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Year 3 - Reproduction and Sexual Health > Week 1 > Flashcards

Week 1 Flashcards

1
Q

3 bones that fuse together to form the “innominate bones” of the pelvis

A

Ilium

Ischium

Pubis

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2
Q

Of the three fused bones that make up the innominate bones of the pelvis, which differs the most between the sexes?

A

Pubis

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3
Q

What vertebral level is the PSIS?

A

S2

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4
Q

What is the bony attachment site for all the hamstring muscles?

What is the bony attachment site for the external genitalia?

A

Ischial tuberosity

Ischiopubic ramus

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5
Q

What nerve runs through the obturator foramen?

What bony processes form the boundaries of the obturatory foramen?

A

The obturator nerve runs through the obturator foramen

Superiorly - superior pubic ramus

Inferiorly - ischiopubic ramus

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6
Q

What kind of joint is the pubic symphisis?

A

Secondary cartilaginous

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7
Q

What bony landmark is palpable on vaginal examination?

A

The ischial spines

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8
Q

What are the attachments of…

  • the sacrospinous ligament
  • the sacrotuberous ligament?

What nerve runs between these two ligaments?

A

Sacrospinous ligament - sacrum and ischial spine

Sacrotuberous ligament - sacrum and ischial tuberosity

The pudendal nerve runs between these two ligaments, curves around the sacrospinous ligament

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9
Q

What ligament separates the greater and lesser sciatic foramina?

A

The sacrospinous ligament (and also the sacrotuberous ligament…)

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10
Q

What are the borders of the pelvic inlet?

What are the borders of the pelvic outlet?

Which is more superior?

A

Pelvic inlet

  • sacral promontory
  • ilium
  • superior pubic ramus
  • pubic symphysis

Pelvic outlet

  • pubic symphysis
  • ischiopubis ramus
  • ischial tuberosities
  • sacrotuberous ligaments
  • coccyx

The pelvic inlet is more superior

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11
Q

What muscle is also known as the “pelvic floor” muscle?

What is the space between the pelvic floor and pelvic inlet called?

A

Levator ani

The space is called the pelvic cavity and contains the pelvic organs and supporting tissues

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12
Q

How does the pelvic anatomy of the female differ to that of the male?

A

AP and transverse diameters of the pelvis are larger in the female, both at the pelvic inlet and outlet

The suprapubic angle is greater in the female

The pelvic cavity is shallower in the female

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13
Q

What is the term given to the movement of one bone over the other that allows the foetal head to change shape during delivery?

A

Moulding

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14
Q

What could the following indicate…

  • bulging fontanelles
  • depressed fontanelles?
A

Bulging - increased fluid/ICP

Depressed - dehydration

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15
Q

Which of the two diameters of the foetal head is bigger?

What is the name of the diamond shape made between the two greatest points of the biparietal diameter (parietal eminences) and the anterior and posterior fontanelles?

A

The Occipitofrontal diameter is greater than the Biparietal diameter

The vertex is the diamond bordered by the two fontanelles and the biparietal eminences

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16
Q

What is the distance of the foetal head from the ischial spines referred to?

What position is the baby’s head initially in when entering the pelvic cavity? Why is this the case?

A

Station (negative number means the head is superior to the spines, positive number means the head is inferior)

The baby’s head is ideally facing left or right. This is because the transverse diameter of the pelvic inlet is greater than the AP diameter, while the OP diameter of the foetal head is greater than the biparietal diameter.

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17
Q

Why does the baby’s head change from being faced left-to-right to an occipitoanterior position (OA), ideally, during delivery?

Should the baby’s head be in extension or flexion at delivery?

A

While at the pelvic inlet, the transverse diameter is greatest, hence left-to-right

At the pelvic outlet, the AP diameter is greater, so the baby’s head needs to rotate, ideally being in the occipitoanterior position i.e. the baby’s occiput and the mother’s anterior

When descending through the pelvis, the baby’s head should be in a flexed position (chin to chest), and when delivered should be in an extended position

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18
Q

When delivering a baby, which shoulder is delivered first?

A

Once head is delivered, the baby must rotate again in order to pass the shoulders

First the top shoulder (mother’s anterior) is delivered, then the bottom shoulder

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19
Q

What is the name of the dense outer shell of connective tissue that surrounds the cortex of the ovary?

What is it covered by?

A

Dense outer shell - tunica albuginea

Covered by a single layer of cuboidal cells called the germinal epithelium

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20
Q

Regarding the structure of the ovary, what are the two main areas of tissue and what do they contain?

A

Cortex - contains ovarian follicles in a highly cellular connective tissue stroma

Medulla - core of the organ, contains neurovascular structures

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21
Q

During embryonic development, at roughly what point do germ cells from the yolk sac invade and proliferate?

What do they form when they do this?

A

Approx week 6

Germ cells invade and proliferate via mitosis to form immature reproductive cells (oogonia). These cells will undergo further development and division via meiosis to form mature oocytes

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22
Q

What is the name of layer of cuboidal granulosa cells present that defines the primary follicle?

What is the name of the layer of specialised ECM that begins to form between the oocyte and these granulosa cells?

A

Layer of cuboidal granulosa cells - zona granulosa

Layer of specialised ECM - zona pellucida

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23
Q

In the late primary follicle, what do inner layers of stromal cells form and what do they then secrete?

A

The inner layers of stromal cells transform into the theca interna, which then secretes oestrogen precursors - these will then be converted to oestrogen by granulosa cells

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24
Q

The development of what structure within the granulosa layer defines a follicle as being secondary, rather than primary?

A

Development of the antrum - space filled with follicular fluid within the granulosa layer

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25
Q

What is the name of the final stage of follicular development, following the secondary follicle?

A

The mature Graafian follicle

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26
Q

Follicles can be classed on the presence of their antrum i.e. pre-antral or antral.

Which stages of follicle are pre-antral, and which are antral?

A

Pre-antral

  • primordial follicle
  • primary follicle
  • late primary follicle

Antral

  • secondary follicle
  • mature Graafian follicle
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27
Q

Following ovulation, what does the follicle then become? What is secreted and by what cells?

A

Follicle becomes the corpus luteum

Theca cells and granulosa cells secrete oestrogens and progesterones

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28
Q

Assuming no implantation occurs, what does the corpus luteum become?

What happens if implantation does occur?

A

A white-coloured connective tissue called the corpus albicans

If implantation does occur, the placenta secretes hCG which prevents degeneration of the corpus luteum and secretion of progesterone

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29
Q

What two components is the endometrium divided into?

What are their functions?

A

Stratum Functionalis - undergoes monthly growth, degeneration and loss

Stratum Basalis - reserve tissue that regenerates the Stratum Functionalis

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30
Q

Describe the transition zone of the cervix

A

At the external cervical os is stratified SQUAMOUS epithelium

In the cervical canal is simple COLUMNAR epithelium

The transition zone is the point at which one cell type changes into another, and is a common site of dysplasia and neoplastic changes that can lead to cervical cancer

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31
Q

How does the mucous secreted by the endocervical glands vary during the menstrual cycle?

What condition might result if these glands become blocked?

A

Thin and watery in the proliferative phase

Thick and viscous following ovulation

Blockage of the endocervical glands could cause them to expand with secretions, forming a Nabothian cyst

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32
Q

What are the four layers of the vagina?

A
  1. non-keratinised stratified squamous epithelium. During reproductive life, this layer is thicker and cells are enlarged due to accumulation of glycogen
  2. lamina propria - connective tissue rich in elastic fibres and thin-walled blood vessels
  3. fibromuscular layer - inner circular and outer longitudinal smooth muscle
  4. adventitia
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33
Q

What proportion of couples in the UK require assessment of infertility? How many of these will require assisted conception treatment (ACT)?

A

1 in 6 couples in the UK will require assessment of fertility

Of these, 50% will require ACT

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34
Q

What are some of the indications for ACT?

A

Endometriosis

Male factor

Tubal disease

Ovulatory disorders

Increase in single and same-sex couples

Increase in treatment with surrogate

Increase in transgender referrals

Fertility preservation in cancer

Treatment to avoid transmission of blood-borne viruses

Pre-implantation diagnosis of inherited conditions

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35
Q

What are some of the conditions that have to be met (in both men and women!) before ACT can be commenced?

A

Alcohol - women limited to 4 units per week

Weight - both male and female to have BMI 19-29

Smoking cessation

Folic acid - 0.4mg/day preconception until 12 weeks gestation

Rubella immunisations for female if not already done (check status)

Cervical smears should be up to date

Full drug history - prescribed, OTC and recreational

Screen for blood-borne viruses - Hep B/C and HIV

Assess ovarian reserve

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36
Q

What are some of the options of ACT available?

A

Donor insemination

Intra-uterine insemination

IVF

Intra-cytoplasmic sperm injection (ICSI)

Fertility preservation

Surrogacy

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37
Q

How is Intrauterine insemination done?

A

Can be done either during a natural or stimulated cycle

Prepared semen sample is inserted into the uterine cavity around the time of ovulation

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38
Q

What are some of the indications specifically for receiving IVF?

A

Unexplained infertility for more than 2 years

Pelvic disease - endometriosis, tubal disease, fibroids

Anovulatory infertility (after a failed induction of ovulation)

Failed intrauterine insemination (after 6 cycles)

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39
Q

How long does ovarian folliculogenesis take?

What two phases does it consist of?

A

Takes 85 days

Tonic phase (65 days) - primary and secondary follicles become antral follicles

Growth phase (20 days) - antral follicles develop into pre-ovulatory follicles, dependent on gonadotropin

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40
Q

What are the requirements when assessing a semen sample? What is it assessed for?

A

Male must have been abstinent for at least 72 hours beforehand

Needs to be either produced on-site, or at home and brought in within 1 hour

Assessed for…

  • volume
  • density - how many are there
  • motility - what proportion of sperm are moving
  • progression - how well are they moving
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41
Q

At what stage of embryo development is the sample usually transferred and cryopreserved?

A

At the blastocyst stage

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42
Q

When transferring the fertilised embro into the woman, what treatment is given alongside?

When is a pregnancy test performed?

A

Progesterone suppositories are given for 2 weeks at the same time as embryo transfer

Pregnancy tests are performed at 16 days after oocyte recovery

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43
Q

What are some of the indications specifically for Intra-Cytoplasmic Sperm Injection (ICSI)?

What is the difference between IVF and ICSI?

A

Severe male factor infertility

Previous failed fertilisation with IVF

Preimplantation genetic diagnosis

ICSI is a form of IVF, however while standard IVF treatment requires between 50 and 100 thousand sperm cells per oocyte, ICSI only requires one as the sperm is injected directly into the egg, bypassing the acrosomal reaction

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44
Q

In instances where the male presents with azoospermia, surgical sperm aspiration may need to be performed. Where is this aspiration taken from in a) obstructive and b) non-obstructive

A

Obstructive - sperm is aspirated from the epididymis

Non-obstructive - sperm is aspirated from the testicular tissue

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45
Q

What are some of the complications associated with ACT?

A

Ovarian Hyper-Stimulation Syndrome

Multiple pregnancy

Ectopic pregnancy

Surgical risks associated with egg and sperm retrieval

Failure of fertilisation (approx. 4%)

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46
Q

What is Ovarian Hyper-Stimulation Syndrome (OHSS) and how is it managed?

A

Spectrum of disease ranging from mild to critical

Features

  • abdominal bloating, pain
  • possible nausea and vomiting
  • if severe, possible ascites, oliguria, hyponatraemia, hyperkalaemia, hypoproteinaemia, raised haematocrit, thromboembolism, ARDS

Management

  • prevention - low dose protocols and use of antagonist for suppression
  • treatment prior to embryo transfer - elective freeze, single embryo transfer
  • treatment after embryo transfer - monitor with scans and bloods, analgesia, reduce risk of thromboembolism
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47
Q

What are some of the abnormal pregnancy outcomes?

Is bleeding a common problem in early pregnancy?

A

Miscarriage (normal embryo)

Ectopic pregnancy (abnormal site of implantation)

Molar pregnancy (abnormal embryo)

Bleeding IS a common problem in early pregnancy (20%)

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48
Q

How does miscarriage present and how can it be diagnosed/confirmed?

A

Bleeding is the primary symptom (more so than cramping, although these may also be described)

Passed products may be brought in

USS to assess whether or not there is a pregnancy in situ, it is in the process of expulsion, or if there is an empty uterus.

Speculum examination confirms if threatened (os is closed), inevitable (products are sighted at open os) or complete (products are in vagina)

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49
Q

Define the following terms and what they mean for the pregnancy…

Threatened miscarriage

Inevitable miscarriage

Incomplete miscarriage

Complete miscarriage

Early Foetal Demise

A

Threatened miscarriage - cervical os is closed, there is a risk to the pregnacy

Inevitable miscarriage - products are sighted at the open os, pregnancy cannot be saved

Incomplete miscarriage - part of the pregnancy is lost already

Complete miscarriage - all of the pregnancy has been lost and the uterus is empty

Early Foetal Demise - the pregnancy is in situ but there is no heartbeat

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50
Q

What is recurrent miscarriage defined as and what are some of the possible causes?

A

Defined as 3 or more pregnancy losses

Causes

  • Antiphospholipid syndrome
  • Thrombophilia
  • Balanced translocation
  • Uterine abnormality
  • Uterine NK cells hypothesis?
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51
Q

What are some of the signs and symptoms of a ruptured ectopic pregnancy?

A

Pain > bleeding

Dizziness/collapse/possible pain at shoulder tip (due to blood from rupture irritating the diaphragm), SOB

Pallor

Haemodynamic instability

Signs of peritonism

Guarding and tenderness

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52
Q

Suspect ectopic pregnancy? What investigations?

A

FBC

beta hCG - comparative assessment 48 hours apart to assess for doubling

USS abdomen/pelvis

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53
Q

What is a molar pregnancy?

What is the difference between a partial and complete mole?

A

Nonviable fertilised egg, overgrowth of placental tissue w/ chorionic villi swollen with fluid, appears as “grape like clusters”

Partial Mole

  • Haploid egg
  • 1 sperm (reduplicating DNA material) or 2 sperms fertilising the same egg resulting in triploidy
  • may have a foetus

Complete Mole

  • Egg but without DNA
  • 1 or 2 sperms fertilise, resulting in diploidy (paternal contribution only)
  • no foetus

Both result in an overgrowth of placental tissue

54
Q

How does a complete mole appear classically on USS?

A

Classic “snowstorm” appearance on USS

55
Q

How might molar pregnancy present clinically?

A

Hyperemesis

Varied bleeding and the passage of “grape-like” tissue

Fundus > dates would suggest

Occasional SOB

Diagnosis confirmed w/ USS

56
Q

What feature might occur when the fertilised egg implants onto the uterine wall, approximately 10 days post-ovulation, and be mistaken for a period?

A

Implantation bleeding

Signs of pregnancy soon emerge

57
Q

What is a chorionic haematoma?

How is it managed?

A

Pooling of blood between the endometrium and the embryo due to separation of the embryo from its original site of implantation

Features - bleeding, cramping and threatened miscarriage

Usually self-limiting, however large haematomas may be a source of infection, irritability and miscarriage. Manage w/ reassurance and surveillance

58
Q

Describe the follicular phase of the menstrual cycle

A

Starts on first day of period

FSH stimulates ovarian follicle development and granulosa cells to produce oestrogens

Raising oestrogen and inhibin by the dominant follcile inhibits further FSH production

Decline in FSH levels cause atrophy of all other follicles, leaving the dominant.

59
Q

Describe the ovulatory part of the menstrual cycle

A

Prior surge of LH triggers ovulation

The dominant follicle ruptures and releases the oocyte

60
Q

Describe the luteal phase of the menstrual cycle

A

Begins right after ovulation

Corpus Luteum forms out of empty follicle. This then starts to secrete progesterone which prepares the uterus for implantation

If the egg has been fertilised, implantation occurs

If the egg has not been fertilised, it passes through the uterus and the uterine lining breaks off, beginning the next menses.

61
Q

Describe a “normal” mentrual cycle

A

Lasts 4-6 days, with peak flow being at 1-2 days

Less than 80ml is lost per menstruation, and no clots are present

Average cycle is 28 days, however may be anywhere between 21 and 35

No inter-menstrual or post-coital bleeding is seen

62
Q

Define the following terms…

  • menorrhagia
  • metrorrhagia
  • polymenorrhoea
  • polymenorrhagia
  • menometrorrhagia
  • amenorrhoea
  • oligomenorrhoea
A

Menorrhagia - prolonged and increased menstrual flow, but cycle is normal

Metrorrhagia - regular intermenstrual bleeding

Polymenorrhoea - menses occurs with an interval of less than 21 days

Polymenorrhagia - increased bleeding and frequent cycle

Menometrorrhagia - prolonged menses and intermenstrual bleeding

Amenorrhoea - absence of menstruation for more than 6 months

Oligomenorrhoea - smenses at intervals of more than 35 days

63
Q

What pathogen typically is the cause of pelvic inflammatory disease (PID), a possible cause of “organic” menorrhagia?

A

Chlamydia

64
Q

What pathology would the appearanec of “chocolate cysts” on the ovary suggest?

A

Endometriosis

65
Q

What endocrine disorders might cause menorrhagia?

A

Hyper/hypothyroidism

Diabetes mellitus

Adrenal disease

Prolactin disorders

66
Q

What is dysfunctional uterine bleeding (DUB)? What two categories is it subdivided into?

A

DUB is vaginal bleeding from the uterus that is abnormally frequent, lasts excessively long, greater amount than normal or irregular. Extremely common and will affect most women during their lives. Numerous causes.

Subdivided into…

Anovulatory - 85% of cases, features irregular cycles, occurs in the extremes of reproductive life and is more common in obese women

Ovulatory - most common between the ages of 35 and 45, regular heavy periods, caused by inadequate progesterone production by the corpus luteum

67
Q

If a patient presents with dysfunctional uterine bleeding, what investigations would you perform?

A

FBC - including haemaglobin to exclude anaemia

Cervical smear - ensure they are up to date

TSH - tends to only be done if thyroid issues clinically suspected

Coagulation screen

Renal and Liver function tests

Transvaginal USS - done to assess endometrial thickness and look for the presence of fibroids

68
Q

NICE and SIGN guidelines state that any menorrhagia in a woman under 40/45 (respectively) needs to be investigated because of the possibility of what condition?

What sign, seen on transvaginal USS, might suggest this condition?

A

Because of the possibility of endometrial carcinoma

Endometrial thickness is assessed - while a thickened endometrium is not diagnostic of endometrial carcinoma, it is an indicative factor and increases the likelihood.

69
Q

Name some of the non-surgical management options for treating dysfunctional uterine bleeding

A

Progestogens - synthetic version has a longer half life and is therefore better for compliance, however causes cessation of periods

Combined oral contraceptive pill - can be used to treat menorrhagia up until menopause

Danazol - may cause virilism

GnRH analogues - may cause osteoporosis

Non-hormonal treatments - NSAIDs, anti-fibrinolytics, capillary wall stabilisers

Progestogen-releasing IUCD e.g. Mirena

70
Q

What hormonal therapy is used specifically to treat endometriosis?

A

GnRH analogues e.g.

(Also combined oral contraceptive, progestogens, danazol and aromatase inhibitors…)

71
Q

What surgical options are available to treat dysfunctional uterine bleeding?

A

Endometrial resection/ablation

Hysterectomy

72
Q

Is Chlamydia trachomatis gram positive or gram negative?

How is treated?

A

Trick question! Doesn’t really stain due to having no peptidoglycan in its cell wall

Treated with doxycycline 100mg bd x 7 days (no longer a single dose of azithromycin!)

73
Q

How is Chlamydia tested for? What other pathogen can be tested for at the same time?

How are samples collected?

A

Combined nucleic acid amplication testing (NAATs) or PCR

Can also test for gonorrhoea at the same time with the same test

Male patients - first pass urine sample

Female patients - HVS or vulvo-vaginal swab

Can also take rectal, throat and eye swabs

74
Q

What is now the recommended treatement for N. gonorrhoeae? What needs to be done after treating it and why is this the case?

A

Recommended treatment is now intramuscular ceftriaxone + oral azithromycin

Once treated, test of cure is also recommended in all patients to ensure the pathogen has been cleared.

This is because resistance is a big concern in gonorrhoea - many strains are already resistant to penicillins, tetracyclines, quinolones (-floxacins) and most oral cephalosporins

75
Q

What bacterial species make up the “normal” vaginal flora?

A

Lactobacillus spp. predominates - produces lactic acid and hydrogen peroxide, making the vagina pH low (acidic)

Other organisms that may be found include…

Strep viridans

Group B beta-haemolytic Streptococcus

Small numbers of Candida spp.

76
Q

Which of the following genital tract infections are sexually transmitted?

  • Candida (vaginal thrush)
  • Bacterial vaginosis
  • Prostatitis
A

None!

77
Q

30% of females have Candida present in their vaginas and exhibit no symptoms. What are some of the predisposing factors for developing Candida infection?

A
  • Recent antibiotic therapy
  • High oestrogen levels (pregnancy, certain types of contraceptive)
  • Poorly controlled diabetes
  • IC/IS patients
78
Q

Candida infection - how does it present, how is it diagnosed and how is it treated?

A

Presentation - intensely itchy white vaginal discharge

Diagnosis - CLINICAL! Remember it is a commensal in many women, so swabbing won’t be useful

Treatment - topical clotrimazole pessary/cream. Oral fluconazole

79
Q

How is bacterial vaginosis caused?

A

Disequilibrium in the vaginal microbiota, resulting in a decline in the amount of Lactobacillus spp.

Most infections appear to begin with Gardnerella vaginalis creating a biofilm, allowing other opportunistic bacteria to thrive

80
Q

Bacterial vaginosis - clinical presentation, diagnosis and treatment

What classic feature, seen on microscopy, indicates bacterial vaginosis?

A

Presentation

  • thin, watery fishy-smelling vaginal discharge

Diagnosis

  • again, CLINICAL, and can be aided with assessing vaginal pH (will be raised above 4.5)
  • The characteristic fishy smell can be detected on wet mount in a test known as the whiff test after the addition of potassium hydroxide
  • The appearance of CLUE CELLS microscopically is indicative of bacterial vaginosis

Treatment

  • oral metronidazole
81
Q

Name some sexually transmitted bacterial infections

A
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
  • Treponema pallidum (syphilis)
82
Q

Name some sexually transmitted viral infections

A

HPV (genital warts)

Herpes simplex virus (genital herpes)

Hepatitis and HIV

83
Q

Name some sexually transmitted parasitic infections

A
  • Trichomonas vaginalis
  • Phthirus pubis (pubic lice/crabs)
  • Scabies
84
Q

Chlamydia trachomatis has 3 serological groups (A-C, D-K and L1-L3). Which is the most common, and the cause of genital infection?

A

Serovar 2 - D-K

85
Q

What bacterial STD appears like “2 kidney beans facing each other”?

How does this organism appear on a gram film?

A

Neisseria gonorrhoeae

Appears as a gram negative diplococci

Easily phagocytosed by polymorphs, so often appears intracellularly on gram stain

86
Q

How does Treponema pallidum stain?

How is syphilis diagnosed?

A

It doesn’t stain!

Diagnosis is reliant on PCR or serology to detect antibodies (however suspecies are serologically indistinguishable!) because T. pallidum cannot be grown

87
Q

What are the 4 stages of syphilis infection and what is each characterised by clinically?

A

Primary - solitary painless lesion (chancre), heals without treatment

Secondary - large numbers of bacteria circulate in blood, multiple manifestations at different sites (“snail-track” mouth ulcers, generalisd rash on palms and soles of feet, flu-like symptoms etc.)

Latent stage - no symptoms, but low levels of spirochetes can be found in the intima of blood vessels

Late stage - cardiovascular/neurovascular complications occur many years later

88
Q

Regarding serology testing for syphilis, what options are available?

A

Non-specific testing - not specific for syphilis, just indicates tissue inflammation and may be positive for numerous other reasons. More useful for measuring response to treatment

  • Venereal Disease Research Lab (VDRL)
  • Rapid Plasma Reign (RPR)

Specific serological testing - specific for syphilis but remain positive for life, hence not useful for measuring response to treatment

  • T. pallidum particle agglutination assay (TPPA)
  • T. pallidum haemagglutination assay (TPHA)
  • IgM and IgG ELISA also useful as a combined “screening” for syphilis, done first in Tayside and a positive result leads to either VDRL or TPPA
89
Q

What is the treatment for syphilis?

A

Penicillin - injectable long-acting preparations (or doxycycline/azithromycin if allergic)

90
Q

What is the most common viral STI?

What causes it?

A

Genital warts

Caused by the Human papilloma virus

91
Q

Why is HPV difficult to study in the lab?

A

Because it cannot be grown in artificial culture media or maintained in lab animals

92
Q

Which types of HPV are associated with warts?

Which types of HPV are associated with cervical cancer?

Which strains does the HPV vaccine protect against?

A

Warts = HPV 6 and 11

Cervical cancer = HPV 16 and 18

HPV vaccine is quadravalent and protects against HPV 6, 11, 16 and 18

93
Q

HPV warts - diagnosis and treatment

A

Diagnosis is clinical - no routine microbiological test

Treatment - cryotherapy, podophyllotoxin cream/lotion

94
Q

What organism is genital herpes caused by?

A

Herpes simplex virus 1 and 2 (HSV-1 and HSV-2)

95
Q

Genital herpes - diagnosis and treatment

A

Diagnosis - swab in virus transport medium of de-roofed blister for PCR - highly sensitive and specific

Treatment - pain relief, aciclovir may be helpful if taken early enough

96
Q

What are the two primitive genital tracts? Which becomes the reproductive tract in the male and which in the female?

A

Wolffian ducts - becomes the male reproductive tract

Mullerian ducts - becomes the female reproductive tract

97
Q

What two substances cause the development of the male reproductive tract? How does this happen?

A

Testosterone and Mullerian Inhibiting Factor (both secreted by the fetal testes)

Mullerian ducts degenerate in the presence of these two substances. Without the stimulus of male testicular hormones, the fetus will develop the female internal genital tract and the Wolffian tract will degenerate

98
Q

At what point to fetal genitalia start to differentiate?

When can they be recognised on an USS?

A

Differentiate from 9 weeks

Recognisable on USS from 16 weeks

99
Q

What’s the condition - presents at puberty with amenorrhoea, lack of pubic hair, and karyotype 46XY but born with phenotypically female external genitalia?

A

Androgen Insensitivity Syndrome

X-linked recessive disorder where the testes develop but don’t descend. Androgen induction of Wolffian ducts DOES NOT occur, but Mullerian inhibition DOES occur.

Absent uterus and ovaries, and a short vagina

100
Q

Describe the passage of sperm from the testes to being ejaculated

A

Created in the seminiferous tubules of the testicle

Moves to the epididymis, then to the vas deferens

Loops around behind the bladder and passes through the prostate gland. Joined by the seminal vesicles which secrete a significant amount of fluid that will ultimately become semen

Then passes through the prostatic urethra, then the membranous urethra, and finally the penile urethra

101
Q

What is the name of the muscle contraction that causes the testicles to raise and lower in response to external temperatures?

A

Dartos contraction (in conjunction with the cremasteric muscle) - not to be confused with the cremasteric reflex!

102
Q

What is Cryptorchidism?

How should it be managed and why?

A

Undescended testicle or testicles in adulthood

Increasingly common and reduces sperm count, but if unilateral then fertility is usually unaffected

Orchidopexy should be performed if the child is under the age of 14 to reduce the risk of testicular germ cell cancer

If in adulthood, consider orchidectomy (risk of testicular germ cell cancer is x6!)

103
Q

Where is sperm produced?

Where is testosterone produced?

A

Spermatogenesis occurs in the seminiferous tubules, and is done alongisde Sertoli cells

Testosterone production occurs in the Leydig cells

104
Q

Which of the following are functions of Sertoli cells?

  • formation of a blood-testes barrier
  • provision of nutrients for developing cells
  • phagocytosis of defective cells and surplus cytoplasm
  • secretion of seminiferous tubule fluid to carry cells to the epididymis
  • secretion of androgen-binding globulin
  • secretion of inhibin and activin hormones to regulate FSH secretion
A

All of the above!

105
Q

What is the release of GnRH like?

What does its release cause and how is GnRH regulated?

A

GnRH release from the hypothalamus occurs in bursts every 2-3 hours

GnRH causes release of LH and FSH from the anterior pituitary

GnRH release is regulated by testosterone via negative feedback

106
Q

In the male, LH acts on ____ and FSH acts on ____

A

LH acts on Leydig cells to regulate tesosterone secretion

FSH acts on Sertoli cells to enhance spermatogenesis

107
Q

Testoserone is derived from ____

A

Cholesterol

108
Q

What cells do Inhibin and Activin act on?

What is their function?

A

Inhibin and Activin act on Sertoli cells to inhibit and stimulate secretion of FSH

109
Q

What iatrogenic causes may result in premature or retrograde ejaculation?

A

Prostate surgery

Anticholinergic medication

110
Q

What is the most common cause of male infertility?

What are some of the obstructive and non-obstructive causes?

A

Most common cause is idiopathic

Obstructive

  • cystic fibrosis
  • vesectomy
  • infection

Non-Obstructive

  • congenital - cryptorchidism
  • infection - mumps orchitis
  • iatrogenic - surgery, anticholinergics, chemo/radiotherapy
  • pathological - tumours
  • genetic - Klinefelter’s
  • specific semen abnormalities
  • systemic disorders - e.g. renal failure
  • endocrine - things affecting prolactin levels
111
Q

What are some of the endocrine causes of male infertility?

A

Pituitary tumours

Hypothalamic disorders

Thyroid disorders (hyper/hypothyroidism - decreased sexual function and increased prolactin)

Diabetes (decreased sexual function and testosterone)

Congenital Adrenal Hyperplasia (decreased testosterone)

Androgen Insensitivity

Steroid abuse (decreased LH, FSH and testosterone)

112
Q

What is the ‘normal range’ for testicular volume?

Below what level would be considered likely infertile?

A

Normal range is 12-25 mls

Below 5mls would be thought to be infertile

Measurement is done with an orchidometer

113
Q

What is semen assessed for when performing analysis?

A

Volume

Density - numbers of sperm

Motility - how many are moving

Progression - how well are they moving

Morphology

114
Q

What are some of the factors that might affect the quality of the semen sample?

A

Not maintaining abstinence for 3 days

Temperature sample has been stored at

Health of the man for the previous 3 months

Incomplete sample

Time between production and assessment (deteriorates after 1 hour)

115
Q

What medication can be given to an individual who has hyperprolactinaemia to improve their fertility?

A

Cabergoline (dopamine receptor stimulator and inhibitor of prolactin)

116
Q

What is the success rate like of vasectomy reversal?

A

75% if done within 3 years

Up to 55% if done 3-8 years

Up to 40% if done 9-19 years

117
Q

What are some of the indications for endometrial sampling?

A

Abnormal uterine bleeding

Investigation of inferility

Endometrial ablation

Abortion (spontaneous and therapeutic)

Assessment of response to hormonal therapy

Endometrial cancer screening in high risk patients e.g. Lynch syndrome (a.k.a. hereditary non-polyposis colorectal cancer)

118
Q

Define the following terms…

  • Menorrhagia
  • Metrorrhagia
  • Polymenorrhoea
  • Polymenorrhagia
  • Menometrorrhagia
  • Amenorrhoea
  • Oligomenorrhoea
  • DUB
A

Menorrhagia - prolonged and increased menstrual blood flow

Metrorrhagia - regular intermenstrual bleeding

Polymenorrhoea - menses occuring at intervals of less than 21 days

Polymenorrhagia - increased bleeding and frequent cycle

Menometrorrhagia - prolonged menses and intermenstrual bleeding

Amenorrhoea - absence of menstruation for >6 months

Oligonemorrhoea - menses occuring at intervals of more than 35 days

DUB - dysfunctional uterine bleeding, AUB with no obvious organic cause

119
Q

What are the most common causes of abnormal menstrual bleeding in adolesence/early reproductive life?

A

DUB

Endometriosis

Pregnancy/Miscarriage

Bleeding disorders

120
Q

What are the most common causes of abnormal menstrual bleeding in mid reproductive life/perimenopause?

A

DUB

Pregnancy/miscarriage

Endometriosis

Endometrial polyp/endocervical polyp

Leiomyoma

Adenomyosis

Exogenous hormone effects (e.g. contraceptions such as the implant)

Bleeding disorders

Hyperplasia

Neoplasia - cervical, endometrial

121
Q

What are the most common causes of abnormal menstrual bleeding in postmenopause?

A

Marked obestiy

Atrophy

Endometrial polyps

Exogenous hormones - HRT, tamoxifen (used to treat oestrogen +ve breast cancer)

Endometriosis

Bleeding disorders

Hyperplasia

Endometrial carcinoma

Sarcoma

122
Q

An endometrial thickness in postmenopausal women of how much (measured by TVUS) is generally taken as an indicator for biopsy?

A

Thickness greater than 3-4mm

123
Q

When performing endometrial sampling, which phase of the cycle should you aim to sample during? Which part of the cycle is the least informative?

A

Aim to sample during the 2nd phase (follicular)

Aim to avoid the 1st phase (menstrual) as this is the least informative

124
Q

What are the 3 phases in each of the following…

Ovarian cycle

Uterine cycle

A

Ovarian cycle

  • Follicular phase
  • Ovulation
  • Luteal phase

Uterine cycle

  • Menstrual phase
  • Proliferative phase
  • Secretory phase
125
Q

When is dysfunctional uterine bleeding as a result of anovulatory cycles at its most common?

What other conditions is DUB associated with?

A

Most common at either end of the reproductive life

The corpus luteum doesn’t form and there is continued growth of functionalis layer, meaning a gap with no periods followed by one heavy menstruation

Associated with PCOS, hypothalamic dysfunction, thyroid disorders and hyperprolactinaemia

126
Q

Name some of the infectious organisms that can cause endometritis

A

Neisseria gonorrhoeae

Chlamydia

TB

CMV

Actinomyces

HSV

127
Q

Endometrial polyps are common and usually asymptomatic, but may present with bleeding or discharge. Is there any reason to be concerned about them?

A

Not really, the vast majority are benign

BUT!!! Endometrial carcinoma can present initially as a polyp!

128
Q

How can Foetal RBCs be spotted during histology?

A

Foetal RBCs are nucleated

129
Q

What is the difference between a partial and complete molar pregnancy?

A

Partial - triploidy. Egg is fertilized by two sperm, or by one sperm which reduplicates itself (69,XXY). Have both maternal and paternal DNA, and a foetus may be present

Complete - diploidy, sperm combines with an egg that contains no DNA. Sperm then reduplicates itself forming 46 chromosome set. Only paternal DNA is present in the complete mole. Presents like a cluster of grapes, no foetus present

130
Q

What treatment is given for gonorrhoea?

A

IM ceftriaxone

(used to also give oral azithromycin to ‘protect’ ceftriaxone from resistance but this has been discontinued due to too many downstream effects of azithromycin)

131
Q

How are gonorrhoea and chlamydia diagnosed these days? What is the advantage of this over the previous technique?

A

Diagnosed primarily using PCR (NAATs)

More sensitive and faster than performing cultures

132
Q

What is the difference between a threatened miscarriage and an incomplete miscarriage?

A

Threatened - bleeding is seen but the cervical os remains closed and the pregnancy is still potentially viable

Incomplete - bleeding is seen and the cervical os is closed. Pregnancy is no longer viable

Year 3 - Reproduction and Sexual Health (7 decks)

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