Reproduction

Most common ovarian tumors

1) Benign cystic teratoma (rare carcinoid like serotonin/thyroid - struma ovarii) 2) Serous cystadenoma (CA 125) 3) Mucinous cystadenoma 4) Serous carcinoma (malignant) 5) Fibroma-thecoma

Atypical Ductal Hyperplasia

4-5X risk for carcinoma

Turner Syndrome

45X OR mosciacism with an abnormal X Short stature, webbed neck, coarctation of aorta, broad chest with widely spaced nipples, unilateral pelvic kidneys Present with: POI or delayed puberty

21 Hydroxylase deficiency

46XX, ambiguous genitalia Congenital Adrenal Hyperplasia Over-viralized, AR Build up of 17OH-progesterone Salt-wasting, no aldosterone made

Swyer Syndrome

46XY Presents at age 13 with no signs of puberty (no breasts, growth, menses) SRY gene problem on Y gene No testes, No testosterone, No Mullerian Inhibiting Substance Wolffian ducts do not form, Mullerian ducts develop Looks like a little girl, but ovaries won't work

Complete Androgen insensitivity syndrome

46XY Under-viralized Defect in Androgen receptor at target tissue (partial or complete) High levels of testosterone MIS is made > Regression of Mullerian ducts, but no development of wolffian ducts due to lack of testosterone receptors No pubic hair, vagina, or menses

5 alpha reductase deficiency

46XY, ambiguous genitalia Under-viralized Defect in androgen biosynthesis Testosterone is not converted to DHT (active) so external genitalia do not develop well Role in hirsutism and BPH Testes are present At puberty, testosterone increases causing increased viralization

BRCA1

60-85% lifetime risk for carcinoma 80% of BRCA1 are basal-like

Embryonal rhabdomyosarcoma

<5 yr old, vaginal Small round blue cell tumor Desmin positive, spindle shaped cells Grape-like mass emerging from vagina

Priapism

>4 hour persistent penile erection High Flow: Non-painful, partially rigid erection resulting from increased arterial in flow (trauma) Low Flow: Painful - resulting from decreased venous out flow Tx: low flow:Corporal Aspiration & Irrigation or shunt, for high flow: non-emergent embolization

Corpus luteum

A remnant of follicle after ovulation that secretes the hormone progesterone which prepares the uterine lining for receiving an embryo Becomes Corpus albicans after 14 days

Ovarian Torsion

Acute Severe pain Rotation of the ovary causing occlusion of the ovarian vein and/or artery Cause: Endometrioma, Cyst weighs down the ovary

Prostatitis

Acute bacterial prostatitis - you may have symptoms associated with the sudden onset of infection, fever, chills, nausea and/or vomiting. Chronic bacterial prostatitis commonly associated with frequent urinary tract infections or over 3 months Tx: Antibiotics, alpha blockers, NSAIDs, massage

Gleason Grade

Add major and minor scores out of 5 Ex: 3+4=7, most of the tumor is grade three but some of the tumor is grade 4

Medical words for irregular menstruation

Amenorrhea: no period oligomenhorrhea: spaced far apart (>35 days) Menorrhagia: heavy/prolonged Metrorrhagia: irregular Menometrorrhagia: heavy AND irregular Polymenorrhea: frequent menses (<24 days)

Mifepristone

Anti-progesterone Withdrawl of progesterone causes detachment of embryo Followed by Misoprostol: PGE1, causes softening and contractions in uterus

Menopause

Apoptosis throughout life, by age 51 or so less than a thousand oocytes left and they don't function well, no dominant follicle produced regularly (intermittent ovulation), *estrogen and inhibin production decrease then cease, FSH rises*, cycles become irregular from anovulatory breakdown of endometrium and then eventually cease when there is no more estrogen production from the ovary. Tx: Low dose daily estradiol with medroxyprogesterone acetate (Extrace and Provera), or SSRIs

Pseudomyxoma

Appendix

Proliferative Breast disease

Benign Fibrocystic: Cystic change and stromal fibrosis Adenosis: Increased acini and intralobular fibrosis Risk is doubled (1.5-2x) for carcinoma

Intraductal papilloma

Benign Growths in lactiferous ducts, beneath areola Nipple discharge Risk is doubled (1.5-2x) for carcinoma

Fibroadenoma

Benign Painless nodule, freely mobile, mostly UOQ Most common tumor in <35 Circumscribed homogenous density Risk is doubled (1.5-2x) for carcinoma

Adenomyosis

Benign invasion of the endometrial tissue into the myometrium of the uterus Pelvic pain, symmetrically enlarged uterus, menorrhagia Tx: NSAIDs, OCP, hysterectomy

Leiomyomas

Benign tumors of the smooth muscle of the uterus, know as fibroids Asymptomatic Menometrorrhagia Iron deficiency anemia Spindle shaped cells with cigar-shape nuclei Estrogen sensitive Intramural most common, but submucosal > could cause heavier bleeding, bleeding remains cyclical *Estrogen and progesterone sensitive* >May regress as estrogen decreases, may increase in size during pregnancy

Brenner Tumor

Benign/Transitional cell Solid tumor

Order of birth control effectiveness

Best: implant, IUD, sterilization Medium: Injectable, OCP, Patch, Ring, Diaphragm Low: Condom, Withdrawl, Spermicide, Sponge, Fertility planning

Treatment for Chlamydia and Gonorrhea

C: Azithrox1 or doxyX7 G: Ceftriaxone IM AND azithro orally

Choriocarcinoma

Children/young adults Solid tumor Derived from germ cell Associated with increased HCG

Pelvic Inflammatory Disease

Chlamydia and Gonorrhea ascending into the uterus Cervical motion tenderness and uterine tenderness Risks: Infertility (adhesions), Chronic pelvic pain, ectopic pregnancy TOA: Tubo-ovarian abscess can rupture and be very dangerous Dx: <25 and sexually active (or Hx of STI, multiple partners) AND tenderness on pelvic exam Tx: CefoxyDoxy for inpatient, Cefoxy (IM) + DoxyX2weeks +- Metronidazole for outpatient

Nuva Ring

Combined estrogen/progesterone

Gestational trophoblastic disease

Complete mole: 46XX or 46XY, no fetal parts, grape like appearance and proliferative villi, high hCG, risk of malignancy (choriocarcinoma and invasive) Partial mole: 69XXY or 69XYY, fetal parts, small numbers of villi "collapsed balloon"

Syphilis

Condyloma latum : *PainLESS* rimmed ulcer Treponema Pallidum Secondary: maculopapular rash, fever, malaise, Condyloma latum in intertriginous areas Tertiary syphilis: gummas, cardiovascular syphilis, neurosyphilis Tx: Penicillin G

IUD

Copper: Inflammatory response (Paraguard), risks of increased bleeding, lasts 10 years Levonorgestrel (Mirena-progestin): Thickening cervical lining, changes cervical mucus, atrophy of endometrium, some people lose their period, 5 years Skyla: 3 years, not likely to lose periods

Vulvovaginal candidiasis

Cottage cheese discharge, itching burning, irritation, higher risk of DM II or immunocompromised Wet mount: blastospores and pseudohyphae (spaghetti and meatballs), normal pH Tx: Fluconazole, avoid moisture, constricting tights/leggings

OCPs

Creates anovulatory patient Estrogen combined: Suppresses FSH release; Avoid in HTN, smoking, older age, migraine with aura, SLE (risk of stroke/DVT) Progesterone only: Inhibits LH surge, need to take in specific range of time *Increase aldosterone activity (raises BP 3-5 mm), increased insulin resistance but no effect on HgbA1C, impairs biliary transport (gallstones), risk of thrombosis Decreases Endometrial and Ovarian cancer Not correlated with decreased fracture risk*

Depot-medroxyprogesterone injection

Depo Provera High levels of progesterone 3 dose injections, stop having periods and stop ovulating Slow return (1 year) to ovulation

HPV infection

Double stranded DNA virus Most resolve spontaneously, 70% clear within 1 year and 90% clear within 2 years 16 and 18 > Dysplasia (E6-p53 and E7-RB product) 6 and 11 > Condyloma CIN often arises in transformational zone at squamocolumnar junction *Staging is NOT modified by operative findings* Dysplastic cells in the squamous epithelium characterize VIN Dx: Colposcopy with acetic acid Tx: Ablation (laser or cryo), LoopEEP, cone biopsy (knife) Gardasil 9 Vaccine: L1 capsid protein

PCOS (Polycystic ovarian syndrome)

Elevated androgen production from ovaries, increased LH/FSH ratio Causes anovulation - no maturation of the dominant follicle, no corpus luteum, no progesterone, no secretory phase, causing disorganized proliferative phase Primary etiology: insulin resistance resulting in hyperinsulinemia (decreases SHBG and increases hyperandrogenism in ovary) Increased Acne and hirsutism "String of pearls" on peripheral imaging Risk of: Endometrial cancer, infertility, Type II DM, Dyslipidemia, CAD Dx: Hyperandrogenism, Ovulatory dysfunction, Polycystic ovaries (Rotterdam criteria: 2/3 findings, and rule out other causes) Tx: OCP (reduce risk of endometrial cancer), weight loss, exercise

Secondary Dysmenorrhea

Endometriosis Adenomyosis Intra-uterine polyps Fibroids Hypertonic uterine contractions from obstruction of outflow from genital tract (fibroid/polyp) Symptoms: menstrual pain (1-2 weeks before menses)

Nexplanon

Etonorgestrel Implant 1/3 have polymenorrhea Side effect of irregular bleeding

Estrogen feedback

Feedback inhibition of FSH and LH EXCEPT during LH surge

DCIS

Fills ductal lumen Arises from ductal atypia Microcalcifications on mammography Precursor 8-10x risk for carcinoma

FSH function

Follicle stimulation (many) One becomes primary dominant follicle (with egg inside)

Krukenberg tumor

Gastric carcinoma spreads to the ovaries (metastatic) Gastric carcinoma may metastasis to the left supraclavicular node (Virchow node).

Development of External Genitalia ***

Grans area: clitoris and glans penis Urethral fold: labia minora opening and shaft Urogenital groove: the urethra Labioscrotal swelling: scrotum and labia majora

Call-Exner bodies

Granulosa/Theca cell tumor Producing estrogen > may lead to endometrial hyperplasia Coffee Bean nucleus (granulosa)

Puberty in Girls

Growth spurt Thelarche: breasts age 9.5 Pubarche: pubic hair age 10 Growth spurt - max acceleration Menarche: age 12.8 period

HPO Axis

H: GnRH AP: FSH/LH O: Estrogen, Progesterone

Hydrocele, Varicocele, Spermatocele

H: fluid collection within the tunica vaginalis surrounding the testis V: abnormal dilation of veins within the pampiniform plexus and internal spermatic vein of the spermatic cord S: epididymal retention cyst that develops within the efferent ductules

Endometrial hyperplasia

High levels of unopposed estrogen Causes: anovulation, exogenous estrogen, estrogen producing tumor, obesity (estrogen formed in adipose tissue from androstenedione), FHx or Lynch, G0 state, PCOS, NOT smoking Spectrum: Simple glands > Complex glansd with cytological atypia (progress to carcinoma) Tx: Progestin therapy, and re-biopsy to monitor for progression, if severe hysterectomy

Sheehan's Syndrome

In females due to post-partum hemorrhage leading to ischemic necrosis of pituitary Possible cause of anovulation

Prolactinoma

Increased Prolactin, Decreased GnRH release (and :. decreased FSH and LH) Present with amenorrhea and galactorrhea Antipsychotics (pheothiazine) and antiemetics can cause this Tx: Dopamine antagonists like cabergoline

Patch

Increased risk of DVT, clots etc.

Tanner Staging

Indicates that HPO axis is intact

Abortion

Informed Consent: Capacity/Competence No coercion Appropriate information to make a decision AND Discussion of gestational age Abortion does NOT increase the risk of breast cancer, depression, infertility, or subsequent poor obstetric outcomes.

Ovarian cancer

Late 50-60s No screen available, sporadic Vague symptoms (bloating, pain, early satiety) Present at advanced stage Genes: BRCA1 or 2, p53 for high grade serous Tx: salpingo-oophorectomy (early), debulking of tumor (cytoreductive surgery) and carboplatin/paclitaxel (late) *Follow with CA-125, but bad for screening*

Stress urinary incontinence

Leakage with increased abdominal pressure. Sneezing, laughing, coughing Common with cystocele

Abnormal Uterine Bleeding

Local organic cause Anovulatory Uterine Bleeding=no local organic cause found (often anovulatory cycle, PCO)

Molecular classification of breast carcinoma

Luminal A(best): ER and PR + Luminal B: ER and PR and HER+ Her2: HER + Basal-like (worst): Triple negative, more common in african american women ER+/PR+ tx: tamoxifen HER2+ tx: traztuzumab

Seminoma

Malignant, most common testicular tumor (~30s) Nests of tumor cells with LOTS of lymphocytes Pale cytoplasm (lots of glyocgen) Cryptorchidism 20-40X risk, 4X risk in contralateral testis >> *The less the descent, the higher the risk* Associated with androgen insensitivity syndrome, Ch. i(12p) (loss of tumor suppression) and higher in white (Scandinavia)

Surgical abortions

Manual vacuum, electric vacuum, OR Complications: Retained tissue, infection

Ovarian Fibroma

Meig syndrome: ascites, hydrothorax with ovarian tumor Pulling sensation in groin

Endometriosis

Migration of portions of endometrial tissue outside the uterine cavity (ovary chocolate-cyst and cul-de-sac) *Estrogen sensitive Varies in appearance, can be minimal or extensive (and varied pain)* Increased with FHx Theories: Retrograde menstruation, lymphatic or vascular dissemination, coelomic metaplasia Inflammation > Cyclical Pain > Adhesions > Fibrosis > infertility Bad Disease: large, deep lesions with cul de sac obliteration and density of adhesions Histo: Endometrial glands, stroma, and hemosiderin-laden macrophages Tx: NSAIDS, progestins, GnRH agonists (continuous), OCPs, IUD

Ella

More effective than plan B (98%) Use within 5 days SERM: mixed progesterone agonist/antagonist - Inhibits ovulation (inhibits follicle rupture and effects endometrium) Need prescription

Congenital Absence of the vagina

Mullerian ducts don't develop naturally Absent vagina and uterus MRKH syndrome

Vagina formation

Mullerian ducts upper 2/3 vagina and fuse AND canalize to form uterus (otherwise bicornuate uterus) Urogential sinus forms lower 2/3 vagina Mullerian duct remnant: appendix testis Wolffian duct remnants: para ovarian cysts, gartners duct cyst

Erection mechanism and ejaculation

Neural, hormonal, and biomechanical components 1) Neural event, with neurotransmitters - specifically nitric oxide (NO)- being released from the terminal of the cavernosal nerve >> relaxation of the sinusoids, 2) Immediately increase blood flow into the penis by dilating the arterioles within the erectile tissue. 3) This filling compresses the venous network that surrounds the erectile tissue but is under the tunica albuginea (which stretches), compressing it and causing a net positive in ow of blood into the penis. Cavernosal nerve receives both sympathetic and parasympathetic - Point and Shoot Somatic Nerves proximal to the glans travel together as the dorsal nerve of the penis, which then enters the pudendal nerve, which itself enters the spinal cord through the S2-S4 nerve roots. Deposition of seminal fluid in the posterior urethra via a sympathetic spinal cord re ex. Contraction of the smooth muscle of the prostate, vas deferens, and seminal vesicles, as well as prostatic glandular secretion. Finally, orgasm, the pleasurable sensation usually associated with ejaculation, results from cerebral processing of the increased pressure in the posterior urethra and contraction of the bulbar urethra bulb and accessory sexual organs.

Erectile dysfunction

Neurogenic Arteriogenic (smoking, CAD) Trauma (bike seat) Drug Induced Endocrine (Diabetes) Tx: Viagra aka Sildenafil (inhibit PDE-5) and muscle relaxation,

Azoospermia

No Exercise, smoking, testosterone leads to decreased sperm count, obesity, hypospadias, varicocele Klinefelter syndrome (XXY) (spermatogenic axis and androgenic axis failure) Y chromosomal microdeletion assay (AZFa, b/c, BUT c will work kind of > sons will all be affected) Partial Androgen Insensitivity Syndrome Cystic Fibrosis <> Congenital Bilateral Absence of Vas Deferens (CBAVD)

Condoms

Nonoxynol-9 is a spermicide used to lubricate Condoms: 3% break from friction, latex and non-latex Important for STD

PAP smear

Normal LSIL: lots of cytoplasm, irregular nuclei HSIL: enlarged nuclei (very small cytoplasm)

Bethesda definitions for cervical dysplasia

Normal LSIL: perinuclear halo with more cytoplasm inner third of epithelium HSIL: enlarged nuclei full thickness of epithelium Cancer: Nests and sheets of malignant epithelial cells with squamous differentiation

Bacterial vaginosis

Overgrowth of bacteria, increased if sexually active, lack of hydrogen peroxide producing lactobacilli Fishy odor, thin gray watery discharge, >4.5 pH, KOH whiff test, clue cells on wet mount (studded with bacteria) Tx: Metronidazole

LH function

Ovulation

Herpes simplex virus

Painful shallow vulvar ulcers No itching or odor Recurrences are less painful Becomes latent in sensory nerve ganglion - does not go away and reinfects again Tx: acyclovir, antivirals; sitz bath for pain when peeing

Kallman's Syndrome

Patients have hypogonadotropic hypogonadism due to lack of GnRH. Present with primary amenorrhea and anosmia

Prostatic Adenocarcinoma

Peripheral Prostate Possible to be asymptomatic Monitored via PSA, rectal exam, biopsy Precursor: PIN Genetics: TMPRSS2/ERG mutation Histo: Single layer of cells (no basal layer) and prominent nucleoli Tx: Surgery and hormone therapy, radiation, NOT CHEMO

Phimosis/Paraphimosis

Phimosis - is a condition in which the foreskin is tight and narrow, making it impossible or painful to retract Paraphimosis - in this condition is the foreskin is fully retracted behind the ridge of the glans and is unable to be pulled back over the glans

Fallopian tube STIC

Precursor for serous carcionma of ovary

Endometrial Adenocarcinoma

Precursor: endometrial hyperplasia Most invasive malignancy in the female reproductive tract *Most common but best survival of the GU cancers* Tx: total abdominal hysteroectomy and bilateral salpingo-oophorectomy (for the estrogen production)

Primary Ovarian Insufficiency

Premature ovarian failure (menses stops before 40) Can cause primary or secondary amenorrhea "Hyperthalamic hypogonadism" with elevated FSH and hypoactive gonad Genetic causes: 45X (Turners) or Fragile X Other causes: autoimmune or chemo/radiation

Functional hypothalamic suppression

Presents as irregular menstruation Decreased GnRh secretion > Decreased FSH and Estrogen Impaired ovulation and decreased endometrial suppression Bone density is below average, increasing stress fractures Causes: Diet, Exercise, Stress Tx: OCP, underlying condition

Invasive Squamous Cell Carcinoma (Cervix)

Presents: abnormal vaginal bleeding Microinvasive: no more than 3mm in depth, 7 mm horizontal Adenocarcinoma is 5-15% of cervical carcinomas (not picked up on PAP, as they are on endocervical canal) Dx: Colposocpy Risks: smoking, immunosuppression, age, lifetime partners, *not alcohol* Death caused by: Renal failure from hydronephrosis (ureters run alongside uterus)

Plan B

Progesterone blocks LH surge, inhibiting ovulation Use within 3 days Reduces risk of pregnancy by 75%

Spermatogenesis

Range from 6 to 11 weeks 1) The immature germ cells, spermatogonia, are present in the pre- pubertal testis, develop into primary spermatocytes (A and B). 2) The A spermatocytes serve as progenitor cells, while the B spermatocytes (2n, double DNA), further divide into secondary spermatocytes (1n, but double DNA), which represents the first meiotic division. 3) The secondary spermatocytes then divide and create spermatids, a division that represents the second meiotic division. 4) The spermatids (1n, 1 DNA) then undergo a process of maturation (spermiogenesis), which creates spermatozoa out of spermatids. Spermiogenesis results in mature sperm and involves the processes of acrosome formation (an important process involving the sperm head piece), creation of the sperm tail piece and cytoplasmic reduction.

Prolapses

Rectocele: Rectum bulges into vagina Cystocele: Bladder impinges upon the vagina

Endometrioid vs. Serous carcinoma

Risks: post-menopausal, obesity, long exposure to estrogen Endometrioid: PTEN in Type 1, younger, hyperplasia, superficial, estrogen driven Serous: highly aggressive, psammoma bodies, p53 in Type 2, older patients, invasion, poor prognosis

Peritoneal implants

Serous borderline tumor Proliferation but no invasion

Trichomoniasis

Sexually transmitted Itching, burning, postcoital bleeding, painful urination Strawberry cervix, thin white, malodorous brother discharge, or green discharge Wet mount: trichomonads with low sensitivity, >4.5 pH, DNA probes are most accurate Tx: Metronidazole one dose, treat partner as well, DO NOT drink alcohol with this med

Dysgerminoma

Solid tumor in teens Derived from germ cell

Steps of fertilization and implantation

Spermatozoa not fertile until reproductive track. 1) Capacitation: destabilization of acrosome membrane 2) Acrosome reaction: fusion of egg and sperm cell membranes, contents of sperm head implant into egg 3) Activation of egg: DNA synthesis and cortical recation = Zygote Implantation 1) Cleavage called morula (no growth) 2) Blastocyst forms, cell lines for embryo and placenta (trophoblast) 3) Decidual cells on uterus keep growing 4) Trophoblastic cells adhere and invade

PCOS Treatment

Spironolactone (Inhibits 5 alpha reductase) Flutamide (androgen receptor antagonist) Finasteride (Inhibits 5 alpha reductase) Eflornithine (Inhibits hair cell division)

Anatomy of penis

The tunica albuginea affords great exibility, rigidity, and tissue strength to the penis. The corpora cavernosa comprise two spongy, paired cylinders contained in the thick envelope of the tunica albuginea. The structure of the corpus spongiosum and glans is similar to that of the corpora cavernosa, except that the sinusoids are larger; the tunica is thinner in the spongiosum and is absent in the glans. The main source of blood supply to the penis is usually through the internal pudendal artery, a branch of the internal iliac artery. The cavernous artery is responsible for tumescence of the corpus cavernosum, and the dorsal artery for engorgement of the glans penis during erection. The venous drainage from the three corpora originates in tiny venules leading from the peripheral sinusoids immediately beneath the tunica albuginea. These venules travel in the trabeculae between the tunica and the peripheral sinusoids to form the subtunical venular plexus before exiting as the emissary veins.

BPHyperplasia

Transitional Zone of Prostate Decreased compliance and contractility of bladder Impaired apoptosis, increased age leads to increased androgen receptors Histo: Hyperplastic glands + stroma, and double layer of cells (epithelial and basal-keratin stain) Tx: Alpha1-antagonists relax the bladder, 5alpha reductase inhibitors bind stromal cells and decrease prostate size Risks: UTIs, bladder stones

Testicular torsion

Twisting of the spermatic cord, which cuts off the blood supply to the testicle and surrounding structures within the scrotum. Risk: bell clapper deformity or trauma Tx: surgery within 6 hours

Primary Dysmenorrhea

Within 1-2 years of menarche When ovulation begins Theory - upregulated COX enzyme and PG synthase activity, increased endometrial PG production (leading to uterine contractions and GI smooth muscle changes > diarrhea) Symptoms: pain at onset of menses or before, suprapubic cramping, backache Tx: heat and NSAIDS (inhibit PG), OCPS or vaginal ring

Schiller-Duval

Yolk Sac tumor Associated with AFP

Clear cell adenocarcinoma of vagina

Young adults Red, friable 2.5cm nodular mass was identified on the upper vagina DES exposure in utero "DES daughters" Adenosis increases risk of CCAC

Sertoli/Leydig cell tumors

Young woman, solid tumor Derived from sex-cord stromal Amenorrhea and hirsutism (androgens produced)

Urge incontinence

the loss of urine in response to a sudden, urgent need to void; the person cannot get to a toilet in time