Chapter 2 — Female Physiology

Question 1

The bleeding & shedding of the endometrial lining that occurs at approximately monthly intervals from menarche to menopause

Answer 1

Menstruation

Question 2

The onset of menses, usually occurring between 11-14 years of age

Answer 2

Menarche

Question 3

Termination of regular menses, usually occurring between 45-55 years of age

Answer 3

Menopause

Question 4

Termination of regular menses prior to age 40

Answer 4

Premature menopause

Question 5

The endometrium & ovaries respond to __________ & __________ levels in the blood, these levels are determined by a feedback mechanism between ovaries & the hypothalamus/ pituitary complex

Answer 5

Estrogen & progesterone

Question 6

Serum estradiol levels fall below a given concentration, the hypothalamus produces gonadtropic releasing hormone (GnRH), signals the anterior pituitary gland to excrete the ________

Answer 6

Pituitary honadotropins

Question 7

What are the 2 pituitary gonadotropins

Answer 7

Follicle stimulating hormone (FSH)
Luteinizing hormone (LH)

Question 8

Which hormone stimulates the growth & development of ovarian follicles, as the follicles grow increasing estradiol levels within the follicles help them respond to LH with eventual ovulation

Answer 8

Follicle stimulating hormone (FSH)

Question 9

Which hormone stimulates maturation of follicle & responsible for graafian follicular rupture causing ovulation also stimulates progesterone production which peaks after ovulation
- fertilized ovum implants into the endometrium, hCG production signals the corpus luteum to continue secreting progesterone to prevent shedding of the endometrial lining
- implantation doesn’t occur decreasing progesterone levels permit sloughing of the uterine lining

Answer 9

Luteinizing hormone (LH)

Question 10

Hypothalamus produces (GnRH) —> Anterior pituitary gland (FSH & LH) —> FSH stimulates & development of ovarian follicles —> Theca cells within follicles produce estrogen & stimulates endometrial growth —> As follicles grow increase estradiol levels within follicles to help them with LH with eventual ovulation —> LH stimulates maturation of follicles & is responsible for gracing follicles rupture causing ovulation —> hCG signals the corpus luteum to continue secreting progesterone to prevent shedding —> If implantation doesn’t happen decrease progesterone & menses occurring

Question 11

Under the influence of the pituitary hormones, the ovaries go through 3 phases during a normal cycle, what are the phases called

Answer 11

Follicular Phase (Days 1-14)
Ovulation (Day 14)
Luteal Phase (Days 15-28)

Question 12

The ___________ follicle may be identified by about day 8 when it measures 10mm

Answer 12

Dominant (Graffian) follicle

Question 13

Any follicle measuring > 11mm will most likely ovulate
Grows linearly (2-3mm a day)
Max diameater varies between 15-30mm
Line decrease reflectivity around follicle suggests ovulation will occur within 24 hrs
Presence of cumulus oophorus (mural nodule with follicle) suggests ovulation will occurs within 36hrs

Question 14

Surge of LH secretion causes rupture of follicular membrane usually with 24-36hrs after surge — fluid in posterior curl-de-sac

Answer 14

Ovulation (day 14) mid cycle

Question 15

Unilateral pelvic pain occurring mid-cycle associated with ovulation

Answer 15

Mittelschmerz

Question 16

Which phase has a crater left by expulsion of the ovum becomes filled with fatty yellowish cells type becoming the corpus luteum.

Answer 16

Luteal phase (days 15-28)

Question 17

What manufacturers and secretes progesterone (& smaller amounts of estrogen) to prepare and maintain the endometrium for implantation but in the absence of hCG this regresses and atrophies becoming corpus albicans

Answer 17

Corpus luteum

Question 18

Name the 3 uterine phases

Answer 18

Menstrual phase (days 1-5)
Proliferating phase (days 6-14)
Secretory phase (days 15-28)

Sonographically changes can be seen during the menstrual cycle

Question 19

This phase is during the final 2-3 days of secretory phase the endometrial intracellular edema is resorbed, desquamation and sloughing of the superficial layer of endometrial tissue and blood cells occurs and is expelled as menses

Answer 19

Menstrual phase (days 1-5)

Question 20

Menstrual phase sono findings
Thickened echogenic endo prior to start of menses
Complex appearance at the beginning of menses
Thin slightly irregular endo after shedding
Max AP diameater (post menses) 2mm

Question 21

This phase is the regeneration and proliferation of the endometrium is stimulated by estrogen secreted by the developing follicles, lasts about 10 days and ends at ovulation

Answer 21

Proliferation phase (days 6-14)

Question 22

Proliferative phase sono findings
Hypoechoic area around prominent midline echo (early phase)
Tri-layer endometrium (late phase) peri-ovulatory endometrium is referred to as the “3 line sign”

Question 23

beginning at ovulation the endometrium prepares for the possible implantation of a fertilized ovum,
Under the influence of progesterone the endometrium becomes grossly edematous and spongy reaching its total maximum thickness
Absence of fertilization implantation and hCG production the endometrial glands fragment and undergo autolysis staring then cycle again
Which phase is this

Answer 23

Secondary phase (days 15-28)

Question 24

Secondary phase sono finding
Hyperexhoic endometrium with obscured midline echo often with posterior acoustic enhancement
Maximum AP diameter up to 14-16mm

Question 25

Endometrial appearance during uterine phases of the menstrual cycle
Day 1-5 uterine phase - menses endo thick - 1-4mm appear -thin
Day 6-14 uterine phase - proliferative endo thick 4-8mm appear hypoechoic (early) trilayer (late)
Day 15-28 uterine phase secondary endo thick -8-16mm appear homogeneously hyperechoic

Question 26

This contraception is synthetic agents similar to natural female sex hormones that prevent conception by inhibiting ovulation
Most common regimen in the US is the combination of estrogen and progesterone and is taken every day
Most won’t develop a dominant follicle
Endo appearance may assist in therapeutic dosage with DUB (dysfunctional uterine bleeding )

Answer 26

Oral Contraceptive Pills (OCPs)

Question 27

Hormones during the menstrual cycle phase
Day 1-5 uterine phase - mense ovarian phase - follicular hormone - FSH/estrogen
Day 6-14 uterine phase - proliferative ovarian phase - follicular hormone - FSH/estrogen
Day 14 uterine phase - proliferative ovarian phase - ovulation hormone - LH
Day 15-28 uterine phase - secondary ovarian phase - Luteal hormone - progesterone

Question 28

Hormones
FSH - anterior pituitary - ovary (follicles)
LH - anterior pituitary- ovary (ovulation)
Estrogen - ovary (follicles) adreanal glands - endo (proliferation)
Progesterone - ovary (corpus luteum) adrenals - endo (implantation prep)

Question 29

This device is a popular method
5-10 year lifespan
On ultrasound they rare reflective and cast a shadow
Uterine perforation is most common at time of insertion

Answer 29

Intrauterine contraceptive device (IUD/IUCD)

Question 30

Malpositioned IUD
Expulsion- passage through external os
Displacement - rotation of IUD or aIUD positioned in LUS or cervix
Embedment - penetration of myometrium by IUD but not involving the serosa layer
Perforation - penetration of the myometrium and the serosa by IUD

Question 31

Pregnancy with IUD
ACOG recommends IUD removal if IUD is in the cervix or if strings are seen
If left in place increases risk of pregnancy loss (IUFD) abruption, chorioanmnionitis, and preterm delivery

Question 32

This is defined as the inability of a man and a woman to achieve pregnancy after at least 1 year of having regular inter course without any type of birth control
Effects 1:7 couples

Answer 32

Infertility

Question 33

Infertility female factors
Anovulation and abnormal ovulation
Tubal and transport factors
Endometriosis
Uterine factors
Polycystic ovarian syndrome
Cervical factors
Other

Question 34

Sono is assisted to
Establish normal/abnormal
Count astral follicles (2-10mm)
Monitor growing follicles
Confirm ovarian response/identify hyperstimulated ovaries
Guide ochre retrieval

Question 35

Pharmacological agents used to increase satisfactory ovulation and increase chances of fertilization include

Answer 35

Clomiphene citrate (clomid, serophene)
Letrozle (femara)
Gonadotropins (repronex, follistim, pergonal, bravelle, fertile x, metrodin, gonal-f)
Glucophage (metformin)
hCG (pregnyl, novarel, ovidrel, profasi)
Parlodel and dostinex

Question 36

Clomiphene Citrate (Clomid, Serophene)
oral medication used for women who have infrequent periods or long menstrual cycles.

Question 37

Letrozole (Femara)
oral chemotherapy drug is used off-label as an alternative to Clomid.

Question 38

Gonadotropins (Repronex, Follistim, Pergonal, Bravelle, Fertinex, Metrodin and Gonal-F)
an injectable medication used to induce the release of the egg once the follicles are developed and the eggs are mature.

Question 39

Glucophage (Metformin)
given to patients as an insulin lowering medication. Most commonly used in polycystic ovarian syndrome patients, this
medication has been shown to reverse the endocrine
abnormalities seen with PCOS within 2-3 months.

Question 40

hCG (Pregnyl, Novarel, Ovidrel, Profasi)
used with other drugs to trigger ovulation

Question 41

Parlodel and Dostinex
medications used to lower prolactin levels, and to reduce pituitary tumor (adenoma) size

Question 42

Ovulation Monitoring
Transvaginal sonography is the method of choice for monitoring follicular development.
Follicals are typicallly aspirated for VIF when they measure 18-24 mm.
IVF sonographic protocol
- baseline sonographic evaluation
- preliminary TV evaluation of follicles
- serial TV to monitor/measure follicles

Question 43

In Vitro Fertilization (IVF)
Consists of ovarian stimulation, needle aspiration of oocytes, incubation of oocytes with sperm, and catheter delivery of typically 1-2 embryos into the uterus

Question 44

Zygote Intrafallopian Tube Transfer (ZIFT)
Embryo (or zygote) is placed into the fallopian tube (rather than the uterus, as with IVF)

Question 45

Gamete Intrafallopian Tube Transfer (GIFT)
Sperm and ova are placed into the fallopian tube

Question 46

Intrauterine Insemination (IUl)
In cases of male factor infertility, ultrasound to may be used on occasion to guide catheter placement of a sperm preparation into the uterine fundus.

Question 47

Which infertility complication is a condition
resulting from excessive stimulation of the ovaries, most commonly occurs in women taking fertility drugs. Mild cases usually resolve spontaneously following the next menstrual cycle. More severe cases are associated with a high mortality rate (up to 50%) and may require hospitalization for correction of fluid and electrolyte imbalances

Answer 47

Ovarian Hyperstimulation Syndrome (OHSS)

Question 48

Infertility complication
Multiple Gestations
Incidence of multiples increases with more prevalent and successful fertility treatment. Multiple gestations can complicate pregnancy by impacting maternal health and well-being, fetal outcome (including prematurity), and there are often associated high costs incurred.