Week 1 Flashcards
1
Q
3 bones that fuse together to form the “innominate bones” of the pelvis
A
Ilium
Ischium
Pubis
2
Q
Of the three fused bones that make up the innominate bones of the pelvis, which differs the most between the sexes?
A
Pubis
3
Q
What vertebral level is the PSIS?
A
S2
4
Q
What is the bony attachment site for all the hamstring muscles?
What is the bony attachment site for the external genitalia?
A
Ischial tuberosity
Ischiopubic ramus
5
Q
What nerve runs through the obturator foramen?
What bony processes form the boundaries of the obturatory foramen?
A
The obturator nerve runs through the obturator foramen
Superiorly - superior pubic ramus
Inferiorly - ischiopubic ramus
6
Q
What kind of joint is the pubic symphisis?
A
Secondary cartilaginous
7
Q
What bony landmark is palpable on vaginal examination?
A
The ischial spines
8
Q
What are the attachments of…
- the sacrospinous ligament
- the sacrotuberous ligament?
What nerve runs between these two ligaments?
A
Sacrospinous ligament - sacrum and ischial spine
Sacrotuberous ligament - sacrum and ischial tuberosity
The pudendal nerve runs between these two ligaments, curves around the sacrospinous ligament
9
Q
What ligament separates the greater and lesser sciatic foramina?
A
The sacrospinous ligament (and also the sacrotuberous ligament…)
10
Q
What are the borders of the pelvic inlet?
What are the borders of the pelvic outlet?
Which is more superior?
A
Pelvic inlet
- sacral promontory
- ilium
- superior pubic ramus
- pubic symphysis
Pelvic outlet
- pubic symphysis
- ischiopubis ramus
- ischial tuberosities
- sacrotuberous ligaments
- coccyx
The pelvic inlet is more superior
11
Q
What muscle is also known as the “pelvic floor” muscle?
What is the space between the pelvic floor and pelvic inlet called?
A
Levator ani
The space is called the pelvic cavity and contains the pelvic organs and supporting tissues
12
Q
How does the pelvic anatomy of the female differ to that of the male?
A
AP and transverse diameters of the pelvis are larger in the female, both at the pelvic inlet and outlet
The suprapubic angle is greater in the female
The pelvic cavity is shallower in the female
13
Q
What is the term given to the movement of one bone over the other that allows the foetal head to change shape during delivery?
A
Moulding
14
Q
What could the following indicate…
- bulging fontanelles
- depressed fontanelles?
A
Bulging - increased fluid/ICP
Depressed - dehydration
15
Q
Which of the two diameters of the foetal head is bigger?
What is the name of the diamond shape made between the two greatest points of the biparietal diameter (parietal eminences) and the anterior and posterior fontanelles?
A
The Occipitofrontal diameter is greater than the Biparietal diameter
The vertex is the diamond bordered by the two fontanelles and the biparietal eminences
16
Q
What is the distance of the foetal head from the ischial spines referred to?
What position is the baby’s head initially in when entering the pelvic cavity? Why is this the case?
A
Station (negative number means the head is superior to the spines, positive number means the head is inferior)
The baby’s head is ideally facing left or right. This is because the transverse diameter of the pelvic inlet is greater than the AP diameter, while the OP diameter of the foetal head is greater than the biparietal diameter.
17
Q
Why does the baby’s head change from being faced left-to-right to an occipitoanterior position (OA), ideally, during delivery?
Should the baby’s head be in extension or flexion at delivery?
A
While at the pelvic inlet, the transverse diameter is greatest, hence left-to-right
At the pelvic outlet, the AP diameter is greater, so the baby’s head needs to rotate, ideally being in the occipitoanterior position i.e. the baby’s occiput and the mother’s anterior
When descending through the pelvis, the baby’s head should be in a flexed position (chin to chest), and when delivered should be in an extended position
18
Q
When delivering a baby, which shoulder is delivered first?
A
Once head is delivered, the baby must rotate again in order to pass the shoulders
First the top shoulder (mother’s anterior) is delivered, then the bottom shoulder
19
Q
What is the name of the dense outer shell of connective tissue that surrounds the cortex of the ovary?
What is it covered by?
A
Dense outer shell - tunica albuginea
Covered by a single layer of cuboidal cells called the germinal epithelium
20
Q
Regarding the structure of the ovary, what are the two main areas of tissue and what do they contain?
A
Cortex - contains ovarian follicles in a highly cellular connective tissue stroma
Medulla - core of the organ, contains neurovascular structures
21
Q
During embryonic development, at roughly what point do germ cells from the yolk sac invade and proliferate?
What do they form when they do this?
A
Approx week 6
Germ cells invade and proliferate via mitosis to form immature reproductive cells (oogonia). These cells will undergo further development and division via meiosis to form mature oocytes
22
Q
What is the name of layer of cuboidal granulosa cells present that defines the primary follicle?
What is the name of the layer of specialised ECM that begins to form between the oocyte and these granulosa cells?
A
Layer of cuboidal granulosa cells - zona granulosa
Layer of specialised ECM - zona pellucida
23
Q
In the late primary follicle, what do inner layers of stromal cells form and what do they then secrete?
A
The inner layers of stromal cells transform into the theca interna, which then secretes oestrogen precursors - these will then be converted to oestrogen by granulosa cells
24
Q
The development of what structure within the granulosa layer defines a follicle as being secondary, rather than primary?
A
Development of the antrum - space filled with follicular fluid within the granulosa layer
25
What is the name of the final stage of follicular development, following the secondary follicle?
The **mature Graafian follicle**
26
Follicles can be classed on the presence of their antrum i.e. pre-antral or antral.
Which stages of follicle are pre-antral, and which are antral?
Pre-antral
* primordial follicle
* primary follicle
* late primary follicle
Antral
* secondary follicle
* mature Graafian follicle
27
Following ovulation, what does the follicle then become? What is secreted and by what cells?
Follicle becomes the **corpus luteum**
**Theca cells** and **granulosa cells** secrete **oestrogens and progesterones**
28
Assuming no implantation occurs, what does the corpus luteum become?
What happens if implantation does occur?
A white-coloured connective tissue called the **corpus albicans**
If implantation does occur, the placenta secretes hCG which prevents degeneration of the corpus luteum and secretion of progesterone
29
What two components is the endometrium divided into?
What are their functions?
Stratum Functionalis - undergoes monthly growth, degeneration and loss
Stratum Basalis - reserve tissue that regenerates the Stratum Functionalis
30
Describe the transition zone of the cervix
At the external cervical os is **stratified SQUAMOUS epithelium**
In the cervical canal is **simple COLUMNAR epithelium**
The transition zone is the point at which one cell type changes into another, and is a common site of dysplasia and neoplastic changes that can lead to cervical cancer
31
How does the mucous secreted by the endocervical glands vary during the menstrual cycle?
What condition might result if these glands become blocked?
Thin and watery in the proliferative phase
Thick and viscous following ovulation
Blockage of the endocervical glands could cause them to expand with secretions, forming a **Nabothian cyst**
32
What are the four layers of the vagina?
1. non-keratinised stratified squamous epithelium. During reproductive life, this layer is thicker and cells are enlarged due to accumulation of glycogen
2. lamina propria - connective tissue rich in elastic fibres and thin-walled blood vessels
3. fibromuscular layer - inner circular and outer longitudinal smooth muscle
4. adventitia
33
What proportion of couples in the UK require assessment of infertility? How many of these will require assisted conception treatment (ACT)?
1 in 6 couples in the UK will require assessment of fertility
Of these, 50% will require ACT
34
What are some of the indications for ACT?
Endometriosis
Male factor
Tubal disease
Ovulatory disorders
Increase in single and same-sex couples
Increase in treatment with surrogate
Increase in transgender referrals
Fertility preservation in cancer
Treatment to avoid transmission of blood-borne viruses
Pre-implantation diagnosis of inherited conditions
35
What are some of the conditions that have to be met (in both men and women!) before ACT can be commenced?
Alcohol - women limited to 4 units per week
Weight - both male and female to have BMI 19-29
Smoking cessation
Folic acid - 0.4mg/day preconception until 12 weeks gestation
Rubella immunisations for female if not already done (check status)
Cervical smears should be up to date
Full drug history - prescribed, OTC and recreational
Screen for blood-borne viruses - Hep B/C and HIV
Assess ovarian reserve
36
What are some of the options of ACT available?
Donor insemination
Intra-uterine insemination
IVF
Intra-cytoplasmic sperm injection (ICSI)
Fertility preservation
Surrogacy
37
How is Intrauterine insemination done?
Can be done either during a natural or stimulated cycle
Prepared semen sample is inserted into the uterine cavity around the time of ovulation
38
What are some of the indications specifically for receiving IVF?
Unexplained infertility for more than 2 years
Pelvic disease - endometriosis, tubal disease, fibroids
Anovulatory infertility (after a failed induction of ovulation)
Failed intrauterine insemination (after 6 cycles)
39
How long does ovarian folliculogenesis take?
What two phases does it consist of?
Takes **85 days**
**Tonic phase (65 days)** - primary and secondary follicles become antral follicles
**Growth phase (20 days)** - antral follicles develop into pre-ovulatory follicles, dependent on gonadotropin
40
What are the requirements when assessing a semen sample? What is it assessed for?
Male must have been abstinent for at least 72 hours beforehand
Needs to be either produced on-site, or at home and brought in within 1 hour
Assessed for...
* volume
* density - how many are there
* motility - what proportion of sperm are moving
* progression - how well are they moving
41
At what stage of embryo development is the sample usually transferred and cryopreserved?
At the **blastocyst stage**
42
When transferring the fertilised embro into the woman, what treatment is given alongside?
When is a pregnancy test performed?
Progesterone suppositories are given for 2 weeks at the same time as embryo transfer
Pregnancy tests are performed at **16 days after oocyte recovery**
43
What are some of the indications specifically for Intra-Cytoplasmic Sperm Injection (ICSI)?
What is the difference between IVF and ICSI?
Severe male factor infertility
Previous failed fertilisation with IVF
Preimplantation genetic diagnosis
ICSI is a form of IVF, however while standard IVF treatment requires between 50 and 100 thousand sperm cells per oocyte, ICSI only requires one as the sperm is injected directly into the egg, bypassing the acrosomal reaction
44
In instances where the male presents with azoospermia, surgical sperm aspiration may need to be performed. Where is this aspiration taken from in a) obstructive and b) non-obstructive
Obstructive - sperm is aspirated from the epididymis
Non-obstructive - sperm is aspirated from the testicular tissue
45
What are some of the complications associated with ACT?
Ovarian Hyper-Stimulation Syndrome
Multiple pregnancy
Ectopic pregnancy
Surgical risks associated with egg and sperm retrieval
Failure of fertilisation (approx. 4%)
46
What is Ovarian Hyper-Stimulation Syndrome (OHSS) and how is it managed?
Spectrum of disease ranging from mild to critical
Features
* abdominal bloating, pain
* possible nausea and vomiting
* if severe, possible ascites, oliguria, hyponatraemia, hyperkalaemia, hypoproteinaemia, raised haematocrit, thromboembolism, ARDS
Management
* prevention - low dose protocols and use of antagonist for suppression
* treatment prior to embryo transfer - elective freeze, single embryo transfer
* treatment after embryo transfer - monitor with scans and bloods, analgesia, reduce risk of thromboembolism
47
What are some of the abnormal pregnancy outcomes?
Is bleeding a common problem in early pregnancy?
Miscarriage (normal embryo)
Ectopic pregnancy (abnormal site of implantation)
Molar pregnancy (abnormal embryo)
**Bleeding IS a common problem in early pregnancy (20%)**
48
How does miscarriage present and how can it be diagnosed/confirmed?
**Bleeding** is the primary symptom (more so than cramping, although these may also be described)
Passed products may be brought in
USS to assess whether or not there is a pregnancy in situ, it is in the process of expulsion, or if there is an empty uterus.
Speculum examination confirms if threatened (os is closed), inevitable (products are sighted at open os) or complete (products are in vagina)
49
# Define the following terms and what they mean for the pregnancy...
Threatened miscarriage
Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage
Early Foetal Demise
Threatened miscarriage - cervical os is closed, there is a risk to the pregnacy
Inevitable miscarriage - products are sighted at the open os, pregnancy cannot be saved
Incomplete miscarriage - part of the pregnancy is lost already
Complete miscarriage - all of the pregnancy has been lost and the uterus is empty
Early Foetal Demise - the pregnancy is in situ but there is no heartbeat
50
What is recurrent miscarriage defined as and what are some of the possible causes?
Defined as 3 or more pregnancy losses
Causes
* Antiphospholipid syndrome
* Thrombophilia
* Balanced translocation
* Uterine abnormality
* Uterine NK cells hypothesis?
51
What are some of the signs and symptoms of a ruptured ectopic pregnancy?
Pain \> bleeding
Dizziness/collapse/possible pain at shoulder tip (due to blood from rupture irritating the diaphragm), SOB
Pallor
Haemodynamic instability
Signs of peritonism
Guarding and tenderness
52
Suspect ectopic pregnancy? What investigations?
FBC
beta hCG - comparative assessment 48 hours apart to assess for doubling
USS abdomen/pelvis
53
What is a molar pregnancy?
What is the difference between a partial and complete mole?
Nonviable fertilised egg, overgrowth of placental tissue w/ chorionic villi swollen with fluid, appears as "grape like clusters"
**Partial Mole**
* Haploid egg
* 1 sperm (reduplicating DNA material) or 2 sperms fertilising the same egg resulting in **triploidy**
* may have a foetus
**Complete Mole**
* Egg but without DNA
* 1 or 2 sperms fertilise, resulting in **diploidy** (paternal contribution only)
* no foetus
Both result in an overgrowth of placental tissue
54
How does a complete mole appear classically on USS?
Classic "snowstorm" appearance on USS
55
How might molar pregnancy present clinically?
Hyperemesis
Varied bleeding and the passage of "grape-like" tissue
Fundus \> dates would suggest
Occasional SOB
Diagnosis confirmed w/ USS
56
What feature might occur when the fertilised egg implants onto the uterine wall, approximately 10 days post-ovulation, and be mistaken for a period?
**Implantation bleeding**
Signs of pregnancy soon emerge
57
What is a chorionic haematoma?
How is it managed?
Pooling of blood between the endometrium and the embryo due to separation of the embryo from its original site of implantation
Features - bleeding, cramping and threatened miscarriage
Usually self-limiting, however large haematomas may be a source of infection, irritability and miscarriage. Manage w/ reassurance and surveillance
58
Describe the follicular phase of the menstrual cycle
Starts on first day of period
FSH stimulates **ovarian follicle development** and granulosa cells to produce **oestrogens**
Raising **oestrogen** and **inhibin** by the dominant follcile inhibits further FSH production
Decline in FSH levels cause atrophy of all other follicles, leaving the dominant.
59
Describe the ovulatory part of the menstrual cycle
Prior surge of LH triggers ovulation
The dominant follicle ruptures and releases the oocyte
60
Describe the luteal phase of the menstrual cycle
Begins right after ovulation
Corpus Luteum forms out of empty follicle. This then starts to secrete **progesterone** which prepares the uterus for implantation
If the egg has been fertilised, implantation occurs
If the egg has not been fertilised, it passes through the uterus and the uterine lining breaks off, beginning the next menses.
61
Describe a "normal" mentrual cycle
Lasts 4-6 days, with peak flow being at 1-2 days
Less than 80ml is lost per menstruation, and no clots are present
Average cycle is 28 days, however may be anywhere between 21 and 35
No inter-menstrual or post-coital bleeding is seen
62
# Define the following terms...
- menorrhagia
- metrorrhagia
- polymenorrhoea
- polymenorrhagia
- menometrorrhagia
- amenorrhoea
- oligomenorrhoea
Menorrhagia - prolonged and increased menstrual flow, but cycle is normal
Metrorrhagia - regular intermenstrual bleeding
Polymenorrhoea - menses occurs with an interval of less than 21 days
Polymenorrhagia - increased bleeding and frequent cycle
Menometrorrhagia - prolonged menses and intermenstrual bleeding
Amenorrhoea - absence of menstruation for more than 6 months
Oligomenorrhoea - smenses at intervals of more than 35 days
63
What pathogen typically is the cause of pelvic inflammatory disease (PID), a possible cause of "organic" menorrhagia?
Chlamydia
64
What pathology would the appearanec of "chocolate cysts" on the ovary suggest?
Endometriosis
65
What endocrine disorders might cause menorrhagia?
Hyper/hypothyroidism
Diabetes mellitus
Adrenal disease
Prolactin disorders
66
What is dysfunctional uterine bleeding (DUB)? What two categories is it subdivided into?
DUB is vaginal bleeding from the uterus that is abnormally frequent, lasts excessively long, greater amount than normal or irregular. Extremely common and will affect most women during their lives. Numerous causes.
Subdivided into...
**Anovulatory** - 85% of cases, features **irregular cycles,** occurs in the extremes of reproductive life and is more common in obese women
**Ovulatory** - most common between the ages of 35 and 45, **regular heavy periods**, caused by inadequate progesterone production by the corpus luteum
67
If a patient presents with dysfunctional uterine bleeding, what investigations would you perform?
FBC - including haemaglobin to exclude anaemia
Cervical smear - ensure they are up to date
TSH - tends to only be done if thyroid issues clinically suspected
Coagulation screen
Renal and Liver function tests
Transvaginal USS - done to assess endometrial thickness and look for the presence of fibroids
68
NICE and SIGN guidelines state that any menorrhagia in a woman under 40/45 (respectively) needs to be investigated because of the possibility of what condition?
What sign, seen on transvaginal USS, might suggest this condition?
Because of the possibility of **endometrial carcinoma**
**Endometrial thickness** is assessed - while a thickened endometrium is not diagnostic of endometrial carcinoma, it is an indicative factor and increases the likelihood.
69
Name some of the non-surgical management options for treating dysfunctional uterine bleeding
Progestogens - synthetic version has a longer half life and is therefore better for compliance, however causes cessation of periods
Combined oral contraceptive pill - can be used to treat menorrhagia up until menopause
Danazol - may cause virilism
GnRH analogues - may cause osteoporosis
Non-hormonal treatments - NSAIDs, anti-fibrinolytics, capillary wall stabilisers
Progestogen-releasing IUCD e.g. Mirena
70
What hormonal therapy is used specifically to treat endometriosis?
GnRH analogues e.g.
(Also combined oral contraceptive, progestogens, danazol and aromatase inhibitors...)
71
What surgical options are available to treat dysfunctional uterine bleeding?
Endometrial resection/ablation
Hysterectomy
72
Is Chlamydia trachomatis gram positive or gram negative?
How is treated?
Trick question! Doesn't really stain due to having no peptidoglycan in its cell wall
Treated with **doxycycline 100mg bd x 7 days** (no longer a single dose of azithromycin!)
73
How is Chlamydia tested for? What other pathogen can be tested for at the same time?
How are samples collected?
Combined nucleic acid amplication testing (NAATs) or PCR
Can also test for **gonorrhoea** at the same time with the same test
Male patients - first pass urine sample
Female patients - HVS or vulvo-vaginal swab
Can also take rectal, throat and eye swabs
74
What is now the recommended treatement for *N. gonorrhoeae*? What needs to be done after treating it and why is this the case?
Recommended treatment is now **intramuscular ceftriaxone + oral azithromycin**
Once treated, test of cure is also recommended in all patients to ensure the pathogen has been cleared.
This is because **resistance is a big concern in gonorrhoea** - many strains are already resistant to penicillins, tetracyclines, quinolones (-floxacins) and most oral cephalosporins
75
What bacterial species make up the "normal" vaginal flora?
*Lactobacillus* spp. predominates - produces lactic acid and hydrogen peroxide, making the vagina pH low (acidic)
Other organisms that may be found include...
*Strep viridans*
Group B beta-haemolytic *Streptococcus*
Small numbers of *Candida* spp.
76
Which of the following genital tract infections are sexually transmitted?
- Candida (vaginal thrush)
- Bacterial vaginosis
- Prostatitis
None!
77
30% of females have *Candida* present in their vaginas and exhibit no symptoms. What are some of the predisposing factors for developing *Candida* infection?
- Recent antibiotic therapy
- High oestrogen levels (pregnancy, certain types of contraceptive)
- Poorly controlled diabetes
- IC/IS patients
78
*Candida* infection - how does it present, how is it diagnosed and how is it treated?
Presentation - **intensely itchy white vaginal discharge**
Diagnosis - CLINICAL! Remember it is a commensal in many women, so swabbing won't be useful
Treatment - **topical clotrimazole pessary/cream**. **Oral fluconazole**
79
How is bacterial vaginosis caused?
Disequilibrium in the vaginal microbiota, resulting in a decline in the amount of *Lactobacillus* spp.
Most infections appear to begin with *Gardnerella vaginalis* creating a biofilm, allowing other opportunistic bacteria to thrive
80
Bacterial vaginosis - clinical presentation, diagnosis and treatment
What classic feature, seen on microscopy, indicates bacterial vaginosis?
Presentation
* thin, watery **fishy-smelling** vaginal discharge
Diagnosis
* again, CLINICAL, and can be aided with assessing vaginal pH (will be raised above 4.5)
* The characteristic fishy smell can be detected on wet mount in a test known as the **whiff test** after the addition of potassium hydroxide
* The appearance of **CLUE CELLS** microscopically is indicative of bacterial vaginosis
Treatment
* **oral metronidazole**
81
Name some sexually transmitted bacterial infections
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Treponema pallidum (syphilis)
82
Name some sexually transmitted viral infections
HPV (genital warts)
Herpes simplex virus (genital herpes)
Hepatitis and HIV
83
Name some sexually transmitted parasitic infections
- Trichomonas vaginalis
- Phthirus pubis (pubic lice/crabs)
- Scabies
84
Chlamydia trachomatis has 3 serological groups (A-C, D-K and L1-L3). Which is the most common, and the cause of genital infection?
Serovar 2 - D-K
85
What bacterial STD appears like "2 kidney beans facing each other"?
How does this organism appear on a gram film?
***Neisseria gonorrhoeae***
Appears as a gram negative diplococci
Easily phagocytosed by polymorphs, so often appears intracellularly on gram stain
86
How does *Treponema pallidum* stain?
How is syphilis diagnosed?
It doesn't stain!
Diagnosis is reliant on **PCR or serology to detect antibodies (however suspecies are serologically indistinguishable!)** because *T. pallidum* cannot be grown
87
What are the 4 stages of syphilis infection and what is each characterised by clinically?
**Primary** - solitary painless lesion (chancre), heals without treatment
**Secondary** - large numbers of bacteria circulate in blood, multiple manifestations at different sites ("snail-track" mouth ulcers, generalisd rash on palms and soles of feet, flu-like symptoms etc.)
**Latent stage** - no symptoms, but low levels of spirochetes can be found in the intima of blood vessels
**Late stage** - cardiovascular/neurovascular complications occur many years later
88
Regarding serology testing for syphilis, what options are available?
**Non-specific testing** - **not specific for syphilis**, just indicates tissue inflammation and may be positive for numerous other reasons. More useful for measuring response to treatment
* Venereal Disease Research Lab (VDRL)
* Rapid Plasma Reign (RPR)
**Specific serological testing** - specific for syphilis but remain positive for life, hence not useful for measuring response to treatment
* T. pallidum particle agglutination assay (TPPA)
* T. pallidum haemagglutination assay (TPHA)
* **IgM and IgG ELISA** also useful as a combined "screening" for syphilis, done first in Tayside and a positive result leads to either VDRL or TPPA
89
What is the treatment for syphilis?
**Penicillin** - injectable long-acting preparations (or doxycycline/azithromycin if allergic)
90
What is the most common viral STI?
What causes it?
**Genital warts**
Caused by the **Human papilloma virus**
91
Why is HPV difficult to study in the lab?
Because it cannot be grown in artificial culture media or maintained in lab animals
92
Which types of HPV are associated with warts?
Which types of HPV are associated with cervical cancer?
Which strains does the HPV vaccine protect against?
Warts = **HPV 6 and 11**
Cervical cancer = **HPV 16 and 18**
HPV vaccine is quadravalent and protects against **HPV 6, 11, 16 and 18**
93
HPV warts - diagnosis and treatment
Diagnosis is clinical - no routine microbiological test
Treatment - cryotherapy, podophyllotoxin cream/lotion
94
What organism is genital herpes caused by?
Herpes simplex virus 1 and 2 (HSV-1 and HSV-2)
95
Genital herpes - diagnosis and treatment
Diagnosis - swab in virus transport medium of de-roofed blister for **PCR** - highly sensitive and specific
Treatment - pain relief, aciclovir may be helpful if taken early enough
96
What are the two primitive genital tracts? Which becomes the reproductive tract in the male and which in the female?
**Wolffian** ducts - becomes the **male** reproductive tract
**Mullerian** ducts - becomes the **female** reproductive tract
97
What two substances cause the development of the male reproductive tract? How does this happen?
**Testosterone and** **Mullerian Inhibiting Factor** (both secreted by the fetal testes)
Mullerian ducts degenerate in the presence of these two substances. Without the stimulus of male testicular hormones, the fetus will develop the female internal genital tract and the Wolffian tract will degenerate
98
At what point to fetal genitalia start to differentiate?
When can they be recognised on an USS?
Differentiate from **9 weeks**
Recognisable on USS from **16 weeks**
99
What's the condition - presents at puberty with amenorrhoea, lack of pubic hair, and karyotype 46XY but born with phenotypically female external genitalia?
**Androgen Insensitivity Syndrome**
X-linked recessive disorder where the testes develop but don't descend. **Androgen induction of Wolffian ducts DOES NOT occur, but Mullerian inhibition DOES occur.**
Absent uterus and ovaries, and a short vagina
100
Describe the passage of sperm from the testes to being ejaculated
Created in the **seminiferous tubules of the testicle**
Moves to the **epididymis**, then to the **vas deferens**
Loops around behind the bladder and passes through the prostate gland. Joined by the **seminal vesicles** which secrete a significant amount of fluid that will ultimately become semen
Then passes through the prostatic urethra, then the membranous urethra, and finally the penile urethra
101
What is the name of the muscle contraction that causes the testicles to raise and lower in response to external temperatures?
**Dartos contraction** (in conjunction with the **cremasteric muscle**) - not to be confused with the cremasteric reflex!
102
What is Cryptorchidism?
How should it be managed and why?
Undescended testicle or testicles in adulthood
Increasingly common and reduces sperm count, but if unilateral then fertility is usually unaffected
**Orchidopexy** should be performed if the child is under the age of 14 to reduce the risk of **testicular germ cell cancer**
If in adulthood, consider **orchidectomy** (risk of testicular germ cell cancer is x6!)
103
Where is sperm produced?
Where is testosterone produced?
Spermatogenesis occurs in the **seminiferous tubules,** and is done alongisde **Sertoli cells**
Testosterone production occurs in the **Leydig cells**
104
Which of the following are functions of Sertoli cells?
- formation of a blood-testes barrier
- provision of nutrients for developing cells
- phagocytosis of defective cells and surplus cytoplasm
- secretion of seminiferous tubule fluid to carry cells to the epididymis
- secretion of androgen-binding globulin
- secretion of inhibin and activin hormones to regulate FSH secretion
All of the above!
105
What is the release of GnRH like?
What does its release cause and how is GnRH regulated?
GnRH release from the hypothalamus **occurs in** **bursts every 2-3 hours**
GnRH causes release of **LH and FSH from the anterior pituitary**
GnRH release is **regulated by testosterone via negative feedback**
106
In the male, LH acts on ____ and FSH acts on \_\_\_\_
LH acts on **Leydig cells** to regulate tesosterone secretion
FSH acts on **Sertoli cells** to enhance spermatogenesis
107
Testoserone is derived from \_\_\_\_
Cholesterol
108
What cells do Inhibin and Activin act on?
What is their function?
Inhibin and Activin act on **Sertoli cells** to inhibit and stimulate secretion of **FSH**
109
What iatrogenic causes may result in premature or retrograde ejaculation?
Prostate surgery
Anticholinergic medication
110
What is the most common cause of male infertility?
What are some of the obstructive and non-obstructive causes?
Most common cause is **idiopathic**
**Obstructive**
* cystic fibrosis
* vesectomy
* infection
**Non-Obstructive**
* congenital - cryptorchidism
* infection - mumps orchitis
* iatrogenic - surgery, anticholinergics, chemo/radiotherapy
* pathological - tumours
* genetic - Klinefelter's
* specific semen abnormalities
* systemic disorders - e.g. renal failure
* endocrine - things affecting prolactin levels
111
What are some of the endocrine causes of male infertility?
Pituitary tumours
Hypothalamic disorders
Thyroid disorders (hyper/hypothyroidism - decreased sexual function and increased prolactin)
Diabetes (decreased sexual function and testosterone)
Congenital Adrenal Hyperplasia (decreased testosterone)
Androgen Insensitivity
Steroid abuse (decreased LH, FSH and testosterone)
112
What is the 'normal range' for testicular volume?
Below what level would be considered likely infertile?
Normal range is **12-25 mls**
**Below 5mls** would be thought to be infertile
Measurement is done with an orchidometer
113
What is semen assessed for when performing analysis?
Volume
Density - numbers of sperm
Motility - how many are moving
Progression - how well are they moving
Morphology
114
What are some of the factors that might affect the quality of the semen sample?
**Not maintaining abstinence for 3 days**
Temperature sample has been stored at
Health of the man for the previous 3 months
Incomplete sample
Time between production and assessment (deteriorates after 1 hour)
115
What medication can be given to an individual who has hyperprolactinaemia to improve their fertility?
**Cabergoline** (dopamine receptor stimulator and inhibitor of prolactin)
116
What is the success rate like of vasectomy reversal?
75% if done within 3 years
Up to 55% if done 3-8 years
Up to 40% if done 9-19 years
117
What are some of the indications for endometrial sampling?
Abnormal uterine bleeding
Investigation of inferility
Endometrial ablation
Abortion (spontaneous and therapeutic)
Assessment of response to hormonal therapy
Endometrial cancer screening in high risk patients e.g. Lynch syndrome (a.k.a. hereditary non-polyposis colorectal cancer)
118
# Define the following terms...
- Menorrhagia
- Metrorrhagia
- Polymenorrhoea
- Polymenorrhagia
- Menometrorrhagia
- Amenorrhoea
- Oligomenorrhoea
- DUB
Menorrhagia - prolonged and increased menstrual blood flow
Metrorrhagia - regular intermenstrual bleeding
Polymenorrhoea - menses occuring at intervals of less than 21 days
Polymenorrhagia - increased bleeding and frequent cycle
Menometrorrhagia - prolonged menses and intermenstrual bleeding
Amenorrhoea - absence of menstruation for \>6 months
Oligonemorrhoea - menses occuring at intervals of more than 35 days
DUB - dysfunctional uterine bleeding, AUB with no obvious organic cause
119
What are the most common causes of abnormal menstrual bleeding in adolesence/early reproductive life?
DUB
Endometriosis
Pregnancy/Miscarriage
Bleeding disorders
120
What are the most common causes of abnormal menstrual bleeding in mid reproductive life/perimenopause?
DUB
Pregnancy/miscarriage
Endometriosis
Endometrial polyp/endocervical polyp
Leiomyoma
Adenomyosis
Exogenous hormone effects (e.g. contraceptions such as the implant)
Bleeding disorders
**Hyperplasia**
**Neoplasia - cervical, endometrial**
121
What are the most common causes of abnormal menstrual bleeding in postmenopause?
Marked obestiy
Atrophy
Endometrial polyps
Exogenous hormones - HRT, tamoxifen (used to treat oestrogen +ve breast cancer)
Endometriosis
Bleeding disorders
**Hyperplasia**
**Endometrial carcinoma**
**Sarcoma**
122
An endometrial thickness in postmenopausal women of how much (measured by TVUS) is generally taken as an indicator for biopsy?
Thickness greater than **3-4mm**
123
When performing endometrial sampling, which phase of the cycle should you aim to sample during? Which part of the cycle is the least informative?
Aim to sample during the **2nd phase (follicular)**
Aim to **avoid the 1st phase (menstrual)** as this is the least informative
124
What are the 3 phases in each of the following...
Ovarian cycle
Uterine cycle
**Ovarian cycle**
* Follicular phase
* Ovulation
* Luteal phase
**Uterine cycle**
* Menstrual phase
* Proliferative phase
* Secretory phase
125
When is dysfunctional uterine bleeding as a result of anovulatory cycles at its most common?
What other conditions is DUB associated with?
Most common at **either end of the reproductive life**
The corpus luteum doesn't form and there is continued growth of functionalis layer, meaning a gap with no periods followed by one heavy menstruation
Associated with PCOS, hypothalamic dysfunction, thyroid disorders and hyperprolactinaemia
126
Name some of the infectious organisms that can cause endometritis
Neisseria gonorrhoeae
Chlamydia
TB
CMV
Actinomyces
HSV
127
Endometrial polyps are common and usually asymptomatic, but may present with bleeding or discharge. Is there any reason to be concerned about them?
Not really, the vast majority are benign
**BUT!!!** Endometrial carcinoma can present initially as a polyp!
128
How can Foetal RBCs be spotted during histology?
Foetal RBCs are **nucleated**
129
What is the difference between a partial and complete molar pregnancy?
**Partial** - triploidy. Egg is fertilized by two sperm, or by one sperm which reduplicates itself (69,XXY). **Have both maternal and paternal DNA**, and a foetus may be present
**Complete** - diploidy, sperm combines with an egg that contains no DNA. Sperm then reduplicates itself forming 46 chromosome set. **Only paternal DNA is present in the complete mole**. Presents like a cluster of grapes, no foetus present
130
What treatment is given for gonorrhoea?
**IM ceftriaxone**
(used to also give oral azithromycin to 'protect' ceftriaxone from resistance but this has been discontinued due to too many downstream effects of azithromycin)
131
How are gonorrhoea and chlamydia diagnosed these days? What is the advantage of this over the previous technique?
Diagnosed primarily using **PCR (NAATs)**
More sensitive and faster than performing cultures
132
What is the difference between a threatened miscarriage and an incomplete miscarriage?
Threatened - bleeding is seen but the **cervical os remains closed and the pregnancy is still potentially viable**
Incomplete - bleeding is seen and the **cervical os is closed. Pregnancy is no longer viable**
