Important points Flashcards
(95 cards)
1
Q
Remnants of the hymen in parous women are called
A
Carunculae myrtiformis
2
Q
The endo and ecto cervix are lined by
A
Simple columnar epithelium
Stratified squamous epithelium
3
Q
The uterine arteries arise from______and give ascending and descending branches at the level of______
A
Internal iliac artery
The internal OS
4
Q
The reason for the torturous course of the uterine artery is
A
to allow its expansion without the tearing of the arteries.
5
Q
Regarding the lymphatic drainage of the uterus:
-Fundus
-Cornu:
-Body:
-Isthmus
A
Fundus: para-aortic lymph nodes via ovarian vessels
Cornu: To superficial inguinal lymph nodes
Body: To the internal then external iliac lymph nodes via uterine vessels
Isthmus: as cervix
Vagina upper 1/3: as cervix
6
Q
Discuss the lymphatic drainage of the cervical lymph nodes
A
Primary group:
-Paracervical
-Parametrial
-Obturator
-Internal and external iliac nodes
2ndry group:
-Common iliac
-Para-aortic
-Lateral sacral
7
Q
The fallopian tubes venous drainage is?
The Fallopian tubes lymphatic drainage is
A
Rt ovarian vein into IVC
Lt ovarian vein into left renal vein
Para-aortic lymph nodes via ovarian lymphatics
8
Q
The only organ in the abdomen not covered by peritoneum?
A
The ovary
9
Q
The ovary is fixed in the pelvis by three attachments which are?
A
Mesovarium: suspends the ovary back to the broad ligament
Infundibulopelvic ligament: suspends the upper pole of the ovary to the lateral pelvic wall and carries and the ovarian vessels, nerves and lymphatics
Ovarian ligament: attaches the lower pole to the cornu of the uterus
10
Q
Tubal pain is referred to the tubal points which lie on
A
The lower abdominal wall 1/2 an inch above the mid inguinal points
11
Q
The lymphatic drainage of the ovaries is directly to the
A
Para-aortic lymph nodes via ovarian vessels.
12
Q
The ureter is supplied through it its course by four arteries
A
Internal iliac
Uterine artery
Inferior vesical
Vaginal
13
Q
Discuss the three sites of ureteric injuries during hysterectomy
A
- On clamping the infundibulopelvic ligament where the ureter passes below ovarian vessels.
- On clamping the uterine arteries as it passes below the uterine artery 1 cm lateral to cervix.
- During clamping the vaginal angles and the parametrium 1.0 cm lateral to vaginal vault.
14
Q
The three ligaments supporting the cervix and upper part of vagina are called
A
Mackenrodt’s ligament (lateral cervical or cardinal ligament): Spreads from lateral surface and into the lateral pelvic wall. The strongest cervical ligament
Utero-sacral ligament: Posterior aspect and surrounding rectum and inserted into the third piece of sacrum
Pubo-cervical: From anterior surface forwards beneath bladder and surrounding urethra to the posterior surface of the pubis
15
Q
The gonads are capable of differentiate at the ______week
A
6th, primitive germ cells migrate from the wall of the yolk sac towards the developing gonads.
16
Q
The TDF gene releases a protein called _________ which is a signal for testicular differentiation
A
H-Y antigen
17
Q
Absence of MDIF will allow the development of
A
Mullerian duct into fallopian tubes, uterus, cervix and upper 4/5 of the vagina
18
Q
External genitalia begins development at the __th week and is developed from the __________
A
10
Urogenital sinus
19
Q
The genital tubercle=
The genital folds=
The genital swellings=
A
Tubercle= clitoris
Folds= labia minora
Swellings= labia majora
20
Q
T/F? Just the absence of the Y chromosome is needed for female sexual differentiation
A
True
21
Q
The ovary develops from the
A
genital ridges at 10th-11th thoracic vertebrae
22
Q
T/F: Accessory ovary is harmful
A
False
23
Q
The fallopian tubes develop from
A
upper parts of the Mullerian ducts
24
Q
The uterus develops from
A
The middle part of the Mullerian ducts
25
The upper 3/4th of the vagina develops from __________while the lower 1/4 develops from_________
the lower parts of the Mullerian ducts
Urogenital sinus
26
Six common clinical presentations of uterine anomalies
1ry amenorrhea
2dry dysmenorrhea
Primary infertility
Recurrent pregnancy loss in 1st trimester
Preterm labor, malpresentations and dysfunctional labor
Cervical atresia may have spasmodic dysmenorrhea, hematometra, endometriosis and infertility
27
Fetal ovary has _______ follicles @ birth then declines gradually to ________follicles at puberty
1.5-2 million
400k
28
What is the Ferning test and how does it concern the cervix
Microscopic examination of a drop of cervical mucus left to dry for 10 minutes on a glass slide in the follicular phase will reveal an arborizing palm leaf pattern, due to its high sodium chloride and potassium content in response to a high estrogenic level (+ve test). In the luteal phase the arborizing pattern is lost giving a negative test.
29
PMS describes a group of physical and/or emotional changes that constantly occur and recur in the _____phase of successive cycles
Luteal
30
Symptoms of PMS should occur in the _______ prior to mensturation
2 weeks; luteal phase
31
The highest incidence of PMS occurs in their
Late 20's to early 30's
32
In __% of cases of severe PMS, there is an underlying_____ condition
60; psychiatric
This is why SSRIs have been used as treatment and show improvement to the symptoms
33
T/F: Women with PMS have abnormal levels of E2 and PRG
False; levels are normal but they have an abnormal response
Cause is not completely understood; maybe due to neurotransmitter serotonin and cyclic changes in ovarian steroids
34
Female puberty steps (5)
Growth spurt: first sign
Thelarche (breast develops under estrogen)
Pubarche: Growth of pubic hair
Menarche: First menses
Axillarche: Growth of axillary hair, under androgens
35
Define isosexual precocious puberty and heterosexual precocious puberty
Isosexual: The secondary sexual characters are in agreement with genetic and phenotypic sex.
Heterosexual: The secondary sexual characters are in disagreement with genetic and phenotypic sex.
36
Give the causes of true IPCP
Constitutional: due to idiopathic premature activation of gene in the GnRH cell, leading to early FSH production
Organic due to CNS legion: Tumors, infections, malformations, head trauma
37
Give the causes of pseudo IPCP
Estrogen secreting ovarian tumor (granulosa cell tumors)
Primary hypothyroidism; elevated TSH may induce FSH production
Exogenous estrogen intake
38
Heterosexual precocious puberty causes
Androgen secreting tumors (virilizing ovarian or adrenal neoplasia)
Congenital adrenal hyperplasia
Exogenous androgen intake
39
Treatment of idiopathic precious puberty
Long acting GnRH agonists which will suppress FSH and LH halting puberty
40
Endocrine changes in Menopause (5)
Decreased serum inhibin-B
Marked increase in FSH and LH
Marked and persistent decrease in ovarian E2
Decrease in sex hormone binding globulin
Increase free testosterone
41
Symptoms of menopause 8
Vasomotor symptoms: cold sweats, hot flushes that start at perimenopause and become more aggressive in menopause. recurrent waves of heat over the chest, neck, and face, followed by cold sweating. A flush may last for 1-5 minutes, and may be associated by palpitation, dizziness or headaches.
CNS: Anxiety, irritability, mood changes, insomnia
CVS: due to decrease HDL, 2ndry to decrease E2
GIT: Constipation, bloating and tendency to gain weight
Urinary: frequency, dysuria and stress urinary incontinence
Tendency to pelvic organ prolapse
Balding and facial hair
Osteoporosis
42
Teriparatide is a drug that
Used for treatment of osteoporosis; stimulate bone remodeling
43
Biphosphates and calcitonin are drugs that
slow down bone breakdown during bone remodeling
44
Raloxifine is a_________ and it is approved for prevention of ________
Selective estrogen Receptor Modulator
Osteoporosis
45
4 contraindications to the use of hormone therapy
Undiagnosed abnormal bleeding from genital tract
Known or suspected breast cancer or estrogen dependent neoplasia
History of DVT, stroke or thromboembolic disease
Acute liver disease
46
Causes of primary amenorrhea
Imperforate hymen
Transverse vaginal septum
Turner syndrome (45XO)
Mullerian agenesis (46XX)
Androgen insensitivity (46 XY)
Congenital GnRH deficiency
Kallman's syndrome
47
Mullerian agensis clinical picture
1ry amenorrhea with normal 2ndry sex traits, normal ovaries as the gonads develop from genital ridge; normal E2
Absent uterus, upper vagina and the short vagina is managed by McIndoe procedure
48
COMPLETE ANDROGEN INSENSITIVITY SYNDROME also known as testicular feminization syndrome is managed by
Removal of gonads as they are incapable of spermatogenesis and can carry a 20% chance of gonadoblastoma
49
ASHERMAN'S SYNDOME is
intrauterine synechiae that is treated by lysis of adhesions and EST/PRG for 3 cycles
50
The commonest cause of 1ry amenorrhea is
Turner (45-XO) syndrome; responsible for 30% of cases. Treatment is HRT in EST/PRG inducing regular cycles
Mosaic karyotype of turner can get pregnant as ovary can develop but most dont
51
The commonest cause of 2ry amenorrhea is
Polycystic ovary
52
Kallmann's syndrome describes
congenital GnRH deficiency in association with anosmia due to congenital failure of neuronal migration of olfactory placode in the nose.
53
Pseudocyesis is
false pregnancy; a rare condition that may occur in emotional women
extremely desirous of pregnancy. The etiology is unknown but appears to be a voluntary alteration of hypothalamic function. Prolactin levels may be elevated enough to cause galactorrhea.
54
Why does hypothyroidism cause elevated prolactin levels
Because the elevation of TRH increase prolactin release
55
The two dopamine agonists that are used to treat hyperprolactinemia and galactorrhea are
Bromocryptine
Cabergoline
56
Clomiphene citrate MOA
competes with endogenous E2 for its hypothalamic receptors leading to their blockage. Hypothalamus increase release of GnRH which increase pituitary FSH production
Used for induction of ovulation
57
Tamoxifen and Letrozole MOA
Tamoxifen is a weak anti-estrogen same MOA of CC
Letrozole is a aromatase inhibitor that blocks conversion of test to estrogen; increasing pituitary FSH
58
The triad of PCOS hormones are
High LH: chronic anovulation, so no suppressed LH
Hyperandrogenemia: due to stimulation of theca cells by high LH and high insulin, with inhibition of aromatase enzyme; causing atresia of follicles, hirsutism, and estrone (in fat)
Hyperinsulinemia: due to peripheral insulin resistance which causes increase sensitivity of ovarian theca cells to LH.
59
U/S in patient showed increase ovary size and volume with necklace appearance and no dominant follicles present. Can this picture be found in normal females?
Yes, US picture may be found in 25% of otherwise normal females
60
What are the three long term risks of PCOS
Increased risk for diabetes, obesity, hyperlipidemia and CVS disease
Increase risk of endometrial hyperplasia due to increase estrogenic effect on the endometrium unopposed by progesterone
Increased risk of endometrial carcinoma if atypical EH develops
61
How would u as a doctor manage PCOS 7
1. Weight reduction; In obese females a reduction of 5-10% of body weight, reduces insulin and androgen and improves response to therapy, and may by itself re-establish ovulation.
2. Hormone therapy: In cases with menstrual disorders as amenorrhea or DUB;
a. Cyclic gestagen therapy for 10 days every cycle (day 16-25), to induce a regular 28-30 days cycle.
b. Combined OCP (day 5-25), to establish regular cycles in cases not requesting pregnancy.
3. Induction of ovulation for infertility
4. Insulin sensitizing drugs (metformin 500 mg/day orally) improve insulin sensitivity, thus decreasing hyperinsulinemia and androgen levels.
5. Corticosteroid therapy to suppress ACTH production in case of adrenal hyperandrogenism.
6. Surgical treatment via laparoscopic ovarian drilling (LOD); aims at decreasing ovarian androgen production.
7. Treatment of Hirsutism
62
What is the difference between hirsutism and and hypertrichosis and Virilization.
* Hirsutism; Excessive growth of androgen dependent sexual hair (present on the upper lip, chin, inner thighs, limbs, chest, abdomen and pubic triangle).
* Hypertrichosis; Excessive growth of androgen independent hair (as in the forearm and legs)
* Virilization; is hirsutism associated with other signs of hyperandrogenism such as; increased muscle mass, clitoromegaly, temporal baldness, and voice deepening.
63
Investigations of hirsutism
Plasma androgen hormones; total and free test
Pituitary hormones: FSH, LH
DHEA and DHEAS; suggest adrenal tumor
Thyroid function tests
Prolactin levels
CT or MRI pituitary
IVP and abdominal US
Pelvic US
64
Treatment of hisutism
Eliminate the cause
Hair removal techniques
Suppress androgen synthesis:
-OCPs decrease ovarian androgen production and decrease free T
-Corticosteroids (dexamethasone) suppresses adrenal androgen production
-Spironolactone: aldosterone agonist that inhibits 5-alpha-reductase
-Diane 35 is an OCP that uses cyrptoterone acetate as a progestin and used in treatment of hirsutism in females that want contraception
Androgen receptor blockers: Finasteride and cimetidine (competes with androgen at the receptor site)
65
Define:
Aspermia
Azoospermia
Oligospermia
Asthenospermia
Teratospermia
Aspermia: Absence of semen
Azoospermia: zero sperm count
Oligospermia: Count < 15 mil/ml
Asthenospermia: < 50% with forward progressive motility
Teratospermia: > 70% abnormal forms
66
Contraindications of HSG
1. Pelvic infection
2. Suspicion of pregnancy
3. Allergy to iodine
4. During menstruation or uterine bleeding
67
Complications of HSG
Shock
Oil embolism
Disturbance of an undiagnosed pregnancy
Flaring or introduction of infection
Iodine allergic reactions
Intravasation (oil passes into uterine vessels)
68
What are the steps to IVF
1. Pituitary down-regulation: daily S.C. doses of GnRH agonists are essential to prevent natural LH surge during follicular stimulation as this may result in follicular rupture before egg retrieval.
2. Ovarian stimulation: controlled ovarian stimulation by daily IM FSH injection to induce multiple follicular growth and maturation.
3. Ovulation trigger: by hCG: to induce for final maturation of the oocytes.
4. Oocyte retrieval: egg collection: is performed via US guided transvaginal needle aspiration of
mature oocytes
5. Sperm is injected directly in cytoplasm of metaphase II oocyte through zona pelludica
6. Embryo transfer after 3-5 days into uterine cavity
7. Luteal phase support: give progesterone to assist decidualization of endometrium for 2 weeks
69
Complications of IVF/ICSI
1. Allergic reaction to ovulation induction agents
2. OHSS with its complications (see later)
3. Trauma during oocyte retrieval: as vaginal hemorrhage, injury to major pelvic vessels, or injury to adjacent uterine, tubal, or intestinal organs.
4. Pelvic infection related to the procedure of oocyte aspiration.
5. Complications of ART pregnancies as; increased incidence of abortion, ectopic pregnancy, MFP , and a slight increase in some congenital anomalies.
70
In Egypt, ____% of women and girls aged 15-49 have undergone some form of FGM, though increasingly condemned and criminalized
92
71
Discuss the types of FGM
Type 1: Partial or total removal of the clitoral glans and/or the prepuce/ clitoral hood.
Type 2: Partial or total removal of the clitoral glans and the labia minora.
Type 3: Also known as infibulation, this is the partial or total removal of the clitoris, labia minora, labia majora with closure of the raw area formed and so narrowing of the vulval opening.
Type 4: This includes all other harmful procedures to the female genitalia e.g. pricking, piercing, incising, scraping and cauterizing the genital area.
72
Contraindications for the use of IUD 5
Undiagnosed vaginal bleeding
Uterine anomalies that interfere with proper insertion
Uterine pathology that interferes with proper insertion or cause complications
History of PID
History of ectopic pregnancy.
73
How does combined hormone contraception work?
Estrogen: Inhibits ovulation via suppression of GnRH, FSH, LH and LH surge
Gestagen: synthetic progesterone exert their contraceptive effect through:
-Endometrial changes unfavorable to implantation
-Cervical mucus changes; thick mucus
-Decrease tubal mobility and secretions
-Suppress FSH and LH but less than estrogen
Gestagens also prevent estrogen induced endometrial hyperplasia
74
Diseases who's risk increases with COCS 3
Ischemic coronary heart disease and ischemic stroke
Venous thrombo-embolism
Breast cancer
75
Diseases who's risk decrease with use COCS
Ovarian cancer: due to anovulation
Endometrial cancer: due to gestagens content
Colorectal cancer
76
SE of OCPS 9 (this topic is related to the relative contraindications of OCPS)
Spotting: increase dose
Break through bleeding: if more than 3 cycles up the dose
Hypomenorrhea: expected effect
Amenorrhea
Thrombo-embolic disorders: due to increase platelet adhesiveness and increase in factor 2, 7, 9 and 10.
HTN: in predisposed patients
DM: impairs carbohydrate metabolism and may predispose to DM
Liver: impairment of liver function is not uncommon can lead to cholestasis and higher incidence of gall stones.
Decrease lactation
77
What are the 8 absolute contraindications for use of OCP?
Thrombophlebitis or thromboembolic disease
History of DVT
Coronary heart disease
Cerebrovascular accidents or strokes
Liver disease
Malignancy of female genital system
Abnormal bleeding of genital tract
Suspected or known carcinoma of the breast or history of benign neoplasm of the breast.
78
Although progestogen only contraception has minimal side effects compared to COC, they are associated with higher incidence of ____________ and _____________
menstrual irregularities
ectopic pregnancies
79
The dominant bacterium in a healthy vagina is the _____________. It releases _________ which maintains a range of pH of :_____.
Lactobacillus acidophilus
Lactic acid and hydrogen peroxide (toxic to anaerobes)
3.8-4.5
Decreased glycogen content of the vaginal mucosa (like in menopause or childhood) will diminish acid production causing rise in vaginal pH
80
A 23 year old female comes to your clinic complaining of a yellowish (or gray) milky like homogenous thin vaginal discharge. It is not causing irritation, but the patient complains of a fishy smell that increases during mensuration and intercourse. Microscopic examination of the discharge shows clue cells (heavy vaginal epithelial cells coated with bacteria). Vaginal pH was under 4.5.
What is the treatment of this case?
Case of bacterial vaginosis. Treatment is Metronidazole 500 mg or intravaginal clindamycin cream
Clindamycin (used in 1sst trimester if pregnant)
Metronidazole (after 1st if pregnant)
81
A 16 year old girl came to your clinic complaining of vulvar itching, vaginal soreness and red/swollen erythema. She also mentions a vaginal discharge that is white, thick and scanty discharge (cottage cheese discharge). Microscopic examination with saline reveals hyphae and the vaginal pH is slightly acidic (<4.5).
What is the treatment?
Candida vaginitis
Fluconazole oral
Clotrimazole cream intravaginal
Only intravaginal treatment is safe for pregnancy (Clotrimazole)
82
A 30 year old married woman complains of vulval burning and painful intercourse with her husband. There is also copious green frothy offensive discharge. Speculum examination shows strawberry spots (punctuate hemorrhage) in the vagina and some in the cervix.
What investigations are needed?
Treatment?
Trichomonas Vaginalis Vaginitis
Nucleic Acid Amplification Test
Saline wet mount: shows highly motile flagellated trichomonads
Culture of vaginal discharge
Oral Metronidazole 2g single oral dose for both partners (as it is sexually transmitted and most of the time from male origin). Retest for female partner after 3 months as high rate of infection.
83
A 50 year old woman comes to you complaining of vaginal burning, tenderness and painful sexual intercourse. Vaginal pH is alkaline.
what is the treatment?
Atrophic vaginitis
Systemic antibiotics; if culture shows bacteria?
Intravaginal estrogen cream
Systemic hormone therapy is only given with other menopausal symptoms.
84
Three factors that increase PID and three factors that decrease PID
Young sexually active female 25-35
Multiple sexual partners
Use of IUD
Condoms
OCPS; due to progestational effect making cervix mucus more thick.
85
4 complications of acute PID
Tubal obstruction and infertility
Ectopic pregnancy
Chronic pelvic pain
Mortality
86
A 22 year old female comes to your clinic complaining of back pain, painful sexual intercourse and mucopurulent discharge. On speculum examination, the cervix is red and swollen. She mentions that she is 4 months pregnant.
Treatment?
Azithromycin 1 g orally single dose or
Doxycycline 100 mg for a week if she wasn't pregnant
87
What are the clinical criteria for diagnosis of PID
One of the following: Cervical motion, tenderness or uterine tenderness or adnexal tenderness during pelvic exam
Additional: oral temp > 38.3
elevated CRP or ESR
cervical inf of gonorrhea or chlamydia
Abundant WBCS from vaginal fluid
Abnormal cervical discharge or friability
88
DD for PID
Ectopic pregnancy
Torsion or rupture ovarian cyst
Degenerating fibroids
Inflammatory bowel disease
89
In mild PID cases; the recommended IM/oral regimen is
Ceftriaxone 500 mg IM single dose AND
Doxycycline 100 mg
90
In severe PID cases the patient is hospitalized and given
Ceftriaxone 1 gm IV every 24hrs AND
Metronidazole 500 mg IV every 12 hrs
91
Surgery in cases with chronic PID cause a high risk of
intestinal and ureteric injury due to associated dense adhesions
92
CDC regimen for uncomplicated gonorrhea
Ceftriaxone 500 mg single IM dose
plus
Doxycycline 100 mg/12 hrs for 7 days if chlamydia is not associated
93
What types of HPV were associated strongly with CIN and with external genital squamous intraepithelial neoplasia?
16
18
31
33
35
94
Treatment of primary, secondary and tertiary syphilis
Treatment of congenital syphilis
Benzathine penicillin G 2.4 million IM in a single dose and doxycycline 100 mg oral
Aqueous crystalline penicillin G 50.000 unit/kg
95
The most important part of the levator ani is
Pubo-coccygeus part
