Week 3 Introduction to Gynaecological Pathology Book

Question 1

What is the function of LH?

Answer 1

Stimulation of progesterone production - triggering ovulation

Question 2

What is the function of HCG?

Answer 2

Stimulation of the corpus luteum to continue oestrogen and progesterone production

Question 3

What is the function of Oestradiol?

Answer 3

Proliferation of the endometrium

Question 4

What is the function of FSH?

Answer 4

Stimulation of oestrogen production
Stimulation of ovarian follicular development

Question 5

What is the function of progesterone

Answer 5

Stimulation of the endometrium to secrete glycogen-rich material

Question 6

What is the function of GnRH

Answer 6

Stimulation of the release of pituitary hormones

Question 7

True or false Ovulation is triggered by a surge of LH production 12-24h prior to the ovulation.

Answer 7

True

Question 8

True or false: In case of pregnancy, the corpus luteum starts to produce hCG.

Answer 8

False, hCG is produced by the placenta

Question 9

True or false: GnRH is controlled by negative feedback of the gonadotropins.

Answer 9

True

Question 10

True or false: Day 1 of the menstrual cycle is defined as the first day after cessation of the menstruation.

Answer 10

False. Day 1 of the cycle is the first day of the menstrual period

Question 11

True or false: Changes in oestrogen and progesterone levels cause cyclic changes in the endometrium.

Answer 11

True

Question 12

How does the uterus, ovaries and endometrium change throughout the menstural cycle?

Answer 12

In the first part of the cycle (proliferative phase) the endometrium has a proliferative appearance and in the ovary you first detect a number of small follicles that have been recruited.

After a few days you can identify the dominant follicle increasing in size until ovulation.

Ovulation usually occurs when the follicle is approximately 20-22 mm, after which you can visualise a corpus luteum in the ovary. The endometrium becomes secretory in appearance.

Question 13

What hormone do each of the following organs produce:
Pituitary gland
Plancenta
Hypothalamus
Uterus
Ovaries

Answer 13

Pituitary gland - LH, FSH
Plancenta - HCG
Hypothalamus - GnRH
Uterus - does not produce
Ovaries - Oestrogen and Progesterone

Question 14

Explain why exogenous administration of oestrogen and progestogen inhibits ovulation?

Answer 14

Both oestrogen and progestogen have an inhibitory effect on the hypothalamus and pituitary resulting in an inhibition of gonadotropin production.

Low FSH results in depressed follicular development but the dominant action for contraception is LH inhibition.

If there is no mid-cycle LH peak, ovulation will be inhibited even if follicular development occurs.

Question 15

Advantages of Tamoxifen?

Answer 15

• Postmenopausal women with breast cancer, tamoxifen reduces mortality by 25 percent and recurrence by 50 percent.
• Healthy women at high risk of developing breast cancer, tamoxifen found to reduce oestrogen receptor positive breast cancer risk by 45 percent.
• Ability of maintaining bone mineral density, lowers incidence of osteoporotic fractures postmenopausal women.
• Reduces cholesterol levels, especially LDL, with possibly a trend in lowering myocardial infarct incidence.

Question 16

Disadvantages of tamoxifen

Answer 16

• Vaginal dryness and discharge.
• Endometrial changes:
  increase in endometrial and endocervical polyps;
  increase in endometrial hyperplasia; and
  increase in endometrial carcinoma.

Question 17

What is the role of ultrasound in the monitoring of patients on tamoxifen?

Answer 17

The role of vaginal ultrasound in the monitoring of patients on tamoxifen is limited to the exclusion of pathology by visualising a thin endometrium.

Monitoring should happen pre-treatment and then yearly starting after two to three years of treatment in the asymptomatic patient. Investigation should be done immediately in case of symptoms, such as spotting, bleeding.

Vaginal ultrasound can be done as a first step and is, as said, useful when a thin endometrium is detected (less than 5 mm).

If the endometrium is more than 5 mm (in 75% of asymptomatic patients on tamoxifen), the only way to obtain a correct diagnosis is to do hydrosonography or hysteroscopy.

Question 18

Describe oestrogen only use

Answer 18

It is very important that patients know why they (who have not had a hysterectomy) need to take a combination of oestrogen and progesterone. Oestrogen will prevent/reduce osteoporosis and solve any menopausal symptoms but increase the risk of endometrial cancer during and after use, unless it is taken with adequate progestogen. Patients usually feel fine without the progesterone and it is only after a reasonably long period of time that problems will occur. Thirty percent of patients will develop atypical endometrial hyperplasia, a premalignant lesion, after three years.

The least you expect to find on Hilary’s ultrasound is a thick hyperplastic endometrium (with or without cellular atypia) but you will need to exclude an endometrium carcinoma (a formal diagnosis is only possible with a biopsy).

Question 19

What is the ultrasound appearance of adenomyomosis?

Answer 19

Echogenic linear striations (Venetian blind) extending from endometrium into myo.
Hyperechoic islands
Irregular endo-myo junction
Tiny anechoic myo and sub endo cysts reflecting fluid in the glands
Cystic striations
Myosis - muscular hyperplasia +/- hypertrophy may be hypoechoic
Focal/diffuse myometrial bulkiness that can be asymmetrical
Generally increased vascularity

Question 20

Describe the normal endometrium appearance during the menstural, proliferative and secretory phase

Answer 20

M: 0.5-1mm thin echogenic line
P: 4-8mm, hypoechoic thickening
S: 7-14mm hyperechoic thickening

Question 21

List the signs of menopause

Answer 21

Fewer follicles grow
Supply depleted
Gonad, FSH, LH raise in an attempt to stimulate follicles.
When these hormones are raised,it is evidence of ovarian failure

Question 22

List the sonographic appearance of the ovary in the premenopausal woman

Answer 22

Follicular: Many follicles (>5+), increasing in size until day 8/9 in which one follicle become dominant and the other atretic, grows 1-2mm per day
Pre-ovulatory: dominant follicle measures 20-25mm
Luteal phase: corpus luteum, 20mm, irregular hypo/iso cyst often with low level echoes, typical ring of fire vascularity

Question 23

What is dysmenorrhea

Answer 23

Painful menstural period

Question 24

What is oligomenorrhoea

Answer 24

Occasional occurrence of menses

Question 25

What is polymenorrhoea

Answer 25

Menses interval <21 days

Question 26

What is hypermenorrhoea / menorrhagia?

Answer 26

Prolonged or increased uterine bleeding at regular intervals

Question 27

What is metorrhagia and menimetrorrhagia

Answer 27

Intermenstural bleeding at irregular intervals

Prolonged menstural flow and intermenstural bleeding

Question 28

What is dyspareunia

Answer 28

Pain during intercourse

Question 29

List the goals of Orval contraceptive pill useage

Answer 29

1. Contraception by inhibiting ovulation
2. Creates an endo lining that resists implantation
3. Thickens cervical mucous which prevents sperm from entry

Most women will not develop a dominant follicle and ovulate.
The ovary appears homogenous with no dominant follicle

Question 30

What clinical conditions are seen less in those who iseOCP

Answer 30

Ectopic pregnancy
Ovarian cysts
PID
Iron deficiency
Decreased menstural symptoms / acne (combined)
Prolonged use combined OCP reduces risk of developing uterine myomata and ovarian/endo cancer

Question 31

Discuss symptoms related to decreased ovarian competence and oestrogen (seen in menopausal patients not taking (HRT)

Answer 31

1. Disturbed menstural pattern
2. Vasomotor instability (hot flashes / sweats)
3. Psychological - anxiety, mood
4. Atrophy conditions - skin, urinary, vulval, vaginal
5. Health problems - secondary to long term deprivation of oestrogen, includes osteoporosis and CVD

Question 32

What is the aim of HRT?

Answer 32

Gives additional oestrogen to reduce effects / symptoms of insuffiencient oestrogen in the body

Question 33

HRT: oestrogen only vs Oestrogen + progesterone

Answer 33

E: increases ris of endometrial cancer
E + P: eliminates risk
Therefore combination should be given

Question 34

Discuss oestrogen only HRT

Answer 34

Oestrogen will prevent and reduce osteoporosis menstura; symptoms
However, increases risk of endo cancer during and after use
Patient normally feel fine without progesterone but after a duration of time, problems occur
30% patients using oestrogen only will develop atypical hyperplasia, a premalignancy
Ultrasound appearance: thick, hyperplastic endo with or without cellular atypica
Only way to exclude endometrial carcinoma is a formal biopsy