Repro 3

Question 1

Disadvantages of HRT in post-menopausal women?

Answer 1

The use of estrogen therapy, without progesterone is associated with an increase in risk of uterine cancer (endometrial cancer, cancer of the lining of the uterus).
Treatment with progesterone along with estrogen substantially reduces the risk of uterine cancer (endometrial cancer) so that the risk of developing this cancer is equivalent to that of women not taking estrogen.
Users of oral hormone therapy (HT) (in the doses of the Women’s Health Initiative) for more than five years are at slightly increased risk of breast cancer risk, heart disease-MIs, and stroke than are nonusers.
Increased risk of DVT and PE- oestrogens increase clotting factors
abnornal vaginal bleeding
minor SEs- headaches, nausea, breast pain

Question 2

why is oestrogen given along with progesterone in those PM women on HRT who haven’t had a hysterectomy?

Answer 2

Uterus still present, and oestrogen given alone increases risk of endometrial cancer

Question 3

what happens to hormones during the menopause?

Answer 3

loss of follicular units decreases oestrogens and progesterone, which normally act by -ve feedback to inhibit the release of GnRH, FSH and LH, hence the decline causes an increase in gonadotropins, especially FSH (no inhibition by inhibin) over a period of yrs.

Question 4

early changes in women during the menopause?

Answer 4

areas of skin hyperpigmentation (melasma), hot flashes., night sweats, reduced vaginal secretions and urogenital atrophy- particularly of vaginal epithelium and ovaries

Question 5

later changes in women during menopause?

Answer 5

net decrease in bone mineral density and increase in cholesterol, increasing risk of OP and bone fractures

Question 6

1st investigation for secondary amenorrhoea?

Answer 6

pregnancy (hCG test)

Question 7

result of disruption to hypothalamic-pituitary-portal system?

Answer 7

high circulating levels of prolactin, low FSH and LH and ovarian atrophy

Question 8

what is the fixed sequence of events occurring in girls at puberty, between 8 and 13 yrs of age?

Answer 8

breast bud (thelarche)
pubic hair growth (adrenarche)
growth spurt
onset of menstrual cycles (menarche)

Question 9

stages of breast development in the female?

Answer 9

1: prepubertal, only papilla elevated
2: breast bud, breast and papilla elevated, areola diameter enlarged
3: juvenile contour, further enlargement of breast and areola
4: areola and papilla project above breast
5: mature stage, projection only of papilla

Question 10

fixed sequence of events occurring in boys at puberty, between 9 and 14yrs?

Answer 10

genital development begins
pubic hair growth
spermatogenesis begins
growth spurt

Question 11

stages of genital development in boys?

Answer 11

1: preadolescent, everything same size and proportion as in early childhood
2: scrotum and testes enlarged, growth in length of penis, texture of scrotal skin changed
3: penis grown primarily in length, and circumference
4: penis further enlarged, glans penis develops, darkening of scrotal skin
5: genitalia adult size and shape

Question 12

stages of pubic hair development in male and female?

Answer 12

1: no pubic hair
2: sparse, pigmented, long, straight, mainly along labia and base of penis
3: dark, coarser, curlier
4: filling out towards adult distribution
5: adult in quantity and type, spreading to medial thighs in male

Question 13

why are men generally taller than women?

Answer 13

growth spurt in boys is longer and slightly faster than in girls, and boys enter puberty later so have a longer period of pre-pubertal growth

Question 14

how is growth spurt ended in both sexes?

Answer 14

fusion of epiphyses

Question 15

what controls pubic and axillary hair growth in the female?

Answer 15

androgens released from adrenals- zona reticularis

Question 16

what hormone is breast development during puberty dependent on?

Answer 16

oestrogens

Question 17

why can some breast devlopment occur in males during puberty?

Answer 17

testosterone produced by leydig cells of testes can be converted to oestrogen in the tissues, and oestrogen stimulates breast development

Question 18

problem for young girls with abnormally high oestrogen levels?

Answer 18

early puberty, with oestrogen closing the epiphyses earlier than normal, so girl may be very small as no further growth in length of bones can occur once epiphyses fused

Question 19

what does the growth spurt depend on?

Answer 19

GH and steroids in both sexes

oestrogen closes epiphyses earlier in girls

Question 20

what is the most important factor in the timing of puberty?

Answer 20

body weight

Question 21

critical weight in girls for menarche?

Answer 21

47kg

Question 22

how can body size be signalled to the hypothalamus?

Answer 22

via leptins- concentration related to amount of fat we have in body
* involved in appetite control- stimulate inhibitory neurone, and inhibit excitatory neurone to suppress appetite
rising leptin levels inhibit NPY, which then releases GnRH from its prepubertal inhibition

Question 23

how is the body weight necessary for puberty to begin affected by how big we are gentically programmed to be?

Answer 23

those programmed to be smaller will have a lower body weight needed to be reached for puberty to begin

Question 24

what structure in the middle of the brain detects the amount of light in our environement?

Answer 24

pineal gland

Question 25

which hormone secretion is affected by the amount of light we are exposed to?

Answer 25

melatonin- secreted by pineal gland in dark

Question 26

why might having more artificial light nowadays contribute to puberty occurring at an earlier age?

Answer 26

effect on secretion of melatonin from the pineal gland, which influences the hypothalamus and hence puberty onset

Question 27

what name is given to puberty that occurs too early?

Answer 27

precocious: signs of puberty before age of 8

Question 28

how can pineal tumours cause precocious puberty?

Answer 28

affect secretion of melatonin, giving impression that there is more light than there actually is

Question 29

how can meningitis cause precocious puberty?

Answer 29

neurones prematurely activated due to inflammation

Question 30

what 'switches on' puberty?

Answer 30

hypothalamus

Question 31

How can hormone secreting tumours cause precocious puberty?

Answer 31

uncontrolled gonadotrophin e.g. LH,FSH or steroid e.g. testosterone, oestrogen secretion

Question 32

overall effect of pre-menopause?

Answer 32

reduced fertility

Question 33

what happens during the pre-menopause?

Answer 33

follicular phase shortens, ovulation occurs early or is absent- anovulatory cycles, which causes hormone sequences to not work properly. As follicles not developing as well, less oestrogen secreted so LH and FSH rise, FSH more, and there is reduced fertility

Question 34

what is the menopause proper?

Answer 34

cessation of menstrual cycles

Question 35

what produces the menopause?

Answer 35

ovary runs out of follicles no more follicles left to develop, oestrogen falls dramatically, no inhibin, so FSH and LH rise, and ovary can't respond to these

Question 36

difference in blood levels of gonadotrophins before and after menopause?

Answer 36

before menopause- LH higher than FSH | after- FSH higher than LH as lose selective inhibition of FSH release by inhibin

Question 37

what are hot flushes?

Answer 37

vascular changes result of oestrogen decrease, transient rises in skin temp and flushing

Question 38

effects of menopause on oestrogen sensitive tissues?

Answer 38

``` uterus- endometrial regression, myometrial shrinkage cervix thinning vaginal rugae lost involution of some breast tissue changes in skin- thinning? changes in bladder- reduction in tone ```

Question 39

why do children with increased body fat tend to not reach the full gentically predetermined adult height?

Answer 39

tend to start puberty earlier as higher leptin levels which feedback to hypothalamus to begin puberty, so they begin their growth spurt after a shorter period of prepubertal growth.

Question 40

what is the start of puberty associated with?

Answer 40

steady rise in levels of FSH and LH

Question 41

what might the rise in GnRH causing puberty onset be due to?

Answer 41

reduced sensitivity to low levels of circulating steroids that act be -ve feedback more likely- maturation of central mechanisms

Question 42

why does reproductive system not work before puberty?

Answer 42

hormone levels too low

Question 43

advantages of HRT in post-menopausal women?

Answer 43

relief of symptoms | can limit osteoporosis, so reduce fracture risk

Question 44

what is amenorrhoea?

Answer 44

absence of periods

Question 45

primary amenorrhoea?

Answer 45

absense of menses by age of 14 with absence of SSC, or absence by age 16 with normal SSC

Question 46

what is secondary amenorrhoea?

Answer 46

established menstruation ceased- for 3mnths in women with history of regular cyclic bleeding, or 9 mnths in woman with history of irregular periods. Usually happens to women aged 40-55.

Question 47

what is oligomenorrhoea?

Answer 47

periods occurring at intervals of between 35 days and 6 mnths

Question 48

what is menorrhagia?

Answer 48

heavy periods- excessive uterine bleeding (>80ml) or prolonged (>7 days) regular

Question 49

what is dysmenorrhoea?

Answer 49

painful periods

Question 50

what is premenstrual syndrome(PMS)?

Answer 50

various symptoms occurring in the 2 weeks before a woman's period

Question 51

most common cause of secondary amenorrhoea?

Answer 51

pregnancy | anorexia 1 of common causes

Question 52

origins of amenorrhoea?

Answer 52

hypothalamic/pituitary ovarian outflow tract i.e. uterus, vagina, cervix

Question 53

FSH levels if outflow tract obstructed, causing amenorrhoea?

Answer 53

normal, as hypothalamic-pituitary-ovarian axis is normal

Question 54

what problems of outflow tract can cause primary amenorrhoea?

Answer 54

Mullerian agenesis- failure of uterus to develop Vaginal atresia Cryptomenorrhoea- hidden periods Imperforate hymen- blood can't leak out

Question 55

what problems of outflow tract can cause secondary amenorrhoea?

Answer 55

intrauterine adhesions/scarring- Asherman's syndrome, e.g. due to trauma or problems with childbirth

Question 56

causes of primary amenorrhoea due to gonadal/end-organ disorder?

Answer 56

gonadal dysgenesis e.g. Turner syndrome- 45,X- 1 X chromosome, or 1 of X chromosomes defective, so would do genetic testing- karyotyping- short stature, cardiac abnormalities androgen insensitivity syndrome- testicular feminisation syndrome, usually genetically male, but external genitalia look female receptor abnormalities for FSH and LH specific forms of congenital adrenal hyperplasia

Question 57

causes of secondary amenorrhoea due to gonadal/end organ disorder?

Answer 57

``` pregnancy anovulation menopause premature menopause polycystic ovarian syndrome- hairy skin, skin problems, larger drug-induced ```

Question 58

cause of primary amenorrhoea as result of pituitary and hypothalamic/central regulatory disorders

Answer 58

kallmann syndrome:the occurrence of hypothalamic gonadotrophin releasing hormone deficiency and deficient olfactory sense - hyposmia or anosmia. It is usually inherited as an X-linked or autosomal recessive disorder with greater penetrance in the male. However, new mutations may arise. Gonadotrophin deficiency arises from a failure of embryonic migration of GnRH secreting neurons from their site of origin in the nose. The same defect affects the olfactory neurones resulting in olfactory bulb aplasia.

Question 59

secondary amenorrhoea pituitary/hypothalamic disorders?

Answer 59

hypothalamus:exercise amenorrhoea, stress amenorrhoea, eating disorders and weight loss pituitary: sheehan syndrome- hypopituitarism, hyperprolactinaemia- may have galactorrhea- spontaneous flow of milk from breast, prolactinoma can press on optic chiasm where optic nerve crosses causing bilateral hemianopia- visual dsiturbance, haemochromatosis hypo or hyper thyroidism

Question 60

evaluation of secondary amenorrhoea?

Answer 60

``` menstrual history contraception pregnancy surgeru medication weight change chronic disease, stress, diet ``` FH: age at menopause of mum, older sister, thyroid dysfunction, diabetes, cancer ``` physical examiniation: BMI hair distribution thyroid visual fields breast-discharge-prolactinoma? abdomen- masses? tenderness? ```

Question 61

management of patient with amenorrhoea?

Answer 61

must always rule out pregnancy ovarian-axis problem: investigate TSH, prolactin, FSH, LH hirsuitism-excessive hair growth on women- testosterone, dehydroepiandrosterone (DHEAS), androstenedione, 17-OH progesterone chronic disease- ESR, LFTs- liver metastases? CNS-MRI- prolactinomas

Question 62

what is dysfunctional uterine bleeding? (DUB)

Answer 62

excessively heavy, prolonged or frequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemic disease diagnosis of exclusion anovulatory- most cases, so no corpus luteum forms, no progesterone produced, so oestrogen continuously produced with uterine bleeding usually extremes of reproductive life and in parts with PCOS may be erratic bleeding if ovulatory but progesterone secretion prolonged as oestrogen low

Question 63

pathophysiology of DUB?

Answer 63

disorder of HPO axis, so changes in length of menstrual cycle no withdrawal bleeding from an oestrogen-primed endometrium if progesterone given then stopped endometrium builds up with erratic bleeding as it breaks down

Question 64

causes of menorrhagia?

Answer 64

usually secondary to distortion of uterine cavity e.g. fibroids- benign growths (leiomyomas) of uterine wall which increase area which can bleed uterus unable to contract down on open venous sinuses in zona basalis usually ovulatory, so can get pregnant, and on a regualr basis

Question 65

management of menorrhagia?

Answer 65

take history and FBC- can become anaemic very quickly of structural of histological abnormality suspected, complete physical exam- anaemia, obesity, hirsuitism, acne, purpura, thyroid, galactorrhoea and ultrasound scan if abnormal tment by GP with no exam if normal NSAIDs e.g. tranexamic acid, or combined OCP injected long-acting progestogens

Question 66

diagnosis of DUB?

Answer 66

o HCG, TSH – Exclude pregnancy, thyroid o Coagulation workup o Smear if appropriate – Exclude cancer o Sample endometrium

Question 67

how are the 1st signs of puberty in the male brought about?

Answer 67

external genitalia development- testicle size increase due to FSH-induced increase in seminiferous tubules

Question 68

what is true precocious puberty?

Answer 68

premature gonadotrophin secretion

Question 69

most common symptom of fibroids?

Answer 69

abnormal bleeding, typically menorrhagia

Question 70

potential disadvantage of removing ovaries as well as uterus in hysterectomy?

Answer 70

sudden onset of menopause as loss of ovarian sex steroids

Question 71

general cause of heavy menstrual bleeding when regular cycles and timing of cycles?

Answer 71

thickening of endometrium over wide SA of uterus

Question 72

what may cause inter-menstrual bleeding and post-coital bleeding in a woman?

Answer 72

cervical ectropion: columar epithelium of endocervix protrudes into the vagina, and subsequently bleeds as arteries of columnar epithelium are less resistant to damage than squamous epithelium of vagina uterine cancer