Week 1 Flashcards
(171 cards)
1
Q
Incidence of endometriosis in all women = ____ %
- infertile women = ___ %
- chronic pelvic pain (>6 months) = ___ 80%
A
- 10
- 35
- 80
2
Q
Risk factors for endometriosis
- family history?
- menarche (late or early)
- long or short cycles?
A
First degree relative (mother, sister, daughter)
with endometriosis
Menarche at age 10 or less
Cycles
3
Q
Which associated with endometriosis
- oligomenorrhea
- polymenorrhea
- dysmenorrhea
- metorrhagia
A
Dysmenorrhea = pain! Esp if worse during menses
4
Q
Dx? 45 year old woman, presents with pain during menses, last menstrual period 14 days ago, menses regular and heavy. PE feels uterosacral nodularity. Urinalysis shows WBC
A
Endometriosis
5
Q
*how would you diagnose endometriomas
A
Ultrasound!
6
Q
- Ultrasound showing dark/empty follicular cyst
- ultra sound showing grayish/ground glassy experience (diffuse low-level internal echoes)
A
- normal follicular cyst
- endometriOMA
7
Q
*T/F - OK to treat endometriosis before operating?
***what is treatment? (2)
A
- YES
- NSAID (800 mg*4/day) also oral contraceptives (continuously … Just keep taking the progesterone)
8
Q
LUPRON = ______ agonist
- used to treat ______
- side effects
A
- GnRH agonist (gonadotropin releasing)»_space; big dose paradoxically suppresses LH/FSH (cause not pulsating)»_space; shots down sex hormones basically just puts someone into menopause»_space; get really low estrogen (hot flashes, bone loss, dryness)
- rx ENDOMETRIOSIS = 1 shot suppresses menses for 1-3 months
9
Q
*most common ovarian mass in young woman is _____
A
Follicular cyst =distention of unruptured graffiti follicle (may be assoc with hyperestrogenism, endometrial hyperplasia)
10
Q
T/F - Supression of menses (with OCP or Lupron) can help with conception in person with endometriosis
A
FALSE … Just delays menses/fertility but worse stop (6 month usually) still no Inc in fertility/conception
11
Q
T/F - surgical option in endometriosis can help with infertility
A
TRUE
12
Q
***should choose surgery for endometriOMA if over > (0.5, 1, 3, never) cm
A
Over 3 cm … Excision of cyst wall more effective than drainage and ablation … Can do multiple but gets more complicated with each
13
Q
Dx? 31 y/o presents with pain in lower abdomen, dysmenorrhea, dyspareurnia; slightly worse with menses. Reports regular menses since age 13. US shows complex mass that is chocolate colored on biopsy
A
ENDOMETRIOMA = endometriosis (ectopic endometrial tissue) within ovary with a cyst formation … Called chocolate cause filled with dark, red brown blood (DON”T DRAIN, REMOVE)
14
Q
Rx with Lupron in patient with _____
A
- endometriosis»> Lupron = shuts down ovaries»_space; puts into menopause
- Aygestin - helps with hot flashes (progesterone OCP)
- MIRENA (levonorgestrel releasing intrauterine system)
- calcium - bone health
15
Q
Letrozole/anastrozole
- Mech
- used for ?
A
- aromatase inhibitors (inhibit conversion of androgens to estrogens)
- can be used for endometriosis – less estrogen means thinner lining, less bleeding, easier menses
16
Q
T/F- hysterectomy while leaving ovaries is good surgical option for endometriosis
A
FALSE (if ovaries left behind - which is usually done - then 60% chance of more symptoms and 30% of surgery) … Can be successful if ovaries left behind but that’s big decision (have to deal with side effects of low estrogen)
17
Q
***when you take BOTh ovaries out, can you still get endometriosis? can you still get estrogen production? HOW?
A
- -ADRENALS!
- T > estradiol
- Androstenedione»_space; estrone
- DHEA»_space; estrogen
*local expression of aromatase enzyme can lead to development of endometriosis even if women has NO ovaries and are NOT on E replacement therapy (aromatase = turns 19C androgens to 18C E)
18
Q
***3 categories of ovarian neoplasms (in terms of cell of origin)
A
- -surface epithelium
- -stroma (with leydig i.e., THECA cells = respond to LH»_space; chol»_space; Progest»_space; ANDROGEN)
- -germ cells (in egg!)
19
Q
PCOS
- etiology?
- ____(Inc or dec) LH:FSH ratio
- ____ (Inc or dec) testosterone secreted by ______(THECA or GRANULOSA) cells
- signs / symptoms
A
- excessive secretion of T (can have acne, hair etc) by THECA cells (respond to high LH)
- also have too much E (T»_space;> E by GRANULOSA)
- high LH, low FSH (high LH:FSH ratio)
- oligomenorrhea, amenorrhea, infertility
- assoc with obesity / hyper insulin or insulin resistance hypothesized to affect H-P axis and feedback
20
Q
PCOS has _____(high/low) LH and ____(high/low) FSH
- get _____(high/low E) and _____(high/low)T
A
- high LH, low FSH (high LH:FSH)
- high E and T
21
Q
_______ is most common ovarian neoplasm…is it benign or malignant
A
Serious cystadenoma (lined with Fallopian tube-liked epithelium) - often bilateral… BENIGN
22
Q
Surface epithelial cell ovarian tumors
- proportion of malignant ovarian the tumors
- age range
- types / ex (4)
A
- 90% (because most common ~65-75% of ovarian tumors, but not necessarily more likely to be malignant)
- 20+
- serous, mucinous, endometroid, transitional (brenner)
23
Q
Ddx of young girl with ovarian tumor? (I.e., which 2 out of the 3 categories is it most likely to be)
A
- probably GERM cell tumor
- teratoma
- dysgerminoma
- told sac
- chorizo carcinoma
Or *leydig/stroma
-fibromyalgia , GRANULOSA, leydig etc
24
Q
Most likely dx? 35 year old presents with pain and bleeding; US shows bilateral clear cysts in ovaries; biopsy shows single ciliates columnar epithelium
A
Benign serous cystadenoma
25
Borderline malignant epithelial ovarian tumors have ____(good or bad) prognosis and more likely in _____(young or old) women
- good
| - young
26
Dx? 19 y/o presents with bleeding and foul smelling discharge. Wbc and labs Re negative. Ultrasound shows mass in ovaries with multioculwr cysts; biopsy shows hair and teeth:
- malignant, immature teratoma
- malignant, mature teratoma
- benign, immature teratoma
- benign, mature teratoma
Mature - benign
27
Dx? Solid tumor in ovary that is partially cystic, clean clear fluid, yellow-brown color grossly, with papillary excretions (psammoma)
Serous cyst adenocarcinoma = most common malignant ovarian neoplasm ... Also frequently bilateral
28
______ tumor is malignant ovarian tumor that can be HUGE, and spill into the peritoneum, rarely malignant, not commonly bilateral, shinny and jelly like grossly
Mucinous cystadenocarcinoma >> can get pseudomyxoma peritoneum-intraperitoneal (jelly belly) = rupture of tumor (can happen if benign or malignant) and be deadly
29
_______ (serous, mucinous, endometroid, brenner) is most common surface epithelial ovarian tumors tumors
- -which type is most commonly malignant
- -which type is most commonly bilateral
SEROUS FOR ALL THREE
30
SURFACE EPI OVARIAN TUMOR CLASSES:
- Endometroid tumors are mostly ____(benign or malignant)
- brenner tumors are _______ (benign or malignant)
- clear cell tumors are ______ ( b or m)
- mostly malignant
- 99% benign
- 99% malignant
31
Dx? 65 year old presents with abnormal uterine bleeding, find a mass in her ovary, estrogen and testosterone is high
THECOMA ... Like GRANULOSA cell tumors but are benign usually
-can produce E or T
32
Dx? 58 year old woman presents with post menopausal bleeding; has mass in ovaries; has high E and P and breast tenderness; histology shows call-exner bodies
GRANULOSA cell tumor = most common malignant stroma tumor (usually in 50s, but can be any age) ...BUT USUALLY BENIGN!
- can have E or P produced ... 25-75% produce E so 1st sign is vaginal bleeding
- C-E bodies = gran cells haphazardly around collections of eosinophilia bodies (coffee-bean pattern)
33
*gross differences between thecoma/fibroma and GRANULOMA
```
Thecoma/fibroma = usually solid , firm not hemorrhagic
GRAN = hemorrhagic, yellow and ugly
```
34
What is KRUKENBERG tumor?
-GI malignancy that metastasizes to ovaries >> mucin-secreting signet cell adenocarcinoma
35
- Germ cell ovarian tumors common in ______(young, middle age, post-menopausal)
- most common is ______
- YOUNG (first 2 decades)
- teratoma is most common
- others = dysgerminoma (aka Seminoma) and yolk sac tumor
36
* *identify class (epi/stroma/germ) and whether benign or malignant
- -mature cystic teratoma
- -thecoma
- -immature teratoma
- -dysgerminoma
- -brenner
- -germ/Ben (could have malig scc tho)
- -stroma/Ben
- -germ/malignant
- -germ/malignant
- -epi/Ben
37
Dx? 18 year old presents with metorrhagia (irregular menstruation) and large ovary found on routine ultrasound. Histology shows sheets of fried eggs
Dysgerminoma ...occurs with gonadal dysgenesis
38
Ovarian lesion with Mucinous sections that is BILATERAL is probably _____
If unilateral probably ________
- metastatic
| - mucinous carcinoma/adenoma
39
Dx? 28 year old presents with lower abdominal pain, fever, and history of NGI, ultrasound shows pelvic masses and malformed Fallopian tube
Acute salpingitis
40
Dx? 38 year old presents because of infertility. Has had chronic fevers and lower abdominal pain over past year . Find bilateral fallopian tubal abscesses
Chronic salpingitis
41
Inflammation of Fallopian tube called _____ and is associated with which of following
- chlamydia
- neisseria gonorrhea
- strep
- TB
- ectopic pregnancies
Salpingitis ... All
42
* **changes in pregnancy
- - insulin resistance _____(increases or decreases)
- -iron ______ (decreases or increases)
- increase >> so glc stays higher = FOOD FOR BABY
| - iron decreases ... (Baby drains) .. So iron sup is important
43
Role of each during pregnancy?
- hBG
- hPL
- hBG = LH analogue >> keeps corpus leut from degenerating >> keep making progesterone until baby can take over
- hPL = human placental lactose not ... Homologous to human grown hormone >> anti-insulin "diabetogenic" and lipolysis effects (Inc BG in mom for baby food)
44
* **maternal GI changes
- GI emptying ____(+/-)
- liver size _______
- ALK phos _____
- albumin ______
- unchanged except in labor (dec motility)
- unchanged
- doubles
- decrease
* also Inc risk of cholestasis (less GB contractility) and iron deficiency
45
*morning sickness during ____ weeks because of _____ (hormone)
- starts 4-8 thru 14-16
- when hCG is high ... Decreases over time
- more severe nausea = hypremesis gravidarum
46
***pregnant women are at increased risk of _____(Hyper or hypo) ventilation , while respiratory rate _____(+/-/0)
- hyper
| - RR doesn't change
47
____(more or less) plasma than erythrocytes so hgb/hct _____(Inc or dec) slightly = dilutionall anemia
- more, decreased
| - that plus baby iron needs makes mom at risk of iron deficiency
48
SrCR and BUN _____(Inc or dec) in pregnancy, so ____(higher or lower levels) are abnormal
- they decrease ...
- so if it is over 1 that can be abnormal
- Cr clearance is 30% increased
49
Blood volume ____(Inc, dec, or is unchanged) during pregnancy
INCREASES + Inc CO and dec. TPR (BP unchanged ideally)
50
***pregnany woman's are _______(hyper or hypocoaguable); clotting times of whole blood is _____(Inc, dec, unchanged)
- INCREASED! Inc clotting factories, fibrinogen
- D-dimmer serum increase
- clotting times UNCHANGED
- avg platelet is decreased
- decrease of coag inhibitors (protein C, S)
51
**when is pregnant woman at greatest risk of DVT and PE???
*POSTPARTUM!!!
52
*should we be worried about _____
-systolic murmur
-wide pulse pressure
... in pregnant woman, otherwise normal?
NO - found in 90% of women because of crazy inc in CO to deal with Inc BV
*wide pulse pressure also normal
53
*BP changes throughout pregnancy
-decreases to nadir mid prego, then increases after
54
***insulin action in late pregnancy is 50-70% _______(greater or lower) than in non-pregnant woman because of action of ______ placenta hormone
- LOWER. (Inc resistance >>Inc glucose for baby)
| - because of hPL
55
LDL ___ (Inc or dec) in pregnancy, HDL _____(Inc or dec) and total serum ____( Inc or dec)
- total serum cholesterol elevated esp in third semester
- LDL peaks at 36w
- HDL peak at 25, then decreases to 32 then constant
56
* **lung changes (+/-/o)
- TV
- FRC
- TPR
- RV
- RR
* mom is little hypercapnic (feeling short of breath) to get rid of baby CO2
- TV, minute o2 increase
- FRC and RV decreases
- TPR decreases
* *RR doesnt' change
57
* ** during pregnancy
- ____(dec or Inc) blood pCO2
- HCO3 / pH changes
- hyper ventilation >> lower pCO2 >> respiratory alkalosis
- HCO3 decreases to compensate
- pH inc minimal
- reduced pCO2 in mom facilitates transport of CO2 from fetus to mom
58
* *what is pathophys behind lines nigra and hyper pigmented stretch marks in pregnant woman?
- increase in ______ hormone
- Inc ACTH (MSH precursor)
| * aldosterone and cortisol also increase
59
* *immune/heme values in pregnancy
- C-reactive protein (CPR) _____ (Inc or dec)
- erythrocytes sedimentation rate _____ (Inc or dec)
- leukocyte(WBC) _______ (Inc or dec)
- -CPR Inc (also during labor)
- -ESR Inc because of elevated plasma globulins and fibrinogen
- -leukocyte count varies, may increased during labor
60
**during pregnancy you get ____(Supression or up regulation) of CD4 and CD8 cells
Supression ... Don't reject fetus
*so may Inc risk of infections but make certain auto-immune diseases better
61
*** name most common cause of 1st trimester bleeding, WHAT IS MOST CONCERNING?
- -1st: spontaneous/threatening (potential) abortion = 50/50 chance if bleeding which will happen in about 25%) ...
- -Most concerning = ectopic pregnancy (clues = prior ect, PID, surgery, endometriosis, chlamydia >> future seq = reoccurrence; infertility, chronic pain)
62
% of 1st trimester bleeding (5, 25, 50 , 90%)
--if bleeding, chance of spontaneous abortion around ______(5,20,50, 90)%
% of 3rd trimester bleeding _____(5, 25, 50, 90%)
1st trimester bleeding very common! (>25%) ... Spontaneous abortion rate ~50%
3rd trimester = more rare - ~5%
63
***name most common causes of 3rd trimester bleeding (what are signs/symptoms/risk factors)
- early labor (>50% )
- placental abruption ~15% = separation of placenta from uterus (PAIN!! .. Some may not have bleeding!) ...CAUSE = trauma (car), smoking/Coke, multiple pregnancy
- placenta previa ~10% = placenta covering internal cerv os (painless, vag bleeding) ... RISK=previous pregnancies, previous C-section, prior D&C) ... R/o 1st with ultrasound!
64
***postpartum hemorrhage causes (4) - most common?!
* #1 Uterine atony = lack of involution (HUGE organ, huge blood supply, needs to contract quickly onto itself) .. RISK FACTORS:
- high parity (twins etc)
- over distention
- long/rapid labor
- prolonged induction agents
* #2genital tract laceration (large baby, complicated pregnancy?)
* #3retain placental fragments
* #4coag disorders
65
T/F - most females will become infected with HPV, but most men will not
T/F - most ppl infected with HPV will resolve itself
T/f - Only increased cancer risk if person has persistent HPV infection
False - M and F
True
True
66
HPV ___ and _____ are the bad HPV types (bad boys) - Inc risk of cancer
16 >> 18
- cervix most common in F (anus, oropharyxn, vaginal)
- oropharyxn, anus, penis in M
67
T/F - infection with HPV is biggest risk factor for cervical cancer ;
***what are other risk factors (sex and non-sex)
TRUE (20x RR) ... Others sex risk factors are previous history of STI, multiple sex partners (more exposure to HPV), early intercourse ... Others are all really related to HPV probes
Non-sex risk - smoking, multiple births, inadequate screening!
68
***mech of HPV transmission
SEX - intercourse, oral sex, non penetrative sex (NAKED GRINDING?!)
note -condoms can reduce risk but not 100% protective)
NONSEX - mother to newborn (transmission - rare); fomites (underwear, globes, biopsy forceps)
69
Majority of HPV infections are in ______(men/women) in _______(80) age group
- women 15-25 (sex activity!) ...most of these are TRANSIENT THO
* note - highest prevalence of both HIGh and LOW risk HPV types are in this demographic
70
***screening for HPV is better _____(30) WHY?
AFTER ... Because HPV prevlance is VERY HIGH before 30 ... But 90% of these ppl are gonna resolve it
AFTER 30 : HPV prevlance declines and cervical cancer increases ... So more sensitive for persistent HPV which is what we care about
71
* ***How do we do cervical cancer screening tests?
- when do we start pap-smear, and how often?
- when do we do HPV testing, and how often?
- pap smear every 3 years from 21-65
- CO-TEST (pap smear + HPV test) every 5 years from 30-65
* don't do co-test until 30 because HPV prevalence is so high before 30 but majority are transient + cerv cancer prevalence is LOW before 30
* *NOTE - also only test for HIGH RISK HPV types
72
***4 prognostic indicators for invasive breast cancers
```
estrogen receptor
progesterone receptor
HER-2/neu
Ki-67 (proliferation index)
**Results of these studies are a major determinant of subsequent therapy**
```
73
**Grade of infiltrating carcinoma is based on what 3 things?
Differentiation – how well does it form a gland?
Nuclear anaplasia – how ugly is the nucleus?
Mitotic rate
74
- -Atypical ductal hyperplasia >> gives rise to ______ (high/low grade DCIS)
- -16/17 mutations are in ________(usual ductule hyperplasia, atypical hyperplasia, both)
- ADH = non-obligate precursor = some progress to LOW-GRADE DCIS, and some don't progress
- 16/17 mutations = in ATYPICAL, not USUAL
75
**what mutations involved in low-grade vs. high-grade DCIS vs. lobular carcinoma in situ (LCIS)
Low-grade = 16q/17p (like ADH which is precursor)
High-grade = HER2/new (no precursor)
LCIS = e-cadeherin/ 16q (poor cohesion) >> atypical lobar hyperplasia (precursor) >> LCIS >> infiltrating lobar carcinoma (
76
Define Paget's disease of nipple
| -what is precursor lesion?
When high grade (occasionally low-grade) DCIS progresses all the way up to nipple
PAGETS = ductule carcinoma that grows up through dipole
PAGETS CELLS = intraepithelial adenocarcinoma cells
77
* basic histo/gross differences between DCIS and LCIS
- which has "Roman bridges"
- which has calcification a
- both Chx of DCIS, not LCIS
- DCIS = has cookie-cut holes
- LCIS = no holes (just big lobular balls); LCIS masses may be harder to feel therefore
LCIS >> infiltrating lobular carcinoma = grow linearly and cells looks like box cars lined up with distinct space between
78
What duct all carcinomas have rounded/expansive peripheries (2) - not to be confused with fibroadenoma
- medullary carcinoma (rare)
| - mucinous (colloid) carcinoma - like DCIS except the lobule balls are floating in lakes of white mucous
79
Differences grossly/histologically between infiltrating ductal carcinoma (IDC) and infiltrating lobular carcinoma (ILC)
IDC = firm, fibrous rock hard masses with sharp margins (have fibrinogen that help them invade and attach to underlyingstrucutres) -- see small, glandular duct-like cells (but it's a MESS (histologically)
ILC = less firm, often bilateral/multiple lesions in same location, -- histo shows orderly rows of cell (INDIAN FILE / BOX CARS) with spaces in between because of E-cadeherin mutations
80
Lactogenesis:
In _______(early/late) pregnancy the hormonal influences of Placental Lactogen, Prolactin, and Chorionic Gonadotropin among others cause a marked and rapid increase in ductular and lobular formation.
In ______ trimester Placental Lactogen causes secretion of colostrum.
Lactogenesis
In early pregnancy the hormonal influences of Placental Lactogen, Prolactin, and Chorionic Gonadotropin among others cause a marked and rapid increase in ductular and lobular formation.
Second trimester Placental Lactogen causes secretion of colostrum.
81
Lactogenesis 1
Under ______(endo/paracrine) Control
Begins ----- weeks prior to parturition
Colostrum composition stable until after delivery
After delivery of placenta rapid decrease in progesterone and estrogen while prolactin remains high signal milk production
Frequent suckling increases ----- receptor sites
Endocrine
12
Prolactin
82
Lactogenesis 2:
- ______ (endo/paracrine) control
- ______ (begins pre or post partum)
Still under endocrine control
2-3 days postpartum
Rapid increase in milk production - engorgement
Milk changes colostrum>transitional milk>mature milk
Need to remove milk every 2-3 hrs for milk supply
83
Lactogenesis 3
- endo or paracrine
- hormone signals
Under autocrine control
Supply is primarily dependent on demand (removal)
Complex interplay of prolactin, oxytocin, and many other hormones including TSH and insulin
If milk is not removed pressure will signal the Feedback Inhibition of Lactation hormone
84
Difference between colostrum and mature breast milk?
Colostrum is high in protein, fat soluble vitamins, immunoglobulins, and WBC’s
Transitional Milk has increased fat, lactose, and water soluble vitamins, and more calories than colostrum
Mature milk is 90% water. The other 10% is carbs, proteins, fats, vitamins, wbc’s, immunoglobulins
85
**explain transformation zone of cervix, how does it change throughout life and significance in cervical disease?
- -Inside (endocervix = columnar/mucinous epithelial
- -Outside (ectocervix) = squamous (thicker, lots of rows)
*Pre-pub = junction inside >> @ Puberty and pregnancy >> endo is pushed out >> undergo SQUAMOUS METAPLASIA (dif pH)
--TRANSFORMATION = area between squamous/columnar Jxn (inside cervix) and new SCJ (can be inside or outside)
***majority of cancers/lesions occur in immature squamous METAPLASIA (leading edge of new SCJ)
86
BUG? Chronic cervicitis, get Intense lymphocytic infiltrate(I.e., " follicular cervicitis" looks like germinal center of lymph node) , purulent discharge
Most likely chlamydia trachomatis (40% of cervicitis STDs) - intense infiltrate (forming "FOLLICES" is key buzz)
87
Nabothian cyst?
- where (vagina, cervix, uterus, ovary?)
- blocking _____ glands
- cervix >> chronic cervicitis
| - endocervical glands blocked >> get big >> top layer can get scarring, inflammation and undergone SQUAMOUS METAPLASIA
88
Tubular METAPLASIA?
When columnar cells get cilia >> can get endocervix and endometrial BENIGN lesions
89
What do metaplastic cells look like on Pap smear
- size/shape (flat, round, big?)
- color (blue, red, pink/orange?)
BLUEISH (like parabasal/intermediate cells) except more STRETCHED/FLAT out with little feet like they are trying to be SQUAMOUS (flat, orange/pink)
90
Dx? Pap smear shows multinucleation, margin action, molding?
Herpes
91
**which is low and which is high risk HPV types (2 each)
T//F - high risk also associated with genital warts
```
High = 16, 18 (45, 31) >> pre-cancerous cervical changes >> CANCER
Low = 6, 11 (42, 44) - benign cervical changes >> assoc with GENITAL WARTS
```
FALSE. - low-risk assoc with warts
92
T/F- there is an HPV vaccine but only protects against high risk types
False - protects against high and low
*can give to boys and girls; most effective before sex but can get up til 26
93
T/F- squamous intraepithelial neoplasia (cervical intraepithelial neoplasia) can have mild or moderate severity (aka - low and high grade) with different risk of cancer
True
94
Dx? Koilocytes with squamous dyspasia in lower 1/3rds of cervical epithelium?
Is it LSIL or HSIL? Cancerous?
KOIL = Empty wheel around cells (clear space around nucleus) = MORPHOLOGICAL EVIDENCE OF HPV ... Don't see them in high-grade (nucleus big/cytoplasm small/cells squished in lower 2/3)
Lower 1/3 = low-grade squamous intraepithelial lesion (LSIL) = CIN1
95
Cervical biopsy
Low - lot Cato, big nucleus
High -
LOW grade = lots Cato, big nucleus
| HIGH = small cytoplasm , big nucleus
96
T/F - squamous cell carcinoma is most common cause of HPV-caused cervical cancer?
TRUE ... SCC is most common type of cervical carcinoma
Clear cell - if exposure to DES
Adeno - rare
97
Viral oncogenes of HPV?
E6 >> bind to TP53
E7 >> bind to RB
*E6/7 cause inactivation of these tumor suppressor genes
98
Exposure to diethylstilbesterol (DES) is risk factor for ______ (SCC, clear cell, adenocarcinoma, neuroendocrine tumor) cervical neoplasia
CLEAR CELL (DES = synthetic estrogen, given in the past)
99
**symptoms of cervical cancer?
- maybe bleeding
- usually nothing
(Dyspareurnia, post coital bleeding, leucorrhoea)
100
* *stage of cervical cancer?
- if involves vagina
- involves bladder
2; 4
| 3 = entire vagina / pelvic wall
101
Lichen sclerosus of vulva will have _____(thin/thick) squamous epithelium while lichen simplex chronicles will have ______(thin/thick)
- thin
| - thick
102
3 def of chronic Htn (1 of 5) in pregnancy:
- any HTN prior to being pregnant
- any HTN occurs before _____ weeks gestation
- any HTN that lasts ______ weeks after delivery
**DEF = BP of _______ on two occasions
- before 20 weeks
- >12 weeks after
> 140/90 on 2 occasions
103
* **pregnancy induced hypertension definition
- HTN occurs ______(before or after) 20 weeks
- +/- protein in urine
- abnormal or normal blood test?
AFTER 20 weeks (if before then considered "chronic")
- NO
- normal
104
* **PREECLAMPSIA
- definition (BP? Level)
- +/- proteinuria
- ________(before or after) 20 weeks gets ion
- >140/90
- YES
- after 20 weeks
*so same as pregnancy-induced except has proteinuria
105
Dx? Woman presents for first time with BP of 145/92; 24 week pregnant; hasn't had history of BP; no edema; CBC normal; 3+ proteinuria on dip stick
- preeclampsia
- chronic
- gestational HTN
- eclampsia
- no dx
No dx .... Consistent with pre-eclampsia but need to take it A SECOND TIME at least 6 hours apart
106
What is difference between eclampsia and preeclampsia?
PRE-ECLAMPSIA - HTN (140/90) after 20 weeks gestation x2 times, proteinuria +/- symptoms
ECLAMPSIA = pre + seizures/ coma/altered mental status (confusion etc)
107
Difference between mild and severe pre-eclampsia?
```
Mild = HTN and proteinuria
SEVERE = SYMPTOMS! (Headaches; confusion; low urine output; PULMONARY EDEMA; organ failure/dysfunction (LIVER PAIN etc) )
```
108
Dx? 32 year old woman 29 week pregnant presents with BP of 152/91; last visit 1 week ago BP of 145/95; she reports no symptoms except occasional headaches and can't concentrate; has trouble answering questions howeve; proteinuria 3+; CBC normal
- gestational HTN
- mild pre-eclampsia
- severe pre-eclampsia
- mild eclampsia
- sever eclampsia
ECLAMPSIA = pre-eclampsia (HTN 140/90 + proteinuria) + seizures or coma or ALTERED MENTAL STATUS
109
Give _______(Mg sulfate/Ativan) to eclampsia patient to PREVENT SEIZURES; give ________(Mg/Ativan) to TREAT seizures
Mg sulfate = prevent
| Ativan = control
110
* **Superimposed pre-eclampsia
- def
- rx
Pre-eclampsia + chronic HTN
- BP 140 / 90 after 20 week pregnant 2x
- proteinuria
- /+ abnormal labs
*proceed with delivery as soon as possible; give Mg Sulfate for seizure prophylaxis
111
#1 thing that kills mom from HTN during pregnancy is _____: #1 thing that will kill fetus is _______
Mom - stroke
| Fetus - placenta abruption (HTN >> catecholamines >> placenta abrupts)
112
Which is not fetal complication from HTN during pregnancy:
- intrauterine growth restriction
- gestational diabetes
- low birth weight
- pre-term birth
- intrauterine fetal demise
Diabetes
113
* **risk factors for pre-eclampsia (4-5)
- 1st time pregnancy or multipartution?
- >40 or
- first time mom
- prior hx
- family hx
- history of chronic HTN/kidney dx
- over 40
- twins/triplets. Etc
- diabetes/lupus
- obesity
114
Dx? 41 year old woman presents at 22 and 23 weeks with BP of 140/90 and 145/95 respectively; all labs normal; history of HTN in family; no protein in urine; all tests normal
RX?!?!
- gestational (preg-induced) HTN
- DON"T NEED MEDS! Unless > 100
- consider delivery close to 37 weeks
115
When to deliver baby (now, 34 wk, 37 wk) if mom has:
- mild pre-eclampsia
- severe pre-eclampsia
- eclampsia
- superimposed pre-eclampsia
- 37
- 34
- now
- now
116
Difference between overt and sub clinical hypothyroidism?
*which do we treat in pregnant women?
Overt = high TSH, low T4, +/- symptoms
Subclinical = high TSH, normal T4, NO SYMPTOMS
*only treat overt (unless subclinical is suspected to be cause of infertility)
117
Antibodies is involved in mechanism of _______(graves/Hashemites/both/neither)
BOTH
Graves >> TSH receptor (over-activate)
Hash >> thyroid peroxidase (can't make T3/T4)
118
CRETINISM is fetal complication of pregnant mom with ________ (HTN, hypothyroid, hyperthyroid, diabetes; eclampsia?)
-mom with HYPOTHYROIDISM (didn't have enough T4 diffusing across placenta for BRAIN DEVELOPMENT)
CRET = severe stunted growth, mental retardation
119
Group ____(A/B) strep can cause miscarriage, endometriosis, bacteria and chrioamniotitis in pregnancy
B
*also leads to still birth, premies, meningitis etc
120
_________(early/late) onset GBS infection causes septic shock and ARDS; while _______(early/late) causes meningitis
*what is time frame for early late
Early (within 1st week) ; late (after1st week)
Late - more insidious, assoc with ear infection, sinusitis, conjunctivitis, pneumonia etc
121
***definition of infertility (= ______ yr/months w/out baby)
-1 yr of unprotected intercourse without baby (can be primary or secondary)
122
Rank causes of infertility
- tubal prob
- endometriosis
- male prob
Male (19%) > tubal (14) > endo (7)
123
Should give T to man with infertility?
NO ... T will decrease FSH/LH = neg feedback >> LESS spermatogenesis
124
- -Man with AZF___(a/b/ or c) will still have sperm that can be used for IVF
- -CFTR mutations lead to infertility? How?
- C
- yes (>95% have obstructive azoospermia) = CONGENITAL BILATERL ABSCENCE OF VAS DEF (CBAVD) .... Abnormal meso duct differentiation is another cause of CBAVD)
125
Should give GnRH/LH to ______(kallman, XXY, both, neither)
Kallman = hypogandotropic hypo
NOT XXY = hyper gonadotropin
126
T/F - progesterone over 3 is proof of ovulation
TRUE ... P not that high unless they are ovulating (P also raises basal body temp = another way to detect ovulation)
127
If patient presents with anovulation and hyperandrogenism which would NOT be good test:
- -T tumor
- -17-OH levels
- -24 hour urine
- -IGF-1
- -dexameth
Dexameth
128
**what is diagnostic criteria for PCOS
- androgen excess
- ovarian dysfunction (oligo-anovulation)
Rotterdam = 2/3 of ^^ those 2 + polycysti can ovaries on US
129
Person who runs a lot usually have ______(low/high) gonadotropins and ____(low/high) estradiol
Low and low = HYPOTHALMIC AMENORRHEA
130
Hydrosalpinges?
- dilated Fallopian tube that is inflamed
- after chlamydia leading to PID
*at risk of ectopic and infertility
131
T/F - increased pain usually means worse endometriosis
FALSe ... Pain not assoc with stage
132
Ovarian reserve testing?
- how it's AMH related to egg count?
- T/F - declines over time
- how is antral follicles assoc with egg ?
AMH = produced by GRANULOSA CELLS (pos assoc with egg fount)
- T - decreased with age
- AIDS transition from primordial follicles to FSH sensitive FOLLICES in natural stage
*antral follicles also assoc with AMH (predict # of oocytes)
133
Clomiphrene citrate (SERM) ?
Letrazole (______ inhibitor) ?
*how does each help/hurt infertility?
Both HELP
--clomiphrene citrate (SERM = some tissue its antag, some agonist like tamoxifen) - sends more FSH to ovaries >> ovulation induction or super-ovulation
--letrazole - blocks AROMATASE >> blocks formation of estrogen >> makes more FSH >> stimulate ovaries
134
T/F - hCG can induce ovulation
TRUE
135
T/F - intra-uterine insemination have high risk of multiple pregnancy (John Kate + 8!)
FALSE ... Actually don't have much more success rate than normal (10-15%)
--FSH/LH/hCG injections is what gives you 18 kids
136
* **preimplantation genetic diagnosis (PGD)
- def indications
T/F - can you do HLA testing? Sex selection?
T/F - must be good candidate for IVF in order to be good candidate
- test embryo (after growing for 5 days) before you put it back in mom (IVF)
- get about 5-10 cells (out of ~100) >> do PCR/ FISH/ microarray etc
**can test single cell (CF), HLA (for sibling who needs it), can do SEX SELECTION TOO
INDICTATION - previous hx, advanced age, multiple miscarriages
137
***Definition of menopause / pre-mature menopause?
- no menses for one year (with normal/high FSH)
| - pre =
138
***causes of pre-menopause (primary ovarian insufficiency) POI?
-idiopathic/autoimmune (60%)
-turners (23%)
-chemo / radiation
-familial stuff
-FRAGILE X
-
139
T/F - turner's but not fragile X patients are at increased risk of POI/POF
FALSE, both are at risk of pre-ovarian insuf/failure (early menopause)
140
FSH levels are _____(higher or lower) near menopause
HIGH!
- E and P may decrease/erratic
- may have early spotting
141
T/F - longer cycles is sign of approaching menopause
FALSE ... Shorter cycles because follicular phase shortens (less E)
142
* *what drops in menopause
- androstenedione
- testosterone
- DHEAS
- estradiol
ALL
NOTE - estradiol (primary E in repro-aged women ... So starts dropping before menopause; and usually UNDETECTABLE AFTER)
143
Which is predominant estrogen in menopause: estrone, estradiol, estriol
estrone (E1) - from adrenals and fat
- estradiol - from ovaries (repro age)
- estriol (E3) = placenta (pregnant)
144
T/F - menopause doesn't increase CVD risk
FALSE ; it does
145
T/F - estrogen should be used for primary prevention of heart disease and can reduce risk in post menopausal women
FALSE - should not ... May increase risk
*although E replacement does raise HDL and lower LDL which should be good??
146
FSH levels / cycles?? Sign of menopause?
FSH over 40 in presence of amenorrhea (irregular/anovulatiory cycles0
147
Should do ______ if postmen opaquely women presents with bleeding
ENDOMETRIAL BIOPSY!! (Should do for anyone with heavy/irregular bleeding to r/o malignancy)
148
MENOPAUSE??
- -45 year old presents with irregular menstrual cycles anovulation; estradiol 25; FSH 35
- -45 year old with " " estradiol 15; FSH 30
- - " " estradiol 15; FSH 50
- no
- no
- yes
*need irregularly/an ovulation with FSH >40; estradiol should be
149
Which are contraindications for E-therapy in menopause?
- ER- BC
- ER+ BC
- CVD?
- HTN?
- hormone POS BC
- CVD
- liver disease
- unexplained uterine bleeding
150
Should give E or E+P or just P in menopause women?
- -person without uterus
- -Pierson with and no probe
- -person with uterus and history of DVT
Generally E and P ... E alone can lead to hyperplasia
**if don't have uterus though then use E only **
- E only also increase risk of stroke
- Both increases risk of BC, and DVT though
151
T/F - E alone increases risk of breast cancer in menopause?
FALSE .. Doesn't; but E and P might (8 our of 10k so clinically significant?)
152
Which helps hot flashes:
- E only
- T only
- SSRi
- Clonidine
- black cohosh
- VIT E
- e only
- SSRi
- Clonidine
*only do last 2 if person can't do E replacement
153
Dx? 32 year old presents with oligomenorrhea; problems becoming pregnant. Has acne and is obese. Progesterone is 2 (not ovulating). Feel enlarged ovaries bilaterally
**ddx?
PCOS - have larger bilateral cystic ovaries (with bunch of black spots)
Dx (2 of 3) = Inc androgens (acne, hirtuism, or lab) + anovulation + polycysti ovaries (esp if in pubertal age this is important) = STRING OF PEARLS
Ddx = ovarian hyperthecosis (MORE T/virilization); CAH; Cushing syndrome ; ANDROGEN TUMOR (ovary, adrenal); ACROMEGALY; RX (T cream)
154
Which is not assoc with PCOS:
- obesity
- hypogonadotropic hypogonadism
- family history
- hyperinsulinemia
- insulin resistance
- hypogonadism (have high LH: FSH >> high T and E
| * can have hyperinsulinemia and or insulin resistance >> hypothesized to alter HPG axis >> Inc FSH/LH and Inc T
155
T/F - PCOS is associated with increased risk of endometrial cancer
TRUE ! Unopposed E >> hyperplasia >> cancer
156
Rx for PCOS?
| -1st line ??
1st = lifestyle (lose weight)
OCP; aromatase inhibitor (-azoles); clomiphene citrate (brain thinks E is
157
What is not a rx of PCOS:
- spironolactone
- clomiphene citrate
- ketoconazole
- continuous leuprolide
- metformin
Leuprolide = GnRH analog that shuts off FSH/LH if CONTINUOUS (used for endometriosis, precocious puberty)
158
**difference in LH and FSH levels between functional HYPOTHALMIC amenorrhea (FHA) and PCOS?
FHA = normal FSH so LH:FSH ratio is lower > HIGH LH:FSH ratio >2
159
*ESSAY: top 3 causes of primary amenorrhea (discuss clinical Chx/signs/labs/dx)
1 - Turners (hypergonadotropin) >> low E/T = gonadal dysgenesis >> high LH/FSH to try to compensate
2 - androgen insensitivity (46,XY >> internal male (NO UTERUS) >> high T but no secondary sex Chx because no receptor)
3 - mullerian anomolies (#1 = MULLERIAN AGENESIS (no uterus, vaginal hypophysis, no mullerian stuff - no uterus, cervix, etc)
Or ... outflow tract obstruction, imperforate hymen)
**know what patients would look like for essay**
160
Are estrogens or progestins more specific?
Estrogens
| Progestins can have "cross talk" with other receptors like E, T, GC etc
161
Match: contraception; contragestation (abortion); infertility
with
Answers: E, progestin, anti-progestin, anti-estrogen
```
Contraception = E+P; P
Contragestation = anti-p
Infertility = anti-E (SERM, leupron) >> inc FSH/follicle stimulation/ovulation
```
162
What does Lupron given continuous vs intermittent treat a?
Continuous = shuts of FSH/LH - used for prostate cancer, endometriosis, PCOS, precocious puberty
Intermittent = stimulates FSH/LH = used for infertility
163
What is each used for::
- levonorgestrel
- minipril
- mifepristone
- mestranol
1st 2 = PROGESTINS! = CONTRACEPTION
Stone = anti-progesterone >> abortion
Stranol = E >> post-menopause/POF
164
Why is E+P combo therapy used? What hormone levels (FSH, LH) does each work on??
*why is acne a side-effect?
E = inhibits FSH; stabilizes endometrium (feel better)
P = prevents LH, thickens cervical mucus, inhibits endometrial prolif (less suitable for implant)
*but some non-specific so can activate T receptors = ACNE side effect!
165
* **contraindications for combined E/P OCP:
- age?
- history of ____disease?
- ____ cancer
- other?
*ie - why would you use these instead of PROGESTINS alone?
- smokers > 35 (Inc risk of CVD)
- hx of CVD, DVT
- breast cancer
- migraines (esp with aura)
- LACTATING (E shuts off prolactin)
166
What are some drawbacks (2) of the E/P patch?
- not effective if fat (>200 lb)
| - 3x higher risk of blood clots due to more E than in the pill
167
Which (2) can be used for contraception:
- E alone
- P (progestin) alone
- E and P together
*why would you use one vs the other??
-E and P - (pill, patch, ring) - preferred 1st line unless can't tolerate the E (BC, CVD, stroke, migraines etc)
P alone - if E is contraindicated/poorly tolerated and in LACTATING WOMEN
168
____ contraceptive drugs thicken the cervical mucus and decrease tubal motility
PROGESTINS!
169
Is each SE caused by too much or too little E or P in OCP:
- -nausea
- -weight gain/appetite
- -early bleeding (deficient ____)
- -edema/fluid retention
- excess E
- excess P
- deficient E
- excess E
170
* **give examples of TERATOGENS (category X):
- ________ (folate antagonist)
- anticonvulsant?
- antibiotics (2)
- vitamin _______
- methotrexate
- valproic acid / phenytoin
- tetracyclines / quinolones
- vitamin A (should be limited to 700 micrograms/day)
Oldies = thalidimide (no limbs/other malformations); DES (clear cell)
Other = ACCUTANE (retinoids)
171
T/F
- teratogens show dose-response (more is always worse)
- teratogens are only harmful early in pregnancy
- true
| - false (tetracyclines for ex is worse later)
