SexReproFlashcards
(374 cards)
1
Q
What is the function of breasts?
A
Production and secretion of milk
2
Q
Where are breasts located/
A
Superior chest wall overlying the fascia coveirng the pectoralis muscles
3
Q
What do breasts look like on histology?
A
15-25 lobes open into the nipple via lactiferous ducts
Interlobar connective tissue divides lobes into lobules
Each lobule ends in a terminal duct lobular unit (TDLU)
4
Q
What is the functional unit of a breast?
A
TDLU - hormonally responsive and undergoes cyclic changes with menstrual cycle
PRoliferates and enlarges in pregnancy, with milk secretion during lactation
Atrophic changes after menopause
5
Q
What is mastitis?
A
Breast inflammation
6
Q
What are signs and symptoms of mastitis?
A
Tenderness, redness, induration
Ocacasionally forms an abscess
7
Q
What are teh two types of mastitis?
A
Puerperal (lactational)
Non-puerperal (non-lactational)
8
Q
What is lactational mastitis?
A
Duct obstuction and milk leakage (breast milk cytoines induce inflammatory response?)
Abscesses with staph and strep spp
Symptoms inclue pain, burning, redness ,fever and swelling
Diagnose iwth H&P, ultrasound to rule out abscess
Treat with antibiotics
9
Q
What are symptoms of lactational mastitis?
A
pain, burning, redness, fever, swelling
10
Q
How do you treat lactational mastitis?
A
Antibiotics
11
Q
How does lactational mastitis present?
A
Pain, burning, redness, fever, swelling,
Duct obstruction and milk leakage
12
Q
What do we see here?
A
Abscess formation in lactational mastitis
13
Q
What can cause non-puerperal mastitis?
A
Duct ectasia, fat necrosis, granulomatous mastitis, inflammatory carcinoma
may present as a breast mass!
14
Q
What are important factors of a history when evaluating a patient witha breast mass?
A
15
Q
What are clinical exam features of breast masses that are useful for identifying malignancy vs benign?
A
16
Q
What od we see here?
A
Duct ectasia - dilated duct
Non-puerperal mastitis
17
Q
What is duct ectasia?
A
Non-puerperal mastitis that typically presents in older women
Duct dilation and secretory stasis, presenting with periductal inflammation and fibrosis
Signs and symptoms of mastitis
Antibiotics can be useful
18
Q
What is fat necrosis non puerperal matitis?
A
sterile mastitis
Trauma, radiation or surgery that can damage fat cells
Inflammation, free fatty acids released complex with calcium to form soaps and can form white chalky deposits
May form lump
19
Q
How are fat necrosis non puerperal mastitis treated?
A
Self-limited, goes away on own
20
Q
What is granulomatous mastitis?
A
Inflammation caused by ruptured silicone breast implants or TB
Clinical history is helpful
Ultrasound or mammography can be used, but biopsy is diagnostic
21
Q
What do we see here?
A
Wight foreign material and foreign body giant cells
Granulomatous mastitis
22
Q
What is inflammatory carcinoma non puerperal mastitis?
A
Reddening of breast skin simulates dermatitis and ocurs in association with underlying breast cancer
Dermal lymphatic invasion by cancer cells leads to erythema nad edema ‘peau d’orange’ skin
23
Q
What do we see here?
A
Dilated dermal lymphatic spaces distended by a tumor
inflammatory carcinoma non puerperal mastitis
24
Q
What is fibrocystic change?
A
Benign condition of breast
affects 30-60% of reproductive aged women
Noncancerous breast lumpiness that can cause discomfort and related to menstrual cycle
25
When do women with fibrocystic change present typically?
30s
FIbrosis and cysts cause lumpiness over years
26
How is the lumpiness of fibrocystic change?
Freely mobile with smooth contours
Features of benignity
27
How is the discomfort of fibrocystic change?
Pain/tenderness peak before each menses and diminsih afterwards
28
How do you diagnose fibrocystic change?
Hystory and PHysical
If findings are intermediate - mammography then ultrasound, then biopsy
29
How does fibrocystic hcange look on histology?
Duct dilation and fibrosis
Apocrine metaplasia
+/- microcalcifications
may or may not epithelial hyperplasia
30
What do we see here?
Duct dilation (top)
Apocrine metaplasia (bottom)
31
What is the importance of duct epithelial hyperplasia in fibrocystic change?
Can indicate proliferative fibrocystic change (vs nonproliferative), which has an increased risk of progressing to cancer
32
What do we see here?
Series of fibrocystic change slides
Left: nonproliferative (no cancer risk)
mid: apocrine metaplasia with moderate proliferation (inreased risk)
right: atypical duct epithelial hyperplasia (4-5x risk of cancer)
33
How do you treat fibrocystic change?
Symptomatic releif
fitted bra for good support
painkilllers (NSIADS)
Heat or ice pack
Change hormonal supplements
decrease caffeine and chocolate
(disappears with age)
34
Abigail Ainsley, a 32-year-old woman previously unknown to you, presents to your office with a chief complaint of pain in her left breast of several months\_\_ duration. She reports she has been otherwise healthy, has two young children (G2P2), and has no family history or personal history of breast cancer. On further questioning you elicit that the breast pain occurs just prior to her menses and resolves following menses. Physical examination reveals slightly lumpy (ropey) breasts, with the left showing a 2.5 cm cystic mass to the left of her areola. The mass is mobile and mildly tender. You perform an in-office ultrasound exam which confirms a cystic structure. You then aspirate the cyst and withdraw clear, straw-colored fluid. Post aspiration, she feels relief and the cyst is no longer palpable. What was it?
Fibrocystic change
35
What is phyllodes tumor?
Rare predominantly benign tumor
Phyllo = leaf (looks leaflike under microscope
Firm, mobile, circumscribed mass
Biopsy for diagnosis, surgical resection
36
What is this?
  
Breast enlargement
Well-circumscribed
MIcroscopic gland and stromal proliferation with stroma jutting inot glands
Phyllodes tumor
37
What is nipple discharge?
Any fluid that seeps form nipple
38
What are casues of nipple discharge?
Physiologic, result of trauma, stimluation, fibrocystic change, infection, abscess, benign tumor (fibroadenoma), cancer, or others
In men, must be investigated; in women, most are benign
39
What are signs that can help narrow your differential when considering nipple discharge?
Sore, red, pus = infection
Greenish discharge, thick, perimenopausal = mammary duct ectasia
Bloody or sticky = intraductal papilloma (most common cause)
40
What does pus and sore, red, warm breasts with discharge suggest?
Infection
41
What does thick, greenish nipple discharge in perimenopausal women suggest?
Mamary duct ectasia
42
What does bloody or sticky nipple discharge suggest?
Intraductal papilloma (most common cause
43
What are tests to run on nipple idscharge?
Sample of discharge and send to pathology
Mammogrand or ultrasound for cyst/masses
Biopsy for masses
44
What is the most common benign breast tumor?
Fibroadenoma
45
what is fibroadenoma?
Most common benign breast tumor
Most common tumor in young
Solitary, but may be miltuiple and iblatera
Painless, freely mobile, well circumscribe,d firm, rubbery
may grow during pregnancy
46
What are the characteristics of fibroadenoma?
Painless, freely mobile, well circumscribed mass, firm, rubbery
47
What is this?
Fibroadenoma
48
What is this?
Fibroadenoma
49
What are tests for fibroadenoma?
Mammorgraphy or ultrasound
Very young patients can be managed conservatively
Older patients - biopsy
50
How do you manage fibroadenomas?
Watched, patient makes informed decision
Surgical removal for lesions that grow with time, or if there is concern for cancer
51
Who gets breast cancer/
Mean age = 60 years old, women mostly (men = 1%)
52
What are nongenetic risk factors for breast cancer?
Signs seem to point to excess estrogen exposure
Early menarche, late menopause
Nulliparity, low parity
No breast feeding
Long duration postmenopausal HRT
Obesity
Alcohol consumption
Ionizing radiation at young age
Atypical duct hyperplasia fibrocystic change
Family history
53
What are genetic risk factors for breast cancer?
BRCA genes (BRCA1 = 56-90%; BRCA2 37-84% risk; and also ovarian
TP53 mutation carriers have increased risk (Li-Fraumeni, SBLA syndrome = soft tissue and bone sarcomas, brain tumors, leukemias, and adrenocortical carcinomas)
54
What is the breast cancer pathogenesis?
Loss of tumor suppressor function (BRCA, TP53)
BRCA1 = 17q21
BRCA2 = 13q12-13
Well studied in Ashkenazi Jews
55
How does breast cancer present?
Breast lump, hard, nontender mass with irregular borders
Or in sreening mammograpy
56
Where is the most common location of breast cacner?
Upper outer quadrant
57
What are associated symptoms with breast cancer/
Redness + warmth, edema (peau d'orange), pain, skin or nipple retraction, discharge, eczematous nipple, axillary lymphadenopathy = sign of spread
58
What are signs/symptoms of advanced disaese?
Bone pain, jaundice, weight loss
Axillary lymphadenopathy indicates spread ot lymph nodes
59
What are the four main types of breast cancer/
Insitu duct = inraductal carcinoma = ductal carcinoma in situ (DCIS)
Invasive duct carcinoma (most common)
Lobular carcinoma in situ (LCIS)
Invasive lobular carcinoma
60
What are duct carcinoma in situ (DCIS)?
Precursor to invasive duct carcinoma
Typically discovered on screening mammography (no mass)
Suspicious calcifications on mammograms
May be multifocal multicentric, bilateral
Resection of suspicious area is treatment
61
How do DCIS present?
No mass = precursor to invasive duct carcinoma
Tpically present on mammography
62
How do you treat DCIS?
Resection
63
What do we see here? 
Malignant epithelial cells growign within ducts but do not invade the duct basement membrane into the stroma
DCIS
64
What is the most common breast cancer?
Infiltrating duct carcinoma
65
How does infiltrating duct carcinoma present?
Mammography, mass or density with irregular borders +/- calcifications
Histologically can see irregular nests of ductal epithelial cells that invade stroma
Treat wiht resection
66
What do we see here?
Irregularly shaped nest of malignant cells infiltrating the pale fibrous stroma
Infiltrating duct carcinoma
67
What is LCIS?
lobular cacinoma in situ
Not a palpable mass
Not calcificated
Usually incidentally found
Histologically neoplastic epithelial cells repalce epithelium of the TDLU and enlarge it
68
What do we see here? 
Lobule distended by carcinoma cells, basement membrane intact
LCIS
69
What is invasive lobular carcinoma?
More frequently bilateral than other type sof breat cancer
Similar to invasive duct carcinoma on mammography and gross apearance
Histologically, small, uniform malignant cells invade stroma in linear pattern (single file)
70
What is this?
Invasive lobular carcinoma
Single file pattern on infiltration by cancer cels into pale firous stroma
71
What are good prognosis breast cancers?
Medullary, mucinous, tubular, papillary carcinoma
paget's disease = cancer cells in epidermis (almost always associated with DCIS or invasive duct carcinoma
72
What is this?
Mucinous carcinoma - tumor cells float in mucous pools = good prongosis
73
What is this?
Tubular carcinoma, small tubular formations = good prognosis
74
What is this?
Paget disease; pale tumor cells in epidermis = good prognosis
75
What are tests for breast cancer?
Mammography = screening or diagnostic (negative mammogram with palpable mass doesnt exclude cancer - perform biopsy)
Ultrasound = useful in young patients in determining cystic vs solid
MRI = high sensitivity, low specificity
Biopsy = definitive
76
What is the definitive test for breast cancer?
Biopsy . traetment shouldnt be undertaken without biopsy
77
How do you treat breast cancer/
Excision of biopsy-proven malignancy or mastectomy with option of reconstruction
Sentinel lymph node dissection
Post-surgical chemo, radiation, or hormone therapy
78
How are breast cancer patients followed up/
Every 3-6 months for 1st 3 years, and then less frequently
79
Where do breast cancers metastesize to?
Lymph nodes = axillary are most common, internal mammary, supraclavicular, infraclavicular
Distant sits = bone, lung, brain, liver
80
What are poor prognostic markers?
Lymph node involvement = most important
Tumor size
Tubular carcinoma and others are good prognosis
Histologic grade
Proliferation index
81
What are predictive markers that indicate response to therapy for breast cancer/
Estrogen receptor + tumors can be treated with tamoxifen and have lower risk of recurrence
HER2/neu gene amplification = patients respond to herceptin
Negative prognostic marker, as HER2 + tumors have increased risk of recurrenc eand death
82
A 59 yo lady, a new patient, presents to you with a chief complaint of a newly discovered breast lump.
You find out her mother had breast cancer at age 72, and there are no other known cancers in the family. She has otherwise been in good health, is married, postmenopausal, with two grown children. She has had regular mammograms and pap smears, which were normal. You palpate a small, firm, fixed lesion in her right breast, without being able to further define due to fatty tissue. Mammogram reveals ![]()
Biopsy shows
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What do we suspect?
She has infiltrating duct carcinoma and needs surgery
83
What is this?
Inner vulva and vagina
not skin - no hair, glands, etc...
84
How does the vaginal epithelium synthesize glycogen?
Estrogen and progesterone stimulates the epithelium
Glycogen is main nutreitn for lactobacilli
85
What is the significance of glycogen produciton by vaginal glycogen?
Main nutrient for lactobacilli
86
What is the normal vaginal pH?
3.8-4.2
87
Why is the vaginal pH low?
Lactobacilli metabolize glycogen into lactic acid, responsible for lowering the pH to 3.8-4.2
88
What is inflammation of the vagina called? What typially causes it?
Vaginitis
Typically infection=
89
What is the most common vaginal disorder?
Vaginitis
90
What is vaginal discharge?
Change in amount, odor, color and/or consistency of secretions
91
What is the main symptom of vaginitis?
Discharge
92
What are the three main causes of vaginitis/vaginal discharge?
Gardnerella
Candida
Trichomonas
93
How do you workup vaginal discharge?
Obtain sample of discharge
Examine it under microscope
94
What is the most common cause of bacterial vaginitis (vaginosis)?
Gardnerella
95
What is the discharge typically associated with gardnerella?
scant grayish to milky white, malodorous and fishy smelling
96
What is the special test to identify gardnerella?
Amine test - fishy odor with 10% KOH
Saline wet mount
Will see clue cells - vaginal cells that are grainy looking since they are studded with bacteria
97
What is the second most common cause of vaginitis?
Candida (1st = gardnerella)
98
What vaginitis causes a thick, curdlike discharge?
Candida
99
What vaginitis can cause an appearance of erythematous skin?
Candida
100
How does candida cause vaginitis?
Opportunisitc pathogen - infection upon vaginal pH alteration
See erythematous skin, normal cervix, dysuria
101
Patient presents with erythematous vulva, normal cervix, dysuria and thick curdlike discharge. What do you think?
Candida
102
What do you see under the microscope in candida vaginitis?
fungal hyphae
103
What is the most prevalent nonviral STI in the US?
Trichomonas
104
What is trichomonas?
Uniflagellate protozoan that resides in lower female genital tract and male urethra that overgrows when the pH changes
Can cause vaginitis with discharge and cervico-vaginal petechial lesions (strawberry spots)
Produces profuse, frothy greenish foul-smelling discharge
Tx with metronidazole to patient and partner
105
What is the discharge seen with trichomonas?
Frothy greenish, profuse, foul-smelling discharge
106
How do you treat trichomonas vaginitis?
Metronidazole
107
What do you see in trichomonas vaginitis under microscopy?
Motile organisms on wet mount
108
What are STIs that are not primarily characterized by vaginal discharge?
Mucopurulent endocervicitis (gonorrhea, chlamydia trachomatis D-K)
Vulvar papular lesion which ulcerates (treponema, hemophilous, klebsiella, chlamydia trachomatis L1-L3)
Anogenital vesicles (HSV)
Anogenital warts (HPV)
109
What organism causes gonorrhea?
Neisseria gonorrhea
110
What is the typical presentaiton fo gonorrhea?
Typically asymptomatic
Can present with urethritis (more common in males) with copious pus-like discharge from glands of lower genital tract
May cause pelvic inflammatory disease if untreated - may lead to fallopian tube scarring and infertility
111
What is a consequence of not treating gonorrhea?
Pelvic inflammatory disease whcih can cause fallopian tube scarring and infertility
112
What is chlamydia trachomatis?
Most common bacterial STI in US
Serovars D-K causes mucupurulent cervicitis and pelvic inflammatory disease (may be asymptomatic)
Serovars L1-L3 cause lymphogranuloma venereum in Asia, Africa and S. America as a painless papule followed by inguinal lymphadenopathy
113
What serovars of chlamydia trachomatis causes mucopurulent cervicitis and PID?
D-K
114
What serovars of chlamydia trachomatis cause lymphogranuloma venereum?
L1-L3
115
What is the life cycle of chlamydia trachomatis?
Obligate intracellular bacterium
Unique in that it exhibits both intracellular and extracellular forms
116
What are risk factors for pelvic inflammatory disease?
Young age, sexual activity
Low socioeconomic status
African americans
Multiple partners
Failure to use barrier methods
Douching
117
What are complications of untreated chlamydia trachomatis?
Pelvic inflammatory disease with resultant fallopian tube scarring and increaed risk for ectopic pregnancy
Can form adhesions and be associated with chronic pelvic pain
118
What is lymphogranuloma venereum?
Caused by chlamydia L strains - more invasive and infect skin and underlying soft tissue -\> lymphadenopathy
Primary lesion is painless genital papule which may ulcerate
May have systemic manifestations (fever, myalgia, arthralgia)
Can cause ulceration and hypertrophy of genitalia, arthirtis, fistula formation of rectum bladder vagina or vulva
Tx with antimicrobials
119
What are consequences of untreated chlamydia L?
Ulceration and hypertrophy of genitalia, arthritis, fistula formation of rectum, bladder, vagina, or vulva
120
What is the guiding principle of treatment for STIs?
Treat patient AND partner
121
What is most important in differentiating infectious etiologies of genital lesions?
Pathology lab - identify the organism
Many can look similar
122
What organism causes syphilis?
Treponema pallidum
123
What is the primary lesion in syphilis?
Painless chancre
124
What does secondary syphilis look like?
maculopapular rash on trunk and extremities (including palms and soles)
Whitish lesions on mucous membranes (condylomata lata)
125
When you see condylomata lata and a maculopapular rash on palms and soles, what are you thinking?
Secondary syphilis
Seen 4-10 weeks after primary infection
126
How does chancroid present?
**Painful** papule - soft chancre - ulcerates
Inguinal lymphadenopathy may break through skin (buboes)
Lymph nodes need drainage and if untreated can cause ulceration and fistula formation
Gram stain needed for diagnosis
127
What organism causes chancroid?
Hemophilus ducreyi
128
What do you see on microscopy of chancroid?
School of fish appearance of hemophilus ducreyi on gram stain
129
What is granuloma inguinale?
Painless papule that may ulcerate
No inguinal lymphadenopathy, but may cause tissue destruction (penile autoamputation has been reported) if untreated
Caused by Klebsiella granulomatis (donovanosis)
130
What disease does klebsiella granulomatis (donovanosis) cause?
Granuloma inguinale
131
How does granuloma inguinale look on microscopy?
Donavan bodies (donavanosis - Klebsiella granulomatis)
Biopsy with Wright-Giemsa stain is gold standard for diagnosis
132
What is the most common cause of genital ulcers in US?
HSV (2)
133
How does herpes cause infection/ulcers?
Enters through skin and travels to nerve roots
In outbreak, travels down nerve to original site of infection causing redness and blisters
Can be systemic - fever, malaise, headache, myalgia
134
What can you see on microscopy of herpes?
Tzanck stain shows Herpes vi ral cytopathic effect: multinucleated giant cells
135
What do you suspect from this Tzanck stain?
Herpes viral cytopathic effect
Multinucleated giant cells with ground glass appearance of nuclei
136
What virus classically causes genital warts?
HPV
137
What do you think this could be?
Whitish warty lesions, on the patients right side
Likely caused by HPV - take biopsy to confirm
138
What are the low risk HPV serotypes?
6,11 - intracellular virus in episomal form
Causes warts, low grade lesions
139
What HPV serotypes are high risk?
16, 18
Integrate into host DNA and are associated with high grade lesions and cancer
140
How is HPV thought to contribute to tumor formation?
Integration of viral DNA into host DNA causes aberrant overexpression of viral E6 and E7 genes
E6 caues degradation of p53 and E7 interferes with Cyclin A and p105 RB (whcih are important in cell cycle regulation)
141
What viral proteins are implicated in tumorigenisis in HPV infection?
E6 and E7
E6 = p53 degradation
E7 = inteference with cyclin A, p107 and p105 RB
142
What do we see here?
Koilocytes
HPV cytopathic effect
143
What is a koilocyte?
Raisin-like nuclei with surrounding space
Seen in HPV infection (HPV cytopathic effect)
 
144
What does this look like?
Condyloma acuminatum
HPV infection
Biopsy is gold standard
145
Emily Ernstweiler, an 18 year old female previously unknown to you, presents to your office with a chief complaint of vulvar pain and dysuria for the past week. She has been previously healthy, started her menses at age 13 and has had fairly regular 28 day menstrual cycles with duration of bleeding of 3
days. She became sexually active during this past month with a boy from her English class. On physical exam, you notice a number of symmetrical, ulcerated lesions on her labia majora bilaterally
What do you think?
Herpes infection
146
What is lichen sclerosus?
Most common vulvar dermatologic disorder
A type of vulvar dystrophy
Patchy white, thin skin (**parchment paper skin**)
Unknown etiology
Causes pruritis, painful intercourse, in troital stenosis, flattening and fusion of labial folds
147
What is this?
Lichen sclerosus
148
How do you treat lichen sclerosus?
Corticosteroids
149
What do you see here?
Skin showing epidermal thinning with loss of rete ridges and superficial dermal sclerosis
Lichen sclerosis
150
Kelly Kalleidoscope is a 34-year-old lady, a mother of two (G2P2) who presents to your office for a follow up of her recent Pap smear which was abnormal, with a high-grade squamous intraepithelial lesion (HSIL). On colposcopic examination of her cervix, you identify an area showing abnormal blood vascular pattern and perform a biopsy. You inform Kelly that the abnormal area is larger than the biopsy sample and, if the Pathology report confirms your suspicion of a high-grade lesion, she will have to return to have the entire lesion excised. The Pathology Lab reports cervical intraepithelial neoplasia II (CIN II, moderate dysplasia). You telephone Kelly with this news and advise her to return at her next convenience for a loop electroexcision procedure (LEEP).
Which portion of the cervix tends to be involved (hence, must be excised in order to ensure optimal treatment)?
Transformation zone
151
What is cervicitis?
Inflammation of cervix
Most common disorder of cervix
Most commonly caused by agents of STI
Treated with antimicrobials and is almost always curable
152
What do we see here?
Cervical histology
See ectocervix - external os and endocervical glands (internal)
153
What is the cervical transformation zone?
High incidence area for devleopment of intraepithelial (precancerous) lesions
Squamo-columnar junction
T-zone moves upward in cervical canal during a woman's lifetime
154
What are cervical intraepithelial neoplasias (CINs)?
Formerly called dysplasias (refers to abnormal maturation of epithelium)
155
What are risk factors for CIN?
Early age of first sexual encounter
Multiple sexual partners
High-risk male partner
Multiple pregnancies
Early age first marriage
Unstable marriage
Low socioeconomic status
Cigarette smoking
Immunosuppresion
History of STI, especially HPV
156
What is an associated infection with CINs?
HPV in \>80% of CINs and 99.7% of cervical cancers
157
How is CIN (cervical dysplasia) graded?
mild, moderate, severe
Mild = CIN I -\> abnormal maturation involving lower 1/3 of epithelium
Moderate = CIN II -\> Abnormal maturation involving lower 1/2 to 2/3 of epithelium
Severe = CIN III -\> Abnormal maturation involving full thickness of epithelium
158
What is pap smear?
Screening test for cerivcal cancer
Has decreased incidence of invasive cervical cancer
There are established guidlines for followup of abnormal pap smears
159
What is ASCUS on pap smear?
Atypical squamous cells of uncertain significance - not treated
160
What is ASC-H on pap smear?
Atypical squamous cells of which a high-grade lesion cannot be excluded - not treated
161
What is LSIL on pap smear?
Low-grade squamous intraepithelial lesion - not treated
162
What is HSIL on pap smear?
High-grade squamous intraepithelial lesion - treated, removed
163
What does a cell whose nucleus takes up more than 50% of the cell volume on pap smear indicate?
HSIL - needs to be treated -\> excision or removal by freezing or burning
164
What is colscopy?
Lesions that look significant can be sampled by colposcopy - biopsy and send to path lab
165
What do we see on left, right?
Left - LSIL = low grade squamous intraepithelial lesion (lower 1/3)
Right = HSIL = high grade squamous intraepithelial lesion (full thickness)
166
What can happen to untreated intraepithelial lesions?
Regress, persist, or progress
167
What does cervical cancer look like on pathology?
168
Millie Millhauser is a new patient of yours. She presents with a chief complaint of postcoital bleeding. She is a 50 year old waitress, mother of two, notable for her flaming red hair and bright red finger nails. She had gone through a stormy divorce three years ago and has had four boyfriends since then. Her current \_\_beau\_\_ is an ex-convict. Millie is a long-time, heavy cigarette smoker with a long history of abnormal Pap smears, but doesn\_\_t recall what the diagnoses were.
What do you tell her?
Your differential includes either cervical or endometrial cancers, so you will want to repeat pap smear or biopsy
169
Nikki Nickelbaum is a 25 year old nulliparous, obese woman, who presents to your office with a complaint of decreased menses (once every 4 or so months, called oligomenorrhea). Her periods when they come, tend to be heavy, lasting around 7 days, and she goes through two boxes of Kotex pads (sanitary napkins) per period. Nikki says she has had bad acne since puberty (age 13). On pelvic exam you find no abnormalities, and no masses are palpated
What lab tests do you order?
Need to rule out pregnancy, thyroid problem, or CNS problem (prolactinoma)
170
What influences the ovaries to secrete estrogen and progesterone?
Hypothalamus and pituitary peptide hormones
171
What changes does the endometrium undergo on a monthly basis?
Proliferative (growth) phase
Secretory (stop growth and secretion) phase
Pregnancy causes endometrium to convert to gestational phase; if not, menstrual breakdown
172
What do we see here?
Proliferative phase of endometrium (estrogen phase)
Mitosis in gland and stromal cells
173
What do we see here?
Early secretory phase of endometrium
Cytoplasmic vacuoles in gland cells
174
What do we see here?
Mid secretory phase of endometrium
Glands begin to distend with intraluminal secretions
175
What do we see here?
Late secretory phase of endometrium
Post secretory glands begin to involute
176
What do we see here?
Menstrual phase of endometrium
Gland and stromal cell death and endometrial tissue dissolution
177
What does this show?
Menstrual cycle
178
What is metrorrhagia?
Bleeding between periods
Causes include endometrial polyp, uterine cancer, hormone replacement therapy
179
What is menorrhagia?
Heavy bleeding during menses
Causes leiomyomas (fibroids), pregnancy complications, adenomyosis, IUDs, endometrial hyperplasia, malignancy, dysfunctinoal uterine bleeding
180
What is menometrorrhagia?
Combination of menorrhagia and metrorrhagia
181
What is endometrial hyperplasia?
Abnormal growth causing thickness of endometrial mucosa and increaed gland-to-stroma ratio
Considered precancerous
Estrogen is implicated in pathogenesis
Associated with microsatellite instability, defects in DNA mismatch repari genes, and PTEN tumor suppressor mutations
182
How does endometrial hyperplasia present clinically?
Abnormal uterine bleedgin (any type)
Abnormal vaginal discharge
Abnormal glandular cells on pap smear (AGUS)
Ultrasound can assess endometrial thickness, but endometrial BIOPSY is GOLD STANDARD
183
What is the gold standard of diagnosis for endometrial hyperplasia?
Biopsy
184
What is this a progression of?
Endometrial hyperplasia
185
What is the gland-to-stroma ratio in typical endometrium?
Glands make up ~\<50% of endometrium
Good amoutn of stroma between, and are separate from neighbors
186
What is characteristic of simple endometrial hyperplasia?
Swiss Cheese hyperplasia
Mildly crowded, some dilatation
187
What is characteristic of complex endometrial hyperplasia?
Animal cracker hyperplasia
Moderately crowded glands, complex shapes
188
What is characteristic of atypical endometrial hyperplasia?
Severely crowded glands with nuclear atypia
189
Which endometrial hyperplasia has the greatest risk of progression to cancer?
Atypical hyperplasia
190
How can the relative risk of the different types of endometrial hyperplasia be remembered?
Penny, nickel, quarter (simple, complex, atypical = 1%, 5%, 25% respectively)
Risk of developing cancer
191
What is the most common pelvic genital cancer in women?
Endometrial carcinoma (adenocarcinoma)
192
What is endometrial carcinoma (adenocarcinoma)?
Most common pelvic genital cancer in women
Usually in older women
Can be seen in younger womeon with unopposed estrogenic stimulation (polycystic ovarian syndrome)
Bleeding facilitates detection of early stage disease -\> better prognosis than others
193
Why do endometrial carcinomas have better prognoses than other gyn cancers?
bleedign facilitates early detection
194
How does an endometrial adenocarcinoma look like grossly?
Uterus containing cancer will show thickend, ragged mucosal lining or polypoid mass(es)
Malignancy of glandular epithelium = adeno carcinoma
195
How does an endometrial adenocarcinoma appear histologically?
Back-to-back arrangement of glands (cribriforming)
Due to invasion of storma by malignant gland-forming cells until they become confluent
196
What do we see here?
Endometrial adenocarcinoma
197
What are the two types of endometrial adenocarcinoma?
Type I = features unopposed estrogen and can occur premenopausal, low grade, lesser invasion, indolent
Type II - no unopposed estrogen and occurs postmenopausally only, high grade, deep invasion, aggressive (p53)
198
What is the most common tumor of the uterus?
Leiomyoma - benign smooth muscle cell neoplasm
More common in African Americans than caucasians
1/3 are symptomatic (menorrhagia)
199
Who gets leiomyomas more commonly?
African americans
200
How do leimyomas present?
only 1/3 are symptomatic with menorrhagia
201
What do we see here?
Leiomyoma
202
What do we see here?
Uterine leiomyoma
203
What is adenomyosis?
Similar clinical picture to leiomyoma (abnormal uterine bleeding or menorrhagia)
Physical exam can distinguish since adenomyosis causes SYMMETRIC enlargement of uterus (leiomyoma is irregular enlargement)
Downgrowth of endometrial tissue into myometrium
204
What is the difference between adenomyosis and leiomyoma?
Adenomyosis presents w/ symmetrical enlargement of the uterus
Leiomyoma is irregular enlargement of the uterus
Adenomyosis is the result of downgrowth of endometrial tissue into myometrium
Leiomyoma is a neoplasm of myometrium
205
What is leiomyosarcoma?
Malignant counterpart of leiomyoma (arise de novo and not from leiomyomas)
Very RARE
Present with abnormal uterine bleeding
Diagnostic histologic features include high mitotic count, nuclear atypia and necrosis
206
What is PID?
Pelvic inflammatory disease (pus in dere)
Infection of upper reproductive tract (uterus, ovaries, fallopian tubes and adjacent soft tissues)
Result of ascending ifnection of vagina and cervix (Typically neisseria and chlamydia)
Risk factors include multiple partners, history of STI, history of sexual abuse)
Symptoms include - lower abdominal pain, abnormal vaginal discharge (may or may not be present)
207
What are some symptoms of PID?
Lower abdominal pain
+/- abnormal vaginal discharge
Fever and pelvic tenderness
208
What are risk factors for PID?
Multiple partners
Hx of STI
Sexual abuse hx
209
What are things on the differential diagnosis with PID?
Appendicitis, cervicitis, UTI, endometriosis, ovarian tumor
210
What are sequellae of untreated or delayed diagnosis of PID?
Chronic pelvic pain from scarring
Tubal infertility
Tubo-ovarian abscess
211
Where do the ovaries lie?
Posterior aspect of uterus, connected via posterior ovarian ligament and behind/in the broad ligament
212
What is female pseudohermaphroditism?
Most common cause of sexual ambiguity of the newborn - congenital adrenal hyperplasia
Normal 46XX karyotype, normal internal genitalia (uterus, ovaries, fallopian tubes), but external genitalia appears ambiguous or male
Due to exposure of fetus to excess male hormones
213
What is the most common cause of sexual ambiguity of the newborn
Congenital adrenal hyperplasia (Female pseudohermaphroditism)
46XX female with internal genitalia intact, but external ambiguous d ue to excess male hormones before birth
214
What is male pseudohermaphroditism?
46 XY - gonadal defects or end organ defects
215
What determines the development of external male genitalia?
Testosterone
216
How does fetal development of the genitourinary tract unfold?
217
What is the "default" sex?
Female
218
What is the function of mullerian inhibiting factor?
Stimulates male duct (mesonephric) development and regression of female (paramesonephric)
219
What is the female internal genitalia duct system?
Paramesonephric ducts give rise to uterus, fallopian tubes, upper vagina
220
What is the male internal duct system?
Mesonephric ducts
Give rise to vas deferens, epididymis, seminal vesicles
221
Where do Mullerian inhibiting factor and testosterone act?
Locally - MIF stimulates Wolffian ducts and inhibits mullerian ducts; Testosterone stimulates external genitalia
222
What are the karyotypes of individuals with mixed gonadal dysgenesis or true hermaphroditism?
Can be normal or not or mosaic
223
What is a true hermaphrodite?
Internal duct development corresponds to adjacent gonad with ambiguous external genitalia
3/4 raised as males
(Mixed gonadal dysgenesis has persistent mullerian duct regardless of adjacent gonad)
224
What is mixed gonadal dysgenesis?
Persistent mullerian duct regardless of adjacent gonad
Streak gonad
1/3 raised as males
(True hermaphroditism has internal duct development that corresponds to adjacent gonad
225
46 yo woman
\_\_ Completed child bearing and desired to have her internal genital organs removed due to her history
\_\_ Gonad is pictured:
What\_\_s your diagnosis
True hermaphrodite
226
What is turner syndrome?
45X0 or mosaic (45XO/46XX)
Short stature, webbed neck, low-set hairline, shield chest, underdeveloped secondary sex characteristics
Gonadal Dysgenesis
227
This is the internal genitalia of what type of patient?
Turner Syndrome
Hypoplastic uterus and fallopian tubes
228
What is this? We're looking at internal genitalia
Streak gonad
Fibrous streak instead of ovary
229
What are the three non neoplastic ovarian cysts?
Functional (follicular) cysts
Endometriotic cysts
Polycystic ovarian syndrome (PCOS)
230
What is a functional cyst?
Benign cysts that tend to occur in women of reproductive age
Size \> 2cm
Follicle fails to release egg and fluid is not resorbed
Typically asymptomatic but can present with pelvic pain, abnormla uterine bleeding, dyspareunia
Most regress in 60 days
231
What is this?
Follicular (Functional) cyst
232
What is endometriosis/endometriotic cysts?
Cells from lining of uterus appear to grow outside uterine cavity (ovaries)
10-15% of reproductive-age women
Symptoms worsen around menses (pelic pain, dysmenorrhea, dyspareunia, dysuria)
Common finding in women with infertility
233
What is this?
Endometriotic cyst
Endometrial tissue in ovary
234
What causes endometriosis?
Unknown - may be genetic, may be estrogen-related
235
What is the gross apperance of endometriosis?
Cysts that contain turbid brownish content ("chocolate cysts")
236
How does endometriosis appear histologically?
Endometrial-like glands and stroma, recent and remote hemorrhage - may cycle with menstrual cycle
237
What is polycystic ovarian syndrome?
One of most common female endocrine disorders
5-10% of reproductive age women
Leading cause of female subfertility
"String of pearls" finding on ultrasoudn - thick, sclerotic cortical ring
-- Release of excess LH by anterior pituitary, or high levels of blood insulin, or reduced sex hormone binding globulin (resulting in excess androgens, elevated LH:FSH ratio)
Oligomenorrhea, secondary amenorrhea, infertility, hyperandrogenemia (hirsutism and acne), metabolic syndrome
238
What is this?
"string of pearls" arrangemnt of ovary
Polycystic ovarian syndrome (PCOS)
239
What is this?
Polycystic ovarina syndrome (PCOS)
240
What are the three broad categories of ovarian tumors?
Epithelial (surface or germinal epithelium)
Germ cell tumors (oocyte)
Sex cord/stromal tumors (follicle cells)
241
What age women are at greatest risk for malignant ovarian masses?
Prepubescent children and postmenopausal women
242
What is an ovarian mass in a reproductive age woman most likely to be?
Functional cyst or endometrioma
243
How do you work up an ovarian mass?
Patient's age
Characteristic of mass on pelvic exam
Radiographic appearance
244
What are physical findings of a benign ovarian mass?
Mobile, cystic, smooht, unilateral
245
What are physical findings of a malignant ovarian mass?`
Fixed, solid, nodular, bilateral
246
You find mobile, cystic, smooth unilateral ovarian mass, what do you think?
Benign
247
You find fixed, solid, nodular, bilateral ovarian masses. What do you thinK?
Malignant
248
How do benign ovarian masses appear on ultrasound?
Simple cyst \<10cm
Septations \< 3mm unilateral
Calcification (teeth)
249
How do malignant ovarian masses appear on ultrasound?
Solid +/- cystic
Septations \>3mm
Bilateral
Ascites
250
What lab tests do you order on a patient with an ovarian mass?
hCG - pregnancy marker, and seen in some malignant germ cell tumors
AFP, LDH (young girls) - malignant germ cell tumor marker
CA125 - postmenopausal women suspected of having ovarian cancer
251
What are epithelial tumors of the ovary?
70% of all primary ovarian neoplasms
Most are benign and serous cystadenoma is most common; they are also ost common malignant primary ovarian neoplasms
Typically post-menopause
252
Tanya Tannenbaum is a 65- year-old nulliparous Caucasian female, who presents to your office with a 6 month history of increasing waist size even though she seems to be eating less. She complains of occasional shortness of
breath even at rest. She denies any nausea, vomiting, or vaginal bleeding. Prior to this, she had always been healthy. What is the diagnosis you suspect?
Mucinous cystadenoma
Ovarian carcinoma
Uterine malignancy
All possible
253
What is the most common malignant epithelial neoplasm in the ovaries?
Papillary serous carcinoma
254
This is an ovarian malignancy. What is it?
Papillary serous carcinoma - papillary structures lined by malignant epithelial cells
255
What are risk factors for ovarian cancer?
Ovulation
High fat diet
Talc exposure
Genetics (BRCA1 or 2; Lynch Syndrome aka HNPCC)
256
What are germ cell tumors?
2nd most common ovarian neoplasms after epithelial tumors - most are benign (90%) and called dermoids
257
What are dermoids?
Benign ovarian neoplasms (germ cell tumors)
Removal recommended
258
Who gets malignant germ cell tumors?
girls and teenagers
259
What are biologic markers for germ cell tumors?
AFP and hCG
260
What is dysgerminoma?
Most common malignant germ cell tumor
COmposed of primordial germ cells
Show good resopnse to radiation and chemo
261
What is a mature cystic teratoma?
Most common benign germ cell tumor
Composed of mature tissues from any of the germ line layers (ecto,meso, endoderm)
MAjority are benign
262
Lora Lane is a 25 year old with normal medical history who recently experienced amenorrhea, beginning breast atrophy, deepening of her voice, and beginnings of a beard.
May have elevated testosterone
May have an adrenal problem
May have ovarian tumor
May have sex-cord stromal tumor
263
What are sex-cord stromal tumors?
10% of primary ovarian neoplasms
Arise from follicle cells (granulosa, theca)
May produce sex hormones (estrogen, testosterone) with clinical consequences (feminization or masculinization)
264
What is a granulosa cell tumor?
Most common malignant sex cord/stromal tumor
Low-grade malignatn tumor
265
What are fibrothecomas?
Most common benign sex cord/stromal tumors
1/3 are inert, 1/3 secrete estrogen and 1/3 secrete androgen
266
AK is a 64 yo lady who complains of increasing abdominal girth and diffuse lower abdominal discomfort for the past six weeks. She has a feeling of fullness in the upper abdomen. Her appetite has been poor in the past few months, but she gained 8 pounds. She has no gynecologic or urinary symptoms. She has been postmenopausal for 14 years, and her past history and family history are unremarkable.
What could it be?
Could be benign, malignant, GI or GYN issue
267
AK is a 64 yo lady who complains of increasing abdominal girth and diffuse lower abdominal discomfort for the past six weeks. She has a feeling of fullness in the upper abdomen. Her appetite has been poor in the past few months, but she gained 8 pounds. She has no gynecologic or urinary symptoms. She has been postmenopausal for 14 years, and her past history and family history are unremarkable.
Physical exam:
Reveals a pale, normal-appearing lady. Notable findings include a distended abdomen with a prominent fluid wave and shifting dullness.
Bimanual and rectovaginal exam reveal a 15x10 cm, irregular, nodular mass fixed to the right pelvic sidewall and extending across the midline
What could it be?
Ovarian cancer
268
AK is a 64 yo lady who complains of increasing abdominal girth and diffuse lower abdominal discomfort for the past six weeks. She has a feeling of fullness in the upper abdomen. Her appetite has been poor in the past few months, but she gained 8 pounds. She has no gynecologic or urinary symptoms. She has been postmenopausal for 14 years, and her past history and family history are unremarkable.
Physical exam:
Reveals a pale, normal-appearing lady. Notable findings include a distended abdomen with a prominent fluid wave and shifting dullness.
Bimanual and rectovaginal exam reveal a 15x10 cm, irregular, nodular mass fixed to the right pelvic sidewall and extending across the midline
Labs:
Hemoglobin and Hct are decreased slightly, otherwise normal
Radiology:
Abdominal CT scan shows a 6x12 cm irregular mass in the mid-abdomen anterior to the stomach; a 15x10 cm pelvic structure consisting of the uterus and right ovary, which is replaced by a partly solid, partly cystic irregular mass that extends to the right pelvic sidewall, compressing the sigmoid colon. The left ovary is irregular and enlarged to 4x6 cm.
Abdominal paracentesis removes 6000 ml of straw-colored fluid, sent to CytoPathology.
What could it be?
Serous adenocarcinoma (most common ovarian carcinoma
Refer to Gyn Oncologiest
269
When does embryonic circuliation begin?
When placenta forms (21 days)
270
When does the placenta form?
21 days
271
What are funcitons of the placenta?
Provide maternal nutrients and oxygen to fetus
Clear fetal waste
Confer passive immunity by transfer of maternal antibodies
Produce hCG, hPL, estrogens, and progesterone
272
What is the funciton of progesterone on the pregantn mother?
Smooth muscle relaxation
273
What is the effect of human placental lactogen on the pregnant mother ?
HPL causes breast growth and lactation; diabetogenic
274
What is the effect of hCG on the pregnant mother?
Nausea
Maintains corpus luteum
275
What aer circulatory system physiologic changes in pregnance?
Increasd venous return, cardiac output and blood volume; Decreased blood pressure
276
What are respiratory physiologic changes in a pregnant woman?
Increased oxygen consumption
277
What are urinary physiologic changes in a pregnant woman?
Renal blood flow increases causing increased urine formation
278
What are digestive physiologic changes in a pregnant woman?
Increased transit time (better absorption, but constipation occurs)
Progesterone relaxes smooht muscle tissue
279
How is pituitary funciton changed in pregnancy?
Increased oxytocin (mostly during labor and lactation) from posterior pituitary
Increasd prolactin, corticotropin, thyrotropin, and GH from anterior pituitary
Decreased FSH, LH from anterior pituitary
280
What is the function of oxytocin in pregnancy?
Involved in uterine contrations of labor and postpartum uterine involution
Causes contraction of myoepithelial cells leading to ejection of milk from TDLUs into large ducts
281
What is the effect of pregnancy on adrenal funciton?
INcreased cortical secretions - mobilizes amino acids for fetus; sodium resorption causes fludi retention
282
What is the effect of preganncy on the thyroid?
Enlarges thyroid, increased thyroxine production
283
What is the effect of pregnancy on parathyroid?
Enlarges - causes calcium resorption from maternal bones if needed by fetus
284
How does uterine fundus hight above pubic symphisis relate to stage of pregnancy?
Each cm ~ week pregnant
285
What changes do you see in hematocrit in pregnancy?
Decreases - dilutional (anemai in pregnancy is marked by Hgb \< 11 or Hct \< 33%)
286
What is weight gain in pregnancy the result of?
Mother (uterus, breasts, blood, fat, other) cause ~ 13 lbs
Fetus causes ~6-9 lbs
Placenta, membranes, fluids cause ~ 4 lbs
287
What are Leopold's maneuvers?
Use abdominal palpation to ascertain position of fetus
288
What is cephalic or vertex presentation?
Fetus has head down in abdomen of mother
289
What is the first stage of labor?
Onset of labor contractions thru full dilation of cervix
290
What is the second stage of labor?
From full cerix dilation to delivery of fetus
291
What is the third stage of labor?
From delivery of fetus to delivery of placenta
292
What are the three stages of labor?
1 - from onset of contracitons to full dilation
2 - from full dilation to delivery of baby
3- from delivery of baby to delivery of placenta
293
What are mechanical factors of parturition?
Stretch of uterine smooth musculature (increases contractility; stretched by fetal growth)
Stretch of uterine cervix ( feedfback mechanism from cervix increases contractions)
294
What are hormonal factors of parturition?
Estrogen increases uterine contractility
Progeserone decreases uterine contractility
E/P ration increases near term
Oxytocin increases contractions during labor
Prostaglandins soften cervix and cause contractions
295
What is the E/P ratio and why is it important in partuition?
Estrogen/Progesterone
INcreases near term
Estrogen increases uterine contractility; progesterone decreases it
296
What assesses the newborn's need for resuscitation?
APGAR score
297
What is normal blood loss durign labor?
\< 500 mL
298
What are identical twins?
From single ovum
299
What are fraternal twins?
From two ova
300
What proportion of twins are identical? What proportion are fraternal?
1/3 identical; 2/3 are fraternal
301
What is the etiology of double ovum (fraternal) twins?
Inherited propensity
302
What is the etiology of single ovum (identical) twins?
Chance splitting of the ovum
303
Twins are boy and girl; what type of twins are they?
Fraternal - by definition; Must have come from two ova and two sperm
Identical are one ova, one sperm; then splits after fertilization
304
What are dizygous twins?
Fraternal - associated with multiple ovulation
Increased frqency with increased maternal age, parity
Frequency dependent on races and ethnicity
305
What are monozygous twins?
Result of division of a fertilized ovum
Fairly constant frequency worldwide - chance
Unclear cause
306
How can the placentas of twins develop?
Devision of fertilized ovum \< 3 days =\> dichorionic-diamniotic placenta
Division at 3-8 days =\> monochorionic-diamniotic placenta
Divisoin at 8-13 days =\> monochorionic-monoamniotic placenta
Divison \> 13 days =\> conjoined twins
307
What is dichorionic, diamniotic placenta?
Fraternal twins, typically; or if divisoin of identical occurs at \< 3 days
308
What is a complication of monochorionic- monoamniotic placenta?
Luckily it is a rare occurance
Can cause cord tangling
309
What are pregnancy complications of twins?
Preterm labor
Discordant fetal growth
Pregnancy-induced HTN
Anemia
Others
310
KL\_\_s face, hands and lower legs appear edematous. Her pulse is 92, respiratory rate 18, BP 160/110, temperature normal. HEENT, neck, heart and lung exams are otherwise normal except for a 2/6 systolic ejection murmur loudest at the left sternal border. Breast exam is significant for bilateral fullness and slight tenderness diffusely. Abdominal exam reveals a nontender uterus with fundal height 38 cm, fetus is in a longitudinal lie, vertex presentation. Dipstick urinalysis reveals 3+ proteinuria.
What do you suspect?
Preeclampsia - HTN and proteinuria
311
What are the signs and symptoms of preeclampsia?
HTN = sys \> 140 or diastolic \> 90
Proteinuria \> 300mg in 24 hr
Symptoms of heaache, RUQ pain
Hematologic or liver enzyme abnormalities
312
What defines preeclampsia?
Hypertension after 20 weeks gestation in previously nonhypertensive woman
Proteinuria over 300mg/24hr or at least 3+ on two random urine samples at least 4 hours apart
313
What are lab abnormalities in preeclampsia?
HELLP (hemolysis; elevated liver enzymes; low platelets) - microangiopathic thrombangitis
314
What is eclampsia?
Occurance of new-onset grand mal seizures in a woman with preeclampsia
315
What is teh effect of preeclampsia on the fetus/placenta?
Mild cases can show no changes
But severe clases can cause small placenta with multiple infarcts
Placental trophoblast cells have not adequately invaded into maternal vasculature and maternal blood vessels fail to show normal changes of pregnancy
316
An ultrasound exam reveals a "snowstorm" pattern of ehoes filling the uterine cavity without a fetus
Hydatidiform mole
317
When do you see extremely high hCGs?
Hydatidiform mole
318
What is a hydatidiform mole?
Benign placental neoplasm that has excess paternal chromosomes
Complete or partial
Complete: all placental villi are abnormal; no fetus
Partial: some villi are normal; may be fetus
319
What type of hydatidiform mole is this?
Complete
320
What type of hydatidiform mole is this?
Partial
321
What factors influence expression of human sexuality?
Age, culture, religion, previous experiences, physcial conditions, partner(s), availability
322
What is dyspareunia?
Pain on intercourse
Can be caused by inflammation, inadequate vaginal lubrication, trauma, other gynecologic problems, or a structural problem
323
What is the human sexual resopnse?
Multisystem autonomic nervous relex that can be reinforced or inhibted by physiological, psychological and social factors
324
What is a broad distinction between the men and women human sexual response?
Women resopnd more to consciousness of being desired as a whole person; Men's satisfaction is more visceral senstion
325
What are the 4 Masters and Johnson stages of sexual response?
1) excitement
2) plateau
3) orgasm
4) resolution
326
What occurs in females during the excitement phase of sexual response?
Vasodilation and congestion of all erectile tissue
Breasts enlarge and vaginal ostium opens
Vestibular gland secretions and vaginal mucosal exudations cause moistening
327
What occurs in men during the excitement phase of sexual response?
Vasodilation and congestion of vessels in corpora cavernosa cause erection
Scrotal skin and dartos muscle contract and draw testes up
328
What occurs during the plateau phase of sexual response in women?
Vasocongestion increases
Uterine ligaments contract and lift uterus into alignment with pelvic axis
Cervix dilates
Lower 1/3 of vag engorges and upper 2/3 balloons
Pulse doubled and RR rises; involuntary pelvic thrusts
329
What occursduring the plateau phase of men sexual response?
Intensity of erection increases; testes enlarge via congestion
Seminal fluid arrives at urethra via sympathetic nerve stimulation ov vas deferens, seminal vesicels and prostate
pre-ejaculate discharge may contain sperm
Pulse doubled and RR rises; involuntary pelvic thrusts
330
What occurs during the orgasm phase of sexual response in women?
Pulse and RR double resting rate; Pelvic floor contraction
Climactic sensation
331
What occurs during the orgasm phase of sexual response in men?
Pulse and RR double resting rate; Pelvic floor contraction
Climactic sensation - strong contractions pass along penis causing ejaculation - intensity related to volume
332
What occurs during the resolution of sexual resopnse in men? women?
Pulse, RR, BP return to normal
Sweating
Vasocongestion receds over 5 minutes
Complete relaxation
Detumescense of erectile tissue in women and in men
333
What is infertility?
Symptom of one or more disease states involving one or both male and female partners
334
What are different features tha tmust be evaluated in infertility?
Anatomical
Hormonal/metabolic
Infectious
Autoimmune
Genetic
Environmental
Psychologic
335
What is definition of infertility?
Involuntary inability to conceiv after one year of unprotected intercourse
336
What factors play a significant role in infertility?
Maternal age \> 35; paternal age \> 40
337
What are factors that limit the ability of couples to seek medical advice for infertility?
Economic
Social/religious/family
Psychological
338
Do fertility drugs make you fertile?
No only make you produce more eggs
339
What are important aspects of the sexual history in evaluating infertility?
Frequency of sex
Technique/position
Lubricants
Coital timing
Timing - clear mucous (ovulation predictor kits)
340
What proportion of infertility cases are caused by female factors? male factors? unexplained/dual factors?
Female = 40-50%
Male = 30-40%
Dual/unexplained = 15-20%
341
What are components from a male patient's history that can affect fertility?
General health
Age
Lifestyle (tub baths, jacuzzi, ritual baths, bicycle seats)
Prior pregnancies
Infectious causes (STDs, prostatis, epididymitis, urethritis)
Varicocele
Toxic Exposure - (Lead, pesticides, solvents, petrochemicals, heavy metals)
342
What is the first step of evaluation of infertility when you resort to lab testing?
Day 2 or Day 3 blood hormone tests (FSH, Estradiol, LH, Prolactin, TSH)
343
What is the second test to perform for infertility when you resort to lab testing?
Post-coital exam - determines if sperm delivery and survival is adequate
344
What can cause bad post-coital tests?
POstition, lubricants, hostile mucus, sperm abnormalities
345
How can you bypass hostile mucus?
Intrauterine insemination (IUI)
Put sperm in sterile medium and basically inject it up into the uterus
346
What is a step to evaluate infertility when you have resorted to lab testing and have evaluated that hormonal levels are good at day 2-3 and that postcoital exam is normal?
Day 21 to day 25 progesterone blood tests (one or a series of them)
Can identify a short luteal phase
347
What is a test to perform once you have ruled out hormonal levels on day 2-3; progesterone on days 21-25; and post coital test is normal?
Hysterosalpingogram - x-ray of uterus and tubes
Performed on day 7, 8 or 9 of cycle (after flow finishes but before ovulation occurs)
Can identify various abnormalities
348
What is a way to evaluate parts of the female GU tract that cannot be assessed by x-ray?
Laproscopy - to identify endometriosis, fibroid tumors, pelvic adhesions
349
What lifestyle modifications can help improve fertility?
Avoid too much: alcohol, exercise, smoking, drugs and self-prescried heerbs
350
What hormone imbalances can cause infertility?
Tyroid (TSH should be \< 2)
Prolactin elevation
Low progesterone
Anovulation (PCOS or hypogonadotropic due to stress)
351
How do oyu best treat infectious etiologies of infertility?
Tx both partners simultaneously with same antibiotics
352
What are 5 mechanismms to acheive contraception?
Prevention of embryo formation (barrier)
Ovulation/egg prevention (hormonal)
Spermicide
Tubal occlusion/destruction
Combined effects
353
What is the perfect use rate (of contraception)?
What percentage of women fail in 1 year with this method, in perfect usage
354
What is the typical use rate (of contraception)?
What percentage of women will fail in 1 year in typical use
355
What is the continuation rate (of contraception)?
What percentage of women continue this method after 1 year of use
356
What is the perfect/typical use rate of using no contraception?
85%
357
What are four common barrier methods?
Condoms (male and female)
Diaphragm
Cervical cap
Contraceptive sponge
358
What are the two main types of hormonal contraception/
Combined hormonal contraception
Progestin/progesterone only contraception
359
How do hormonal contraception methods work?
Suppress HPO axis by high levels of exogenous estrogen and progestin and thus prevent follicle formation and ovulation by negative feedback
Also thin cervical mucus and endometrial lining
360
What is a difference between combined estrogen/progestin pills and progestin only pills?
Progestin only are continuous - amenorrhea (no drop off of progesterone levels0
Combined you have placebo (every month or three months) - which produces menstruation
361
What are the two IUD types availabile in the US?
Copper (Paragard IUD) - secretes copper as a spermicide
Levonorgestrel (Mirena IUD) - secretes levonorgestrel - thickens cervical mucus, thins endometrial lining, spermicidal, and blocks ovulation
362
What is the mirena IUD?
Levonorgestrel secreting IUD
Multiple contraceptive actions, including thickening of cervical mucus, thinning of endometrial lining, spermicidal effects, and ovulation
363
What is the Paragard IUD?
Copper IUD - spermicidal - increase in uterine and tubal fluids containing copper ions, enzymes, prostaglandins, and WBCs that impair sperm function
364
What is a permanent method of contraception?
Tubal occlusion
365
What are four methods of tubal occlusion?
Post-partum tubal ligation
Laprascopic bipolar fulguration
Laprascopic unipolar fulguration
Laprascopic clips
366
What is an essure coil?
Placed hysteroscipially in tubal ostia; provides tubal occlusion within 3 months
Permanent contraception
367
What is Emergency Contraception?
Plan B - not to be used as contraception, not as effective as any form of contraception
Decreases chances of getting pregnant by 85% if used within 5 days after event
368
35 y/o para 3 who presents to your office requesting permanent sterilization. What do you recommend?
Tubal occlusion - permanent, but cant go back
Laprascopic
Should consider vascetomy
369
19 y/o para 0 who is sexually active with a history of chlamydia treated 2 months ago presents to the Adolescent Health Center to discuss contraceptive options. What do you discuss?
STI risk (cant do IUD with recent history of STI)
Use multiple methods - i.e. condom! STI is far more dangerous than pregnancy
370
26 y/o para 2 with history of DVT in pregnancy s/p 1st trimester abortion presents to your office for a contraceptive evaluation. What do you discuss?
DVT, and abortion - not ready for other child
Bad option are estrogen products
Recommend IUDs
371
23 y/o para 1 who presents to office for contraceptive evaluation. She was recently on OCP, but stopped due to side effects, and forgetting to the pill everyday. Issues to discuss?
COmpliance is an issue
IUD could be considered
Patch or nuvaring coudl be considered (less frequent)
372
17 y/o para 0 who presents to the clinic because the condom broke last night during intercourse. She consistently uses condoms as her form of contraception. What do you tell her?
Plan B
Counseling on proper condom use
373
What is sexual dysfunction?
Exists only if the person or couple is distressed by a particular aspect of their sexual response, rather than on the basis of an "objective" criterion
374
What are categories of sexual dysfunction?
Disorders of: desire, arousal or orgasm; or painful intercourse
