Reproductive AP

Question 1

Ovarian and Uterine blood supply?

Answer 1

• ovarian artery comes off of the aorta: feeds ovary, fallopian tube, uterus, anastomes with uterine artery
• internal iliac artery feeds uterine, vaginal, middle rectal, and internal pudendal artery

Question 2

Relationship of uterine artery and ureter?

Answer 2

• ureter is underneath the uterine artery

Question 3

Anatomic variations in position of the uterus?

Answer 3

• mid-position
• anteverted (MC variation)
• anteverted and anteflexed
• retroverted
• retroverted and retroflexed

Question 4

Why are there so many diff uterine anomalies?

Answer 4

• b/c in fetal development first mullerian or paramesonephric ducts form fallopian tubes and then fuse caudally to form uterus, cervix, and upper vagina
• usually don’t notice any problems until pregnancy (early labor, miscarriage)

Question 5

What are gartner’s duct and cyst?

Answer 5

• remnants of male reproductive system - from : sites of mesonephric duct remnants - epoophoron (by ovaries), cervix, and vagina

Question 6

DES was assoc with what?

Answer 6

• b/t 1941-71 given to 3 mill preg ladies to decrease miscarriages
• in 1971 - fetal exposure in daughters assoc with rare clear cell adenocarcinoma vaginal cancers in girls 14-22
• later assoc with uterine anomalies (T shaped uterus) which increased preg. complications and infertility as well as increased risk of cervical and breast cancer
  (women now 45 and older)
• exposed sons: increased risk of cryptorchidism, hypogonadism, and epidymal cysts
• mothers have modest increase risk of breast cancer

Question 7

Pelvic types?

Answer 7

• round = gynecoid
• wedge = android
• oval = platypelloid
• oval-long = anthropoid

Question 8

How many eggs are left at puberty? How many get the chance to develop? How many ovulations are in a lifetime?

Answer 8

• 500,000 eggs left at puberty
• only 8,000 have chance to develop
• 400-500 ovulations in a lifetime

Question 9

Where is hypothalamus located? Circulation to anterior pituitary?

Answer 9

• located at base of brain, just above junction of optic nerves
• hypothalamic-hypophyseal portal circulation: blood supply of anterior pituitary originates in hypothalamus - no direct nerve connections

Question 10

5 hormones that hypothalamus releases?

Answer 10

• GnRH - gonadotropin releasing hormone
• TRH - thyrotropin releasing hormone
• SRIF - somatotropin release inhibiting factor
• CRF - corticotropin releasing factor
• PIF - prolactin release- inhibiting factor = dopamine

Question 11

What are anterior and posterior pituitaty glands derived from? Main fxns?

Answer 11

• anterior (adenohypohysis): derived from ectoderm, diff cell types that produce 6 diff hormones
• posterior (neurohypophysis): derived from neural tissue, transports oxytocin and vasopressin

Question 12

Hormones produced by anterior pituitary?

Answer 12

• FSH - gonadotrophs (ovaries)
• LH - gonadotrophs (ovaries)
• TSH - thyrotrophs
• prolactin - lactotrophs (breast)
• GH
• ACTH - MSH (melanocyte stim hormone - Addison’s)

Question 13

Effect of secretion of GnRH from (arcuate nucleus) hypothalamus?

Answer 13

• stim by NE
• inhibited by dopamine (PIF)
• influenced by endogenous opioids
• low pulse frequency triggers FSH
• high pulse frequency triggers LH

Question 14

How does GnRH reach the anterior pituitary? What does this stimulate?

Answer 14

• by hypothalamic pituitary portal vascular system and stimulates secretion of FSH and LH

Question 15

What does low levels of LH stimulate?

Answer 15

• stimulate secretion of androgens (testosterone and androstenedione) from theca cells, these androgens are converted to estrogens in granulosa cells

Question 16

What does FSH stimulate?

Answer 16

• secretion of estrogens (estradiol and estrone) by granulosa cells of ovarian follicles

Question 17

When does FSH and LH spike?

Answer 17

• LH spikes 36 hrs b/f ovulation

Question 18

When does estrogen spike? Progesterone?

Answer 18

• estrogen spikes - during end of follicular proliferative phase (the granulosa cells of chosen follicle is making estrogen)
  ovulation occurs 36 hrs after LH surge
• progesterone spikes during luteal secretory phase

Question 19

Feedback mechanism of estrogen and LH?

Answer 19

• initially estrogen creates negative feedback to pituitary to decrease LH and FSH
• in late follicular phase, peak estradiol levels from dominant follicle trigger a midcycle surge of LH needed for ovulation and preparing the ovary to make progesterone

Question 20

What secretes progesterone? What phase of menstrual cycle begins?

Answer 20

• with ovulation, dominant follicle becomes a progesterone secreting cyst called corpus luteum and luteal phase of menstrual cycle begins?

Question 21

Negative feedback of progesterone?

Answer 21

• negative feedback on pituitray secretion of LH and FSH causes decreasing E and P to be made in corpus luteum

Question 22

What occurs to progesterone levels if there is no conception?

Answer 22

• lifespan of corpus luteum is then 9-11 days, and then progesterone levels fall
• menstrual period is triggered
• negative feedback for FSH secretion stops and FSH levels start to rise b/f onset of menses

Question 23

What occurs to progesterone levels if there is implantation?

Answer 23

• HCG (human chorionic gonadotropin) from zygote sustains corpus luteum for 6-7 wks until placenta takes over
• this is time when a lot of miscarriages occur, hard to transition with change in hormones

Question 24

Characteristics of follicular (proliferative) phase - what hormone dominates?

Answer 24

• estrogen dominates
• development of mature follicle
• culminates with LH surge preceding ovulation (LH surge necessary for ovulation)

Question 25

Characteristics of luteal (secretory) phase - what hormone dominates?

Answer 25

- reqrs that ovulation has occurred - progesterone dominant - elevated basal body temp - further prepares uterine lining (endometrium) to receive fertilized egg

Question 26

Importance of estrogen - on diff parts of body?

Answer 26

- breast: pubertal development - endometrium: stim cell growth (proliferative phase) - cervix: stimulates abundant, clear mucus at mid cycle (helps with motlity of sperm) - vagina: growth and maturation of epithelium, lubrication - bone: helps to maintain density, estrogen receptors in osteoblasts - brain: we don't really know

Question 27

Importance of progesterone on diff parts of body?

Answer 27

- thermogenic effects at level of hypothalamus: increase BBT by 0.5-1.F - cervical mucus thickens and decreases in amt (prevents sperm from easy travel) - breasts: stim of ducts, nipple and areola contributes to fullness and tenderness - fallopian tubes: decrease mucus and causes relaxation to speed transport of ovum

Question 28

What are diff ways to tell if ovulation has occurred?

Answer 28

- track length of menstrual cycles - serial transvaginal US to follow follicular development from dominant follicle to corpus lute - measure LH surge (OTC urine kits): ovulation 36 hrs after LH surge, LH shows up in urine 12 hrs after surge - LH also increased with PCOS, POI, and menopause - BBT rises 0.5-1.0 defree F - measure serum progesterone at mild luteal phase: expect more than 6 ng/ml - ovulation to menses: 12-14 days - menses to ovulation - more variable

Question 29

What is the reproductive physiology of breasts - when does it present, what occurs during pregnancy? What is thelarche?

Answer 29

- both males and female infants may have palpable breast tissue at birth. Some will have galactorrhea - an effect of maternal hormones - by 2-3 months of age, the breast tissue regresses - thelarche: onset of breast development starts at 12.5 in US in 95% of girls - growth during pregnancy from hormones including: prolactin, estrogen, progesterone, cortisol, insulin, thyroid hormones, and growth hormone

Question 30

Composition of the breasts?

Answer 30

- nipple - areola - milk glands (lobules) - ducts: transport milk from glands - connective (fibrous) tissue that surrounds the lobules and ducts - fat

Question 31

What happens to the breasts during pregnancy?

Answer 31

- breasts increase in size: increase in lobules= alveoli lined by milk secreting epithelial cells - the release of estrogen and progesterone from the placenta and prolactin from the anterior pituitary causes breast development - breast milk production: inhibited during pregnancy by effect of progesterone on prolactin

Question 32

lactation physiology?

Answer 32

- colostrum produced first 3-6 days - milk production stimulated by prolactin, prolactin release stimulated by direct stimulation of the nipple - milk ejection results from nipple stimulation: neuro endocrine reflex with release of oxytocin - neuro-endocrine reflex disturbed by maternal tension resulting in problems with nursing

Question 33

What are diff causes of galactorrhea?

Answer 33

this is non-physiologic milky d/c from nipples - idiopathic - meds: tranquilizers, antidepressants, antiHTN meds, herbal supplements, birth control pills - hypothyroidism - pituitary tumors - stimulation of breasts - chest surgery, burns, nerve damage from injury - spinal cord injury

Question 34

Duration of the menstural cycle? Define Menarche and menopause?

Answer 34

- majority are b/t 24-35 days and are ovulatory - about 15% are 28 days - less than 1% are less than 21 or more than 35 days - menarche: first menses - menopause: final menses

Question 35

Diff phases of menstrual cycle?

Answer 35

- follicular: begins with onset of menses and ends with LH surge ovulation occurs w/in 36 hrs of LH surge - luteal phase: begins with LH surge and ends with onset of next menses - day 1 is 1st day of menses and date used in LMP

Question 36

Usual age of first menses? What is this the onset of?

Answer 36

- age of first menses: US median age: 12.5 - one of final events in continuum of puberty: onset of puberty signals reactivation of hypothalamic-pituitary gonadal axis with pulsatile Gn-RH secretions

Question 37

What is puberty?

Answer 37

- endocrine process that influences physical, sexual and emotional transition from childhood to adulthood - triggers for onset not well defined - US: puberty starting 6-12 months earlier than last century

Question 38

Sequence of events in puberty?

Answer 38

sexual maturation extends about 4.5 yrs - growth acceleration - breast development (thelarche) - in US by age 12.5 in 95% - pubic hair development (pubarche): preceded by increased adrenal androgen production (adrenarche), and axillary hair development - max growth rate - menarche (further ht limited to about 2.4 in) - ovulation

Question 39

What is onset of puberty influenced by?

Answer 39

- ethnic background: African American earlier, then Mexican American, then white and then Asian American (black girls begin around 8-9 but can be as early as 6, white girls around 10 but as early as 7 is normal) - BMI: higher the earlier onset - possible effect of leptin (from adipocytes) on pulsatile GnRH secretion - genetics - possible role of enviro toxins acting as endocrine disruptors (pesticides, fertilizers)

Question 40

Role of estrogens in puberty?

Answer 40

- augments accrual of bone during puberty. 2 estrogen receptors (alpha and beta) mediate the actions of estrogen, and presence of both has been demonstrated in growth plate - contributes to growth plate fusion at end of puberty - stimulates breast development

Question 41

What hormone causes pubertal growth spurt?

Answer 41

- Growth Hormone - pulsatile release from pituitary - both GH and sex steroids contribute to growth and epiphyseal fusion - stimulates secretion of IGF-1

Question 42

What is delayed puberty?

Answer 42

- absent or incomplete seual maturation by age at which 95% of girls started pubertal development: - absence of secondary sexual characteristics by age 13 - absence of menarche by 15-16 - no menarche 5 yrs after onset of thelarche (breast development)

Question 43

Causes of delayed puberty?

Answer 43

- hypergonadotrophic hypogonadism: FSH greater than 35 - gonadal dysgenesis (turner's syndrome) - hypogonadotropic hypogonadism: FSH and LH less than 10 - constitutional (physiologic delay) of HPO. Suppression of HPO axis by illness, malnutrition or excessive exercise Elevated prolactin (certain drugs, pituitary tumors) Kallman syndrome (genetic) - anatomic: Imperforate hymen/transverse vaginal septum Mullerian agenesis: absence of uterus, cervix, and upper vagina

Question 44

What is precocious puberty? What is this caused by?

Answer 44

- onset of secondary sexual characteristics b/f age 6 in black girls and prior to 7 in white girls (or more than 2 SD from normal) - caused by early sex hormone production

Question 45

Evaluation goals of precocious puberty?

Answer 45

- define cause, determine if tx is necessary and minimize psychosocial impact - hx and exam (tanner staging) - xray of non-dominate wrist and hand for bone age: premature closure of epiphyseal plates limits stature - lab - pelvic sono - MRI of brain

Question 46

Causes of GnRH-dependent (central) precocious puberty?

Answer 46

early activation of HPO with both breast and pubic hair development - 90% idiopathic (dx of exclusion: MRI) - CNS lesions (tumor, hydrocephalus), trauma, inflammatory disease - severe hypothyroidism: high TSH activates FSH receptor - generally tx with GnRH agonist

Question 47

Causes of Gn-RH independent (peripheral) precocious puberty?

Answer 47

- autonomous fxnl ovarian cysts - McCune-Albright syndrome (rare genetic disorder) - adrenal pathology: nonclassical congenital adrenal hyperplasia (CAH). May mimic PCOS due to accompanying hyperadrogenism, adrenal tumors - exposure to exogenous estrogens or xenoestrogens (endocrine disruptors which mimic estradiol)

Question 48

What is menopause? Median age?

Answer 48

- permanent cessation of menses: retrospective dx: no period for 12 months w/o other explanation = post menopause - median age: 51.4, primary ovarian insufficiency (premature ovarian failure): cessation of menses prior to 40, confirmation of infertility is a common concern

Question 49

What is happening with the hormones in menopause?

Answer 49

- ovaries are no longer listening to brain - the oocytes are resistant to FSH: this represents depletion (or near depletion) of follicles FSH, although elevated is seldom needed for dx unless confirmation of infertility is a concern

Question 50

What occurs secondarily to estrogen loss in postmenopause?

Answer 50

- urogenital atrophy - increase in LDL and decrease in HDL - decrease in bone density: estrogen acts to maintain the appropriate ratio b/t bone-forming osteoblasts and bone-resorbing osteoclasts in part through the induction of osteoclast apoptosis - vasomotor sxs (hot flashes)