1. placenta previa
2. vaso previa
1. maternal
| 2. fetal
70
random facts
1. should you do a pelvic exam on someone with 3rd trimester bleeding
2. can you diagnose abruptio placenta on US? placenta previa?
1. NO: could cause hemorrhage
| 2. NOT: abruptio placenta, YES placentia previa
71
Mirena
IUD with levonorgesterol: thickens cervical mucus and prevents implantation
only LOCAL acting steroidal contraceptive
every 5 years
failure rate: 0.2%
benefits: amenorrhea
EXPENSIVE
72
Cu IUD
```
every 10 years
Cu is a spermacide
failure: 0.8%
AE: dysmenorrhea, heavy periods
CI: Wilson's, Cu allergy
MOST EFFECTIVE emergency contraception: prevents implantation (all pregnancies not just implantation)
```
73
Least effective to most effective contraception
1. condoms
2. OCs
3. depo provera
4. Cu IUD
5. mirena and skyla
6. nexplanon
LARCs work better
74
condoms
only contraception that protects against STI
ALWAYS use
user failure: 21%
75
combination OCs
estrogen: stabilize endometrium for regular menses
progesterone: neg. feedback prevents pregnancy (AE vary according to progestin)
non-contraceptive benefits: treat cramps, acne, heavy bleeding; prevent PID (but more likely to have cervicitis) and CA (endometrial, ovarian, colon; NO increase in breast CA)
AE: nausea, irregular bleeding, thromboembolic
user failure: 9%
76
depo provera
medroxyprogesterone: neg. feedback on FSH,LH
IM every 12 weeks
user failure: 6%
benefits: no menses
AE: weight gain, more likely to contract HIV from partner (thins vagina)
BBW: bone loss: must come off in 3 years
77
skyla
like mirena but for 3 years
| for nulliparous, younger patients
78
past IUD concerns vs. current
PAST: risk of infections, PID with infertility
braided string, left in for decades
CURRENT: slick string so bacteria can't get up: SAFE, can give to nulliparous women, teens, those with past Hx of STI and PID
still have to culture for GC and chlamydia (don't take it out, just Tx infection)
79
nexplanon
3 years
failure: 0.05%
AE: irregular menses
80
long acting reversible contraception (LARC) benefits
IUD, implant
insert and forget it
highly effective few CI
decrease unwanted pregnancy rates in teens and medicaid
81
contraception preference for someone with previous DVT
progestin only: mirena or depo
82
CI for estrogen contraceptives like OCs
1. smoking and over 35 years (in younger patient give it to them and tell them to quit smoking)
2. liver disease
3. cardiac disease
4. breast CA
5. irregular undiagnosed bleeding
83
How does estrogen cause clots?
| Highest risks?
increase platelets and decreases ATIII
| highest risk: PREGNANCY, oral contraceptives
84
tubal ligation
```
req. hospital and anesthesia
sterilization
between pregnancies: laparoscopic
during Cesarean
vaginal birth: umbilical incision
failure: 0.5% first year; 1/100 pregnancy if follow out 10 years and include ectopic
```
85
tubal occlusion (essure)
can be done in clinic
scarring causes occlusion
new AE: rash, hair falling out, bleeding
86
Plan B
levonorgestral
must be 16 years or older, expensive
within 72 hours of unprotected sex
decrease risk for 8% to 2%
87
male sterilization
office visit
ligation of vas deferent
failure: 0.15%
more easily reversed than female sterilization
88
zona pelucida
becomes impenetrable after fertilization so no other sperm can get in
89
blastocyst
fate of
1. inner cell mass
2. outer layer of cells
morula cavitates
1. becomes fetus
2. become trophoblasts
90
implantation of embryo
travels thru uterine cavity and hatches
implants: day 8-9
trophoblastic cells invade decidua
91
trophoblast
invades decidua
| produces hCG
92
decidua
promoted by progesterone produced by corpus luteum
| glycogen and lipid rich layer of endometrium
93
estimated due date/date of delivery: EDD
count back 3 months from first day of LMP and add 7 days
94
normal gestation time
40 weeks +/- 2 weeks
95
first trimester
0-14 weeks since LMP
96
second trimester
14-28 weeks since LMP
97
third trimester
28-40 weeks since LMP
98
abortion
less than 20 weeks since LMP or less than 500gm
99
viability
greater than 23 weeks since LMP
100
preterm
less than 37 weeks since LMP
101
late term
greater than 41 weeks since LMP
102
postterm
greater than 42 weeks since LMP
103
gravid
pregnant
104
parity
had a baby (dead or alive)
105
abortion
previable pregnancy loss: spontaneous or induced
106
G?P??a?b?c
?: numbers
what do each mean
```
G: pregnancies
P: full term delivery
a: preterm delivery
b: abortion/miscarriages
c: living children
```
107
When can hCG be detected in pregnancy (weeks and amount)
1. serum
2. urine
What should levels do in pregnancy? When do they peak
1. greater than 5 mIU/ml; 3 weeks gestation (from LMP)
2. greater than 25 mIU/ml; 5-6 weeks gestation (from LMP)
double every 48 hours in early pregnancy
peak: 10-12 weeks
108
When can you first perceive fetal movement?
1st pregnancy: 18 weeks
| G2 or greater: 16 weeks
109
PE of pregnancy
1. uterus
2. cervix
3. fetal heart tones
1. soft at 6-7 weeks, enlarged at 7-8 weeks
2. blue and engorged with blood
3. 10 weeks
110
uterus landmarks in pregnancy
1. 12 weeks
2. 20 weeks
3. after that
1. pelvic brim
2. umbilicus
3. once centimeter from pubic bone is one week gestation (goes up)
111
US dating
1. transvaginal
2. abdominal
gestational weeks
1. 3-4 weeks; hCG 1000-2000
2. 5-6 weeks, cardiac activity; hCG 4000-5000
112
first prenatal visit: labs
1. routine
2. optional
1. CBC (anemia, thrombocytopenia), urine culture, blood group, infectious disease profile (syphilis, Hep B and C, chlamydia, GC)
2. HIV (opt out), pap smear, genetic screening
113
Rh (D) antigen
1. AD or recessive
2. Ab formed
1. autosomal dominant
| 2. IgG: crosses placenta
114
1. pathology of Rh- mom and Rh + fetus
2. results in?
3. signs of failure on US
4. what can be done if Ab are already formed?
1. Ab-antigen complexes on fetal RBC
2. HEMOLYSIS, HYDROPS FETALIS, high output HF
3. edema, fetal tachycardia
4. intrauterine transfusion, early delivery
115
What anti-D Ab titer would be concerning in pregnant mom?
8 fold increase
116
prenatal visits
1. early
2. 18-20 weeks
3. 28 weeks
4. 36 weeks
5. at birth
1. US for dating; prescribe vitamins (folic acid should be started before); avoid sushi, improve diet
2. US for anomalies
3. one hour post Glucola serum glucose: screen for DM; Rhogam if Rh -
4. repeat STI screen, culture for group B strep
5. Rhogam if Rh-, penicillin if GBS pos.
117
```
how often do prenatal visits occur
1. first visit to 28 weeks
2. 28- 36 weeks
3. 36 wks to delivery
what in general is being addressed at each visit
```
1. q 4 weeks
2. q 2 weeks
3. q 1 week
address: BP, complaints, FHTs, fundal height, EDUCATION
118
Signs of labor
contractions
rupture membranes
bleeding
119
What causes labor in
1. mammals
2. humans
1. fetal cortisol increases to threshold, estrogen and progesterone fall, signals PGs
2. not clear; fetus born with/out rise in cortisol; PGs if given do produce labor though
120
latent phase of labor
How long in
1. primigravida
2. multiparous
not in labor to 4-6cm
contractions become regular, painful, cervical dilation picks up
1. may be 18 hours
2. may be very rapid
121
active phase of labor
How fast should it go in
1. primigravida
2. multiparous
4-5cm to delivery
1. 0.8 cm/hr
2. 1.3cm/hr
do NOT push until fully dilated: 10cm
122
cervix effacement
```
thinning of cervix
NOT dilation (happens prior to cervical dilation)
```
123
ruptured membranes
discharge?
c-section?
don't discharge: RISK of INFECTION
| do NOT indicate C-section
124
3 stages of active phase of labor
1. from 4-6cm to completely dilated
2. completely dilated to delivery
3. delivery of baby to delivery of placenta
125
Why should you not give oral fluids in labor?
risk of aspiration if need anesthesia
126
vaginal birth
1. place
2. recovery time
3. blood loss
4. episiotomy
5. where is baby after delivery before mom is discharged
1. labor/delivery/recovery room
2. 24-36 hours, discharge
3. 500cc
4. no
5. with mom
127
C-section indications
1. malpresentation
2. failure to descend, dilate (in active labor: 0.8-1.3cm/hr)
3. abnormal fetal heart tones
4. birth defects
5. previous c-section
6. triplets or higher order
7. active HSV
8. HIV
9. placenta previa
128
c-section
1. place
2. recovery time
3. blood loss
4. what else do they need?
1. Sx room
2. 24-48 hrs
3. 1000cc
4. ANTIBIOTICS
129
c-section complications
1. hemorrhage
2. surgical injury to bladder/bowel or infection
2. adhesions
3. need for repeat CD in future
130
station of presentation
1. neg.
2. 0
3. pos.
cm above or below ischial spine
-5 (beginning) to +5 (time for delivery)
1. neg.: baby has dropped but hasn't settled into pelvis
2. 0: before descent but in pelvis (lowest baby can get before full dilation)
3. pos.: descent of baby through pelvic canal
don't push before stage 0
131
lochia
vaginal bleeding/discharge persists 3-8 weeks postpartum
132
What might a heavy bleed at day 7-14 postpartum be?
shedding of Eschar at placental site
133
postpartum depression
Sx?
risks?
Tx?
due to withdrawal of hormones at delivery
Sx: crying, helpless, exaggerated worry about baby, sleeplessness
risks: previous episode, inner city, preterm baby, adolescent mother
Tx: SSRI, breast feed, freq. OB visit, hospitalization sometimes necessary
8 weeks pp Sx remitted
134
postpartum blues
realization that life is forever changed, frustration with new duties and lack of support
135
Edinburgh depression scale
determines postpartum depression
| often given by pediatrician
136
Pregnancy effects on breast
1. progesterone
2. estrogen
3. hPL (placental lactogen)
1. growth of alveoli and lobes
2. stimulate duct system to grow and differentiate
3. breast, nipple, areola growth
137
benefits of breast feeding
1. to infant
2. to mom
1. immunity (IgA/G/M), nutrition, bonding, protect against allergies/asthma/obesity
2. natural contraception, weight loss, bonding, protect against breast CA
138
How does PRL work to promote milk production?
1. transcription of casein mRNA
2. stimulate synthesis fo alpha-lactalbumin
3. increase lipoprotein synthesis
139
alpha-lactalbumin
syn. by PRL
| regulatory protein of lactose synthetase
140
oxytocin effects (besides milk let down)
1. increase GI mobility and absorption
| 2. bonding
141
colostrum
compare to mature milk
1. rich in what
2. less of what
first few days of nursing
low volume, high nutritional content
1. rich in: protein, vit. A, NaCl, GFs, antimicrobial factors, Ab
2. less: carbs, lipids, K
142
breast milk
glucose
also: amino acids, minerals, lipids (lipids rise through nursing episode)
nursing increases blood flow to breast: increase CO and vasodilation
Maternal diet variation: does NOT cause variation in milk components
143
What should you do in a mom that is worried she isn't producing enough milk in the first few days postpartum?
reassure mom: it's colostrum
| do NOT supplement formula: will stop producing milk
144
def. and causes of chronic pelvic pain
DAILY pain (can be worse around menses)
1. endometriosis
2. PID
3. leiomyomata
4. ovarian cysts RARELY cause pain (same with fibroids unless large)
5. adhesions
often hard to pinpoint so GI, GU and musculoskeletal causes can be confused with it
145
Clues that chronic pain is
1. endometriosis
2. GI
3. GU
4. PID
5. adhesions
6. NM
1. in 30s; cyclic, dyspareunia
2. diarrhea, constipation
3. frequency or pain when urinating
4. rather acute, bilateral (exam reveals tenderness)
5. Hx. of Sx or PID
6. pain with moving or lifting
146
Chronic pelvic pain workup
Hx, physical, US
| last resort: laparoscopy (may detect endometriosis, adhesions)
147
Chronic pelvic pain Tx
NEVER start narcotics for chronic pain: can get addicted
AVOID: laparotomy (leads to adhesions that cause pain and more Sx cycle)
Requires a TEAM: Gyn, Uro, PT, pain management center, Psych
no known cause: sympathy, counsel. laparoscopy can be therapeutic: women get better if told pelvis is ok
non-narcotic pain meds for NM pain
148
somatization
1. define
2. what should you do first
3. associations
4. hints that this is somatization
5. besides symtoms, what else might the patient express
psychiatric Dx
1. expresses emotional distress in form of somatic pain: OFTEN chronic pelvic pain
2. make it clear you believe they have pain
3. associated with: physical, emotional, sexual abuse
4. distress out of proportion to PE findings; multiple shifting somatic complaints at different times in life
5. anxiety and pain about the Sx
149
adenomyosis Tx
first line: OCPs (prevent ovulation), NSAID
| severe: hysterectomy
150
dyspareunia
1. on insertion
2. on deep penetration
3. after sex
4. nonspecific complaint or nothing on exam
pain with intercourse
need to know what part of sex, onset, if interfering with relationship
1. vaginitis, vulvitis, vaginal atrophy, vestibular adenitis (can detect inflammation and reproduce discomfort on exam)
2. cervicitis, endometriosis, adhesions, PID, mass effect of fibroids, bladder neck? (can reproduce on exam)
3. contractions
4. ask more questions, may need to refer to specialist, may need education on positions, empathy between partners, couples therapy
151
epididymis
stores, protects, and promotes maturation of spermatozoa, recycles damaged sperm
152
ductus (vas) deferens
movement of spermatozoa from the epididymis
153
seminal glands
secretes seminal fluid: 60% of semen volume
| fructose, PGs, enzymes
154
prostate gland
secretions make up 30% of semen
155
bulbourethral gland
secretes alkaline mucus that help to neutralize acids in vagina
156
detumescence
anti-erectile
sympathetic thoracolumbar: T10-L2
occurs as cGMP is degraded by PDE5 in erection
157
tumescence
erection
PNS: S2-4
cGMP: NO
158
absolute prereqs for erection
1. adequate arterial flow
| 2. sufficient nitric oxide synthase to produce NO
159
causes of decreased libido
1. meds, alcohol
2. depression, fatigue
3. relationship problems
4. systemic illness
5. testosterone deficiency
160
causes of ED
1. vascular: ED can be a sign of CV disease
2. neurologic
3. local penile
4. drugs
5. hormones
6. psychological
161
best predictors of ED
DM, smoking, HTN, obesity, dyslipidemia, CV disease, meds
162
what suggests psychogenic cause of ED
1. one night couldn't perform, followed by persistent ED
2. nocturnal or early mooring erections
3. inability to maintain erection once penetrated the vagina (can have other reasons)
163
Tx of erectile dysfunction
1. PDE5 inhibitors
2. alprostadil suppositories
3. intracavernosal vasoactive drug injection
4. vacuum erection device
5. penile prosthesis Sx
164
premature ejaculation
brief ejaculatory latency, lack of control of ejaculation, distress in patient or partner
Tx: couples therapy, behavioral approach, manual techniques, topical anesthetics in condom, SSRI
165
retrograde ejaculation
1. caused by
2. described/present as
3. Dx
ejaculate semen into bladder
1. bladder neck damage (in prostate Sx), alpha adrenergic block
2. dry ejaculate, infertility
3. low vol. ejaculation with ample sperm count in post ejaculation urine
166
```
hematospermia
differential and what to do
1. under 40
2. with ongoing lower urinary tract symptoms
3. older
```
blood in semen
1. usually benign and self-limited; nothing
2. infection; urinalysis, culture, studies for STI
3. prostate CA: referral or CA evaluation
167
genetic potential growth (MPH)
1. boys
2. girls
3. SD
1. boys: (dad height + mom height + 13cm)/2
2. girls: (dad heigh - 13cm + mom height)/2
3. SD: +/- 10cm (4in)
can sub 5.07in for 13cm
168
average height velocities
1. age 3
2. age 10
3. peak pubertal growth spurt
1. 8cm/year
2. 5cm/year
3. 10cm/year
169
orchidometer
1. blue
2. yellow
1. blue: 1-3cc: prepubertal
| 2. yellow: 4-20cc: pubertal
170
factors that play a role in GnRH suppression
1. GnRH
2. NPY
3. GABA
4. Leptin
5. TGF-alpha
171
What two things increase at puberty in response to GnRH? What do they cause to happen
kisspeptin and GPR54
| stimulate FSH and LH
172
genetic factors controlling puberty
```
GnGHR
KAL-1
FGFR-1
GPR54
LHX3
```
173
What effect do these have on H-P-G axis
1. GABA
2. glutamate
1. inhibit
| 2. stimulate
174
GH-IGF
affects onset and tempo of puberty
175
routes of signaling in pubertal control
1. post. hypothalamus
2. anterior hypothalamus
1. inhibitory
| 2. stimulatory
176
leptin and puberty
| what happens in deficiency
acts on hypothalamus
reduces appetite and stimulate gonadotropin secretion
deficiency: obese and gonadotropin deficiency
excess: down regulation of GnRH release
177
tanner stages of testicular enlargement
I: smaller than 4cc and 2.5cm
II: growth to 4cc or greater in volume; scrotum reddens and changes in texture
III: enlargement of penis (length first); further growth of testes (10cc)
IV: increased penis breadth and development of glans; scrotum darkens, testes (16cc) and scrotum larger
V: adult genitalia (25cc)
178
lower age limit of tanner stage II
AA: 8 years (avg. 11)
| white, mexican: 9 years (avg. 12)
179
adrenarche
growth spurt, axillary and pubic hair growth; NO sexual development
change in adrenal response to ACTH
rise in hydroxypregnenlone and DHEA relative to cortisol
DHEA greater than 40
180
constitutional delay
more common in boys
age of onset of puberty delayed
girls: 2.5 years
boys: 3 years
