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236 Cards in this Set
- Front
- Back
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Gonadal drainage - Venous drainage
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Left ovary/testis --> left gonadal vein --> left renal vein --> IVC (Just as the left adrenal vein drains to the left renal vein before the IVC)
Right ovary/testis --> right gonadal vein --> IVC Because the left spermatic vein enters the left renal vein at a 90 degree angle, flow is less continuous on the left than on the right --> left venous pressure > right venous pressure --> varicocele more common on the left |
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Gonadal drainage - Lymphatic drainage
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Ovariest/testis --> para-aortic lymph nodes
Distal 1/3 of vagina/vulva/scrotum --> superficial inguinal nodes Proximal 2/3 of vagina/uterus --> obturator, external iliac, and hypogastric nodes |
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Female reproductive anatomy - Suspensory ligament of the ovaries - Connects? Structures contained? Notes?
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Connects: ovaries to lateral pelvic wall
Contains: Ovarian vessels Notes: Ureter at risk of injury during ligation of ovarian vessels in ovariectomy. |
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Female reproductive anatomy - Cardinal ligament - Connects? Contains? Notes?
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Connects - Cervix to side wall of pelvis
Contains - Uterine vessels Notes - Ureter is at risk of injury during ligation of uterine vessels in hysterectomy. |
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Female reproductive anatomy - Round ligament of the uterus - Connects? Contains? Notes?
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Connects - Uterine fundus to labia majora
Contains - 0 structures Notes - Round ligament like the number 0. Derivative of gubernaculum. Travels through round inguinal canal. |
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Female reproductive anatomy - Broad ligament - Connects? Contains? Notes?
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Connects - Uterus, fallopian tubes, and ovaries to pelvic side wall
Contains - Ovaries, fallopian tubes, and round ligament of the uterus Notes - Mesosalpinx, mesometrium, and mesovarium are the components of the broad ligament |
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Female reproductive anatomy - Ligament of the ovary - Connects? Contains?
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Connects - Ovary to lateral uterus
Contains - nothing |
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Female reproductive histology - Ovary
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Simple cuboidal epithelium
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Female reproductive histology - Fallopian tube
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Simple columnar epithelium, ciliated
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Female reproductive histology - Uterus
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Simple columnar epithelium, pseudostratified, tubular glands
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Female reproductive histology - Endocervix
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Simple columnar epithelium
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Female reproductive histology - Ectocervix
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Stratified squamous epithelium
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Female reproductive histology - Vagina
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Stratified squamous epithelium, nonkeratinized
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How to remember the pathway of sperm during ejaculation?
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SEVEN UP
Seminiferous tubules Epididymis Vas deferens Ejaculatory ducts (Nothing) Urethra Penis |
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Describe anatomy of testicle and male reproductive system.
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Testicle - tunica albuginea surrounds the seminiferous tubules which are divided by septa, the rete testes is in the middle of all the tubules and leads to the epididymis which has a head and a tail
The tail of the epididymis leads into the vas deferens (2 of them) - they travel through the inguinal canal and loop over the top of the bladder, traveling medial to the insertions of the two ureters, and empty into the seminal vesicle. Semen then empties into the ejaculatory duct within the prostate, and after being bathed in material from the Cowper's gland, enters and subsequently exits the urethra through the tip of the penis. |
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Autonomics of the male sexual response - Erection
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Parasympathetic nervous system (pelvic nerve):
1. NO --> inc. cGMP --> smooth muscle relaxation --> vasodilation --> proerectile 2. NE --> inc. [Ca2+]in --> smooth muscle contraction --> vasoconstriction --> antierectile Sildenafil and vardenafil inhibit cGMP breakdown. |
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Autonomics of the male sexual response - Emission
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Sympathetic nervous system (hypogastric nerve)
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Autonomics of the male sexual response - Ejaculation
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Visceral and somatic nerves (pudendal nerve)
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Seminiferous tubules - Spermatogonia (germ cells)- Function? Location/notes?
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Function - maintain germ pool and produce primary spermatocytes
Location: Line seminiferous tubules |
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Seminiferous tubules - Sertoli cells (non-germ cells) - Function? Location/notes?
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Function:
1. Secrete inhibin --> inhibit FSH 2. Secrete androgen-binding protein (ABP) --> maintain levels of testosterone in the seminiferous tubules 3. Tight junctions between adjacent Sertoli cells form blood-testis barrier --> isolate gametes from autoimmune attack 4. Support and nourish developing spermatozoa 5. Regulate spermatogenesis 6. Produce anti-mullerian hormone Temperature sensitive: decreased sperm production and decreased inhibin with increased temperature (increased temperature seen in varicocele and cryptorchidism) |
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Seminiferous tubules - Leydig cells (endocrine cells) - Functin? location?
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Function - Secrete testosterone. Testosterone production unaffected by temperature.
Location - interstitium |
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Describe the histological anatomy of the seminiferous tubule.
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Spermatogenesis
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Spermatogenesis begins at puberty with spermatogonia. Full development takes 2 months. Occurs in seminiferous tubules. Produces spermatids that undergo spermiogenesis (loss of cytoplasmic contents, gain of acrosomal cap) to form mature spermatozoon.
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_N for spermatogonium? Primary spermatocyte? Secondary spermatocyte? Spermatid? Spermatozoon?
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Spermatogonium - diploid (2N)
Primary spermatocyte - diploid (4N) Secondary Spermatocyte - Haploid (2N) Spermatid - Haploid (N) Spermatozoon - Haploid (N) |
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What does the spermatogonium cross before becoming the primary spermatocyte?
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Blood-testis barrier which is produced by Sertoli cell tight junctions.
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How does ciliary dyskinesia/Kartagener's syndrome lead to male infertility?
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Impaired sperm tail mobility
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Describe the Hypothalamic-Pituitary-Gonadal axis in men.
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Hypothalamus secretes GnRH --> LH and FSH secretion from anterior pituitary.
LH --> testosterone synthesis from Leydig cells --> Testosterone goes into bloodstream and diffuses into seminiferous tubules --> induces spermatogenesis and negatively feeds back onto the pituitary (dec. LH secretion) and hypothalamus (decreased GnRH secretion) FSH --> sertoli cell secretion of ABP and inhibin --> ABP concentrates testosterone in the seminiferous tubule while inhibin acts on anterior pituitary to inhibit the secretion of FSH Note: Inhibin does not act on the hypothalamus! |
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Androgens - Testosterone - Source? Functions?
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Source - Testis)
Functions - 1. Differentiation of epididymis, vas deferens, seminal vesicles (internal genitalia, except prostate) 2. Growth spurt - Penis - Seminal vesicles - Sperm - Muscle - RBCs 3. Deepening of voice 4. Closing of epiphyseal plates (via estrogen converted from testosterone) 5. Libido Testosterone and androstenedione are converted to estrogen in adipose tissue and Sertoli cells by enzyme aromatase. Exogenous testosterone --> inhibition of HPG axis --> decreased intratesticular testosterone --> decreased testicular size --> azoospermia |
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Androgens - Androstenedione - source?
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Adrenal gland
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Androgens - DHT - source? Function?
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Source: Testis
Function: Early - differentiation of penis, scrotum, prostate Late - prostate growth, balding, sebaceous gland activity Testosterone is converted to DHT by the enzyme 5alpha-reductase, which is inhibited by finasteride. |
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Androgens - potency?
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DHT > Testosterone > Androstenedione
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Estrogen - Source? Functions?
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Source: Ovary (17beta-estradiol), placenta (estriol), blood (aromatization)
Function: 1. Development of genitalia and breasts, female fat distribution 2. Growth of follicle, endometrial proliferation, increased myometrial excitability 3. Upregulation of estrogen, LH, and progesterone receptors; feedback inhibition of FSH and LH, then LH surge; stimulation of prolactin secretion (but blocks its action at the breast) 4. Increased transport of proteins, sex-hormone binding globulin; increased HDL; decreased LDL |
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Estrogen - changes during pregnancy?
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50-fold increase in estradiol and estrone
1000-fold increase in estriol (indicator of fetal well-being) Estrogen receptors expressed in the cytoplasm; translocate to the nucleus when bound by ligand. |
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Explain the HPO axis and its effects on Estrogen production.
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Pulsatile GnRH leads to secretion of LH and FSH.
LH -> activates desmolase in theca cells of the ovary which convert cholesterol to androstenedione. Androstenedione diffuses to granulosa cells. FSH activates aromatase in granulosa cells which catalyze the conversion of androstenedione to estrogen which then diffuses out into the bloodstream. |
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Progesterone - Source? Function?
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Source - corpus luteum, placenta, adrenal cortex, testes
Function - 1. Stimulation of endometrial glandular secretions and spiral artery development. 2. Maintenance of pregnancy. 3. Decreased myometrial excitability 4. Production of thick cervical mucus, which inhibits sperm entry into the uterus. 5. Increased body temperature 6. Inhibition of gonadotropins (LH, FSH) 7. Uterine smooth muscle relaxation (preventing contractions) 8. Decreased estrogen receptor expressivity Elevation of progesterone is indicative of ovulation. |
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Tanner stages of sexual development
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I. Childhood
II. Pubic hair appears (adrenarche); breasts enlarge III. Pubic hair darkens and becomes curly; penis size/length increase IV. Penis width increases, darker scrotal skin, development of glans, raised areolae V. Adult; areolae are no longer raised |
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Menstrual Cycle - details?
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Follicular growth is fastest during 2nd week of proliferative phase.
Estrogen stimulates endometrial proliferation. Progesterone maintains endometrium to support implantation. Decreased progesteron --> decreased fertility. Follicular phase can vary in length. Luteal phase is usually a constant 14 days. Ovulation day + 14 days = menstruation. Oligomenorrhea: > 35-day cycle Polymenorrhea: <21-day cycle Metrorrhagia: frequent but irregular menstruation Menometrorrhagia: heavy, irregular menstruation at irregular intervals |
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Hormone changes leading to menstruation
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Estrogen increases --> LH surge --> Ovulation --> Progesterone (secreted from corpus luteum) --> Menstruation (via apoptosis of endometrial cells)
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Ovulation - details?
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Increased estrogen --> increased GnRH receptors on anterior pituitary. Estrogen surge then stimulates LH release, causing ovulation (rupture of follicle).
Increased temperature (progesterone induced). |
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Mettelschmerz
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Blood from ruptured follicle causes peritoneal irritation that can mimic appendicitis.
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Oogenesis - steps?
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Primary oocyte begins meiosis I during fetal life and completes meiosis I just prior to ovulation.
Meiosis I is arrested in prophase for years until ovulation (primary oocyte). Meiosis II is arrested in METaphase until fertilization (secondary oocyte). (An egg MET a sperm.) If fertilization does not occur, the secondary oocyte degenerates. |
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_N for oogonium? primary oocyte? secondary oocyte? ovum?
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Oogonium - Diploid (2N)
Primary Oocyte - Diploid (4N) Secondary Oocyte - Haploid (2N) Ovum - Haploid (N) |
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Pregnancy - details?
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Fertilization most commonly occurs in upper end of fallopian tube (the ampulla). Occurs within 1 day after ovulation.
Implantation within the wall of the uterus occurs 6 days after fertilization. Trophoblasts secrete hCG, which is detectable in blood 1 week after conception and on home test in urine 2 weeks after conception. |
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Describe curves of various hormones during pregnancy.
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hCG - peaks by week 10 and then drops to near 0 by week 40
Prolactin and progesterone - both continuously increase throughout pregnancy Estriol - increases throughout pregnancy but not as much as prolactin/progesterone |
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Lactation
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After labor, the decrease in progesterone induces lactation. Suckling is required to maintain milk production, since increased nerve stimulation increases oxytocin and prolactin.
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Prolactin
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induces and maintains lactation and decreases reproductive function
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Oxytocin
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Appears to help with milk letdown and may be involved with uterine contractions (function not yet entirely known).
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hCG - source? Function?
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Source - syncytiotrophoblast of placenta
Function - 1. Maintains the corpus (and thus progesterone) for the 1st trimester by acting like LH (otherwise no luteal cell stimulation, and abortion results). In the 2nd and 3rd trimester, the placenta synthesizes its own estriol and progesterone and the corpus luteum degenerates. 2. Used to detect pregnancy because it appears early in the urine (see above). 3. Elevated hCG in pathologic states (e.g., hydatidiform moles, choriocarcinoma, gestational trophoblastic tumors). |
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Menopause - details
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Decreased estrogen production due to age-linked decline in number of ovarian follicles. Average age of onset is 51 years (earlier in smokers).
Usually preceded by 4-5 years of abnormal menstrual cycles. Source of estrogen (estrone) after menopause becomes peripheral conversion of androgens. Increased androgens causes hirsutism. Very increased FSH is the best test to confirm menopause (loss of negative feedback for FSH due to decreased estrogen). Early menopause can indicate premature ovarian failure. |
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Hormonal changes during menopause?
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Decreased estrogen, very increased FSH, increased LH (no surge), Increased GnRH
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How to remember sequelae of menopause?
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Menopause causes HHAVOC:
Hirsutism Hot flashes Atrophy of the vagina Osteoporosis Coronary artery disease |
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Sex chromosome disorders - Klinefelter's syndrome
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Male, XXY, 1:850
Testicular atrophy, eunuchoid body shape, tall, long extremities, gynecomastia, female hair distribution. May present with developmental delay. Presence of inactivated X chromosome (Barr body). Common cause of hypogonadism seen in infertility workup. Dysgenesis of seminiferous tubules -> decreased inhibin --> increased FSH. Abnormal Leydig cell function --> decreased testosterone --> increased LH --> increased estrogen. |
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Sex chromosome disorders - Turner syndrome
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Female, XO
Short stature (if left untreated, < 5 feet), ovarian dysgenesis (streak ovary with infertility), shield chest, bicuspid aortic valve, defects in lymphatics --> webbing of neck (cystic hygroma) and lymphedema in feet and hands, preductal coarctation of the aorta, horseshoe kidney, dysgerminoma most common cause of primary amenorrhea. No Barr body. Menopause before menarche. Decreased estrogen leads to increased LH and FSH. |
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Sex chromosome disorders - Double Y males
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Male, XYY, 1:1000
Phenotypically normal, very tall, severe acne, antisocial behavior (seen in 1-2% of XYY males). Normal infertility. Small percentage diagnosed with autism spectrum disorders. |
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Diagnosing disorders of sex hormones - Increased Testosterone, Increased LH
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Defective androgen receptor.
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Diagnosing disorders of sex hormones - Increased testosterone, decreased LH.
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Testosterone-secreting tumor, exogenous steroids.
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Diagnosing disorders of sex hormones - Decreased Testosterone, increased LH.
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Primary hypogonadism.
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Diagnosing disorders of sex hormones - Decreased testosterone, decreased LH
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Hypogonadotropic hypogonadism.
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Pseudo-hermaphroditism - details?
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Disagreement between the phenotypic (external genitalia) and gonadal (testes vs. ovaries) sex.
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Pseudo-hermaphroditism - Female pseudohermaphrodite (XX)
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Ovaries present, but external genitalia are virilized or ambiguous. Due to excessive and inappropriate exposure to androgenic steroids during early gestation (e.g., congenital adrenal hyperplasia or exogenous administration of androgens during pregnancy.)
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Pseudo-hermaphroditism - Male pseudohermaphrodite (XY)
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Testes present, but external genitalia are female or ambiguous. Most common form is androgen insensitivity syndrome (testicular feminization).
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True hermaphroditism
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(46,XX) or (47,XXY)
Both ovary and testicular tissue present (ovotestis); ambiguous genitalia. Very rare. |
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Androgen insensitivity syndrome
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(46, XY)
Defect in androgen receptor resulting in normal-appearing female; female external genitalia with rudimentary vagina ("blind pouch"); uterus and uterine tubes generally absent; present with no sexual hair; develops testes (often found in labia majora; surgical removal to prevent malignancy). Increased testosterone, estrogen, LH (vs. sex chromosome disorders). |
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5alpha-reductase deficiency
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Autosomal recessive; sex limited to genetic males. Inability to convert testosterone to DHT. Ambiguous genitalia until puberty, when increased testosterone causes masculinization/increased growth of external genitalia. Testosterone/estrogen levels are normal; LH is normal or increased. "Penis at 12." Internal genitalia are normal.
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Kallmann syndrome
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Defective development of GnRH cells and olfactory placode; decreased synthesis of GnRh in the hypothalamus; anosmia; lack of secondary sexual characteristics; autosomal dominant; decreased GnRH, FSH, LH, testosterone, and sperm count
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Hydatidiform mole - basics
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Cystic swelling of chorionic villi and proliferation of chorionic epithelium (trophoblast) that presents with abnormal vaginal bleeding. Most common precursor of choriocarcinoma. Increased Beta-hCG. "Honeycombed uterus," "cluster of grapes" appearance, abnormally enlarged uterus. Complete moles classically have "snowstorm" appearance with no fetus during 1st sonogram. Moles can lead to uterine rupture. Treatment: dilation and curettage and methotrexate. Monitor beta-hCG.
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Hydatidiform mole - Complete mole vs. Partial mole
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Complete mole:
46,XX or 46,XY hCG is hugely increased Uterine size is increased. Converts to choriocarcinoma in 2% of cases. No fetal parts. Components include 2 sperm and empty egg. Risk of complications: 15-20% malignant trophoblastic disease Partial Mole: 69,XXX; 69,XXY; or 69,XYY Increased hCG but not that much. No change in uterine size. Rarely converts to choriocarcinoma. Components include 2 sperm + 1 egg. Risk of complications: low risk of malignancy (<5%) |
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Pregnancy-induced hypertension (preeclampsia-eclampsia)
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Preeclampsia- hypertension, proteinuria, and edema. Eclampsia - preeclampsia + seizures
Occurs in 7% of pregnant women from 20 weeks' gestation to 6 weeks postpartum (before 20 weeks suggests molar pregnancy). Increased incidence in patients with preexisting hypertension, diabetes, chronic renal disease, and autoimmune disorders. Caused by placental ischemia due to impaired vasodilation of spiral arteries, resulting in increased vascular tone. Can be associated with HELLP syndrome (Hemolysis, Elevated LFTs, Low Platelets). mortality due to cerebral hemorrhage and ARDS. |
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Preeclampsia - clinical features
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Headache, blurred vision, abdominal pain, edema of face and extremities, altered mentation, hyperreflexia; lab findings may include thrombocytopenia, hyperuricemia.
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Preeclampsia - Treatment
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Delivery of fetus as soon as viable. Otherwise bed rest, salt restriction, and monitoring and treatment of hypertension. Treatment: IV magnesium sulfate and diazepam to prevent and treat seizures of eclampsia
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Pregnancy complications - Abruptio placentae
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Premature detachment of placenta from implantation site. Fetal death. May be associated with DIC. Increased risk with smoking, hypertension, cocaine use.
Painful bleeding in 3rd trimester. Abrupt detachment/death. |
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Pregnancy complications - Placenta accreta
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Defective decidual layer allows placenta to attach to myometrium. No separation of placenta after birth. Increased risk with prior C-section, inflammation, and placenta previa.
Massive bleeding after delivery. Accreta = "encased in" = encased in myometrium |
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Pregnancy complications - Placenta previa
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Attachment of placenta to lower uterine segment. May occlude internal os. Increased risk with multiparity and prior C-section.
Painless bleeding in any trimester. |
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Pregnancy complications - Ectopic pregnancy
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Most often in fallopian tubes. Suspect with history of amenorrhea, increased hCG, and sudden lower abdominal pain; confirm with ultrasound. Often clinically mistaken for appendicitis. Endometrial biopsy shows decidualized endometrium but no chorionic villi (develop only in intra-uterine pregnancy).
Pain with or without bleeding. Risk factors: History of infertility Salpingitis (PID) Ruptured appendix Prior tubal surgery |
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Pregnancy complications - Retained placental tissue
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May cause postpartum hemorrhage.
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Amniotic fluid abnormalities - Polyhydramnios
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>1.5-2L of amniotic fluid; associated with esophageal/duodenal atresia, causing inability to swallow amniotic fluid, and with anencephaly.
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Pregnancy complications - Oligohydramnios
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< 0.5 L of amniotic fluid; associated with placental insufficiency, bilateral renal agenesis, or posterior urethral valves (in males) and resultant inability to excrete urine. Can give rise to Potter's syndrome.
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Cervical pathology - Dysplasia and carcinoma in situ
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Disordered epitelial growth; begins at basal layer of squamo-columnar junction and extends outward. Classified as CIN 1, CIN 2, or CIN 3 (carcinoma in situ), depending on extent of dysplasia. Associated with HPV 16 (E6 gene product inhibits p53 suppressor gene), and HPV 18 (E7 gene product inhibits RB suppressor gene). Vaccine available. May progress slowly to invasive carcinoma if left untreated.
Risk factors: multiple sexual partners (#1), smoking, early sexual intercourse, HIV infection |
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How does HPV 16 affect genes leading to CIN? HPV 18?
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HPV 16 has E6 gene product that inhibits p53 suppressor gene
HPV 18 has E7 gene product that inhibits RB suppressor gene |
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Cervical pathology - Invasive carcinoma
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Often squamous cell carcinoma. Pap smear can catch cervical dysplasia (koilocytes) before it progresses to invasive carcinoma. Lateral invasion can block ureters, causing renal failure.
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What histology pattern is seen in cervical condyloma (CIN)?
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Koilocytes - note the wrinkled, "raisinoid" nuclei, some of which have clearing or a perinuclear halo.
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Endometritis
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Inflammation of the endometrium associated with retained products of conception following delivery (vaginal/C-section)/miscarriage/abortion or foreign body such as an IUD. Retained material in uterus promotes infection by bacterial flora from vagina or intestinal tract. Presents as abdominal pain, fever, uterine tenderness, menstrual abnormalities, infertility.
Often polymicrobial. Treatment: Cefoxitin, ticarcillin-clavulanate, ampicillin-sulbactam |
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Endometriosis
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Non-neoplastic endometrial glands/stroma in abnormal locations outside the uterus.
Characterized by cyclic bleeding (menstrual type) from ectopic endometrial tissue resulting in blood-filled "chocolate cysts." In ovary or on peritoneum. Manifests clinically as severe menstrual-related pain. Often results in painful intercourse and infertility. Can be due to retrograde menstrual flow. Presents with menorrhagia, dysmenorrhea, dyspareunia, infertility; uterus is normal-sized. Treatment: danazole |
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Adenomyosis
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Endometrium within the myometrium.
Presents with menorrhagia, dysmenorrhea, pelvic pain; uterus is enlarge. Treatment: hysterectomy |
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Clinically, how does the presentation of adenomyosis differ from regular endometriosis?
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Adenomyosis presents with an enlarged uterus while endometriosis does not.
The other characteristics of the presentation are fairly similar. |
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What is the #1 risk factor for developing CIN?
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Multiple sexual partners
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Endometrial proliferation - Endometrial hyperplasia
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Abnormal endometrial gland proliferation usually caused by excess estrogen stimulation. Increased risk for endometrial carcinoma.
Clinically manifests as postmenopausal vaginal bleeding. Risk factors include anovulatory cycles, hormone replacement therapy, polycystic ovarian syndrome, and granulosa cell tumor. |
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Endometrial proliferation - Endometrial carcinoma
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Most common gynecologic malignancy. Peak occurrence at 55-65 years of age. Clinically presents with vaginal bleeding. Typically preceded by endometrial hyperplasia. Risk factors include prolonged use of estrogen without progestins, obesity, diabetes, hypertension, nulliparity, and late menopause. Increased myometrial invasion --> poor prognosis.
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Myometrial tumors - Leiomyoma (fibroid)
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Most common of all tumors in females. Often presents with multiple tumors with well-demarcated borders. Increased incidence in blacks. Benign smooth muscle tumor; malignant transformation is rare. Estrogen sensitive - tumor size increased with pregnancy and decreased with menopause. Peak occurrence at 20-40 years of age. May be asymptomatic, cause abnormal uterine bleeding, or result in miscarriage. Severe bleeding may lead to iron deficiency anemia. Does not progress to leiomyosarcoma. Whorled pattern of smooth muscle bundles.
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Myometrial tumors - leiomyosarcoma
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Bulky, irregular shaped tumor with areas of necrosis and hemorrhage, typically arising de novo (not from leiomyoma). Increased incidence in blacks. Highly aggressive tumor with tendency to recur. May protrude from cervix and bleed. Most commonly seen in middle-aged women.
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Gynecologic tumor epidemiology
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Incidence - endometrial > ovarian > cervical (data pertain to the US; cervical cancer is most common worldwide)
Worst prognosis - ovarian > cervical > endometrial |
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Most common causes of anovulation
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Polycystic ovarian syndrome, obesity, Asherman's syndrome (adhesions), HPO axis abnormalities, premature ovarian failure, hyperprolactinemia, thyroid disorders, eating disorders, Cushing's syndrome, adrenal insufficiency
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Polycystic ovarian syndrome
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Increased LH production leads to anovulation, hyperandrogenism due to deranged steroid synthesis by theca cells. Enlarged, bilateral cystic ovaries manifest clinically with amenorrhea, infertility, obesity, and hirsutism.
Associated with insulin resistance. Increased risk of endometrial cancer, secondary to increase in estrogen from aromatization of testosterone in fat cells. Treatment: weight reduction, low-dose OCPs or medroxyprogesterone (decreased LH and androgenesis), spironolactone (treats acne and hirsutism), clomiphene (for women who want to get pregnant). |
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Ovarian cysts - Follicular cyst
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Distention of unruptured graafian follicle. May be associated with hyperestrinism and endometrial hyperplasia. Most common ovarian mass in young women.
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Ovarian cysts - Corpus luteum cyst
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Hemorrhage into persistent corpus luteum. Commonly regresses spontaneously.
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Ovarian cysts - Theca-lutein cyst
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Often bilateral/multiple. Due to gonadotropin stimulation. Associated with choriocarcinoma and moles.
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Ovarian cysts - Hemorrhagic cyst
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Blood vessel rupture in cyst wall. Cyst grows with increased blood retention; usually self-resolves.
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Ovarian cysts - Dermoid cyst
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Mature teratoma. Cystic growths filled with various types of tissue such as fat, hair, teeth, bits of bone and cartilage.
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Ovarian cysts - Endometrioid cyst
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Endometriosis within ovary with cyst formation. Varies with menstrual cycle. When filled with dark, reddish-brown blood it is called a "chocolate cyst."
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Ovarian germ cell tumors - Dysgerminoma
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Malignant, equivalent to male seminoma but rarer (1% of germ cell tumors in females vs. 30% in males). Sheets of uniform cells. Associated with Turner syndrome.
Tumor markers: hCG, LDH |
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Ovarian germ cell tumors - Choriocarcinoma
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Rare but malignant; can develop during pregnancy in mother or baby. Malignancy of trophoblastic tissue; chorionic villi are not present. Increased frequency of theca-lutein cysts. Along with moles, comprise spectrum of gestational trophoblastic neoplasia. Early hematogenous spread to lungs.
Tumor markers: hCG |
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Ovarian germ cell tumors - Yolk sac (endodermal sinus) tumor
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Aggressive malignancy in ovaries (testes in boys) and sacrococcygeal area of young children.
Yellow, friable, solid mass. 50% have Schiller-Duval bodies (resemble glomeruli). Tumor markers: AFP |
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What are Schiller-Duval bodies?
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Characteristic finding on histology of yolk-sac tumors.
Resemble glomeruli. Found in 50% of cases. |
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Ovarian germ cell tumors - Teratoma
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90% of ovarian germ cell tumors. Contain cells from 2 or 3 germ layers.
Mature teratoma ("dermoid cyst") - most frequent benign ovarian tumor. Immature teratoma - aggressively malignant. Struma ovarii - contains functional thyroid tissue. Can present as hyperthyroidism. |
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Ovarian non-germ cell tumors - details?
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Increased CA-125 is general ovarian cancer marker. Good for monitoring progression, not for screening.
Risk factors - BRCA-1, BRCA-2, HNPCC. Significant genetic predisposition makes family history the most important risk factor. |
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Ovarian non-germ cell tumors - Serous cystadenoma
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20% of ovarian tumors. Frequently bilateral, lined with fallopian tube-like epithelium. Benign.
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Ovarian non-germ cell tumors - Serous cystadenocarcinoma
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45% of ovarian tumors, malignant and frequently bilateral. Psammomma bodies seen on histology.
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Ovarian non-germ cell tumors - Mucinous cystadenoma
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Multilocular cyst lined by mucus-secreting epithelium. Benign. Intestine-like tissue.
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Ovarian non-germ cell tumors - Mucinous cystadenocarcinoma
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Malignant. Pseudomyxoma peritonei - intraperitoneal accumulation of mucinous material from ovarian or appendiceal tumor.
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Ovarian non-germ cell tumors - Brenner tumor
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Benign and unilateral. Looks like Bladder. Solid tumor that is pale yellow-tan in color and appears encapsulated. "Coffe bean" nuclei on H&E.
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Ovarian non-germ cell tumors - Fibromas
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Bundles of spindle-shaped fibroblasts. Meigs' syndrome - triad of ovarian fibroma, ascites, and hydrothorax. Pulling sensation in groin.
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What is Meigs' syndrome?
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Triad of ovarian fibroma, ascites, and hydrothorax associated with ovarian fibroma.
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Ovarian non-germ cell tumors - Granulosa cell tumor
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Secretes estrogen --> precocious puberty (kids).
Can cause endometrial hyperplasia or carcinoma in adults. Call-Exner bodies - small follicles filled with eosinophilic secretions (see picture). Abnormal uterine bleeding. |
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Call-Exner bodies are seen in what disease?
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Granulosa cell tumor of the ovary (see picture)
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Ovarian non-germ cell tumors - Krukenberg tumor
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GI malignancy that metastasizes to ovaries, causing a mucin-secreting signet cell adenocarcinoma.
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Vaginal carcinoma - 3 types
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1. Squamous cell carcinoma (SCC) - secondary to cervical SCC
2. Clear cell adenocarcinoma - affects women who had exposure to DES in utero 3. Sarcoma botryoides (rhabdomyosarcoma variant) - affects girls < 4 years of age; spindle-shaped tumor cells that are desmin positive |
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What cancer do female patients get after exposure to DES in utero?
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Clear cell adenocarcinoma of the vagina
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Breast pathology - describe anatomy associated with various diseases
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Nipple - Paget's disease, breast abscess
Lactiferous sinus - Intraductal papilloma, breast abscess, mastitis Major duct - Fibrocystic change, ductal cancer Terminal duct - Tubular carcinoma Lobules - Lobular carcinoma, sclerosing adenosis Stroma - Fibroadenoma, phyllodes tumor |
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Benign Breast Tumors - Fibroadenoma
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Small, mobile, firm mass with sharp edges
Most common tumor in those < 35 years of age. Increased size and tenderness with increased estrogen (e.g., pregnancy, menstruation). Not a precursor to breast cancer. |
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Benign breast tumors - Intraductal papilloma
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Small tumor that grows in lactiferous ducts.
Typically beneath areola. Serous or bloody nipple discharge. Slight (1.5-2x) increase in risk for carcinoma. |
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Benign breast tumors - phyllodes tumor
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Large, bulky mass of connective tissue and cysts. "Leaf-like" projections.
Most common in 6th decade. Some may become malignant. |
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Malignant breast tumors - details?
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Common postmenopause. Arise from mammary duct epithelium or lobular glands. Overexpression of estrogen/progesterone receptors or erb-B2 (HER-2, an EGF receptor) is common; affects therapy and prognosis. Axillary lymph node involvement is the single most important prognostic factor. Most often located in upper-outer quadrant of breast.
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Malignant breast tumors - risk factors?
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Increased estrogen exposure, increased total number of menstrual cycles, older age at 1st live birth, obesity (adipose tissue serves as major source of estrogen in postmenopausal women by converting androstenedione to estrone; therefore, obesity is associated with increased estrogen exposure.)
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Malignant breast tumors - Ductal carcinoma in situ (DCIS)
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Fills ductal lumen. Arises from ductal hyperplasia.
Early malignancy without basement membrane. |
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Malignant breast tumors - Comedocarcinoma
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Ductal, caseous necrosis. Subtype of DCIS.
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Malignant breast tumors - Invasive ductal carcinoma
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Firm, fibrous, "rock-hard" mass with sharp margins and small, glandular, duct-like cells. Classic "stellate" morphology.
Worst and most invasive. Most common (76% of all breast cancers). |
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Malignant breast tumors - Invasive lobular carcinoma
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Orderly row of cells.
Often multiple. Bilateral. |
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Malignant breast tumors - Medullary
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Fleshy, cellular, lymphocytic infiltrate.
Good prognosis. |
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Malignant breast tumors - Inflammatory
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Dermal lymphatic invasion by breast carcinoma. Peau d'orange (breast skin resembles orange peel); neoplastic cells block lymphatic drainage.
50% survival at 5 years. |
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Malignant breast tumors - Paget's disease
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Eczematous patches on nipple. Paget cells = large cells in epidermis with clear halo.
Suggests underlying carcinoma. Also seen on vulva. |
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Common breast conditions - Fibrocystic disease
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Most common cause of "breast lumps" from age 25 to menopause. Presents with premenstrual breast pain and multiple lesions, often bilateral. Fluctuation in size of mass. Usually does not indicate increased risk of carcinoma.
Histology types: 1. Fibrosis - hyperplasia of breast stroma 2. Cystic - fluid filled, blue dome. Ductal dilation 3. Sclerosing adenosis - increased acini and intralobular fibrosis. Associated with calcifications. 4. Epithelial hyperplasia - increase in number of epithelial cell layers in terminal duct lobule. Increased risk of carcinoma with atypical cells. Occurs in women > 30 years of age. |
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Common breast conditions - Acute mastitis
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Breast abscess; during breast-feeding, increased risk of bacterial infection through cracks in the nipple; Staph. aureus is the most common pathogen.
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Common breast conditions - Fat necrosis
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A benign painless lump; forms as a result of injury to breast tissue. Up to 50% of patients may not report trauma.
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Common breast conditions - Gynecomastia
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Results from hyperestrogenism (cirrhosis, testicular tumor, puberty, old age), Klinefelter's syndrome, or drugs (estrogen, marijuana, heroin, psychoactive drugs, Spironolactone, Digitalis, Cimetidine, Alcohol, Ketoconazole).
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How to remember some of the less obvious drugs that cause gynecomastia?
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Some Drugs Create Awesome Knockers
Spironolactone Digitalis Cimetidine Alcohol Ketoconazole |
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Prostate pathology - Prostatitis
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Dysuria, frequency, urgency, low back pain.
Acute: bacterial (e.g., E. coli) Chronic: Bacterial or abacterial (most common) |
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Prostate pathology - Benign prostatic hyperplasia
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Common in men > 50 years of age. Hyperplasia (not hypertrophy) of the prostate gland. May be due to an age-related increase in estradiol with possible sensitization of the prostate to the growth-promoting effects of DHT. Characterized by a nodular enlargement of the periurethral (lateral and middle) lobes, which compress the urethra into a vertical slit. Often presents with increased frequency of urination, nocturia, difficulty starting and stopping the stream of urine, and dysuria. May lead to distention and hypertrophy of the bladder, hydronephrosis, and UTIs. Not considered a premalignant lesion. Increased prostate-specific antigen (PSA).
Treatment: alpha1-antagonists (terazosin, tamsulosin), which cause relaxation of smooth muscle; finasteride. |
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Which lobes of the prostate are associated with BPH? Adenocarcinoma?
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BPH - anterior and middle
Adenocarcinoma - posterior |
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Prostate pathology - Prostatic adenocarcinoma
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Common in men > 50 years of age. Arises most often from the posterior lobe (peripheral zone) of the prostate gland and is most frequently diagnosed by digital rectal examination (hard nodule) and prostate biopsy. Prostatic acid phosphatase (PAP) and PSA are useful tumor markers (increased total PSA, with decreased fraction of free PSA). Osteoblastic metastases in bone may develop in late stages, as indicated by lower back pain and an increase in serum alkaline phosphatase and PSA.
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Cryptorchidism
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Undescended testis (one or both); impaired spermatogenesis (since sperm develop best at temperatures < 37 degrees celsius); normal testosterone levels (Leydig cells are unaffected by temperature); associated with increased risk of germ cell tumors. Prematurity increases the risk of cryptorchidism. Decreased inhibin, increased FSH, normal LH and testosterone.
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Why do you have normal testosterone levels in cryptorchidism?
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Leydig cells are unaffected by increased temperature.
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Varicocele
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Dilated veins in pampiniform plexus due to increased venous pressure; most common cause of scrotal enlargement in adult males; most often on the left side because of increased resistance to flow from left spermatic vein drainage (occurs at right angle) into the left renal vein; can cause infertility due to increased temperature; "bag of worms" appearance; diagnosed by ultrasound.
Treatment: varicocelectomy, embolization by interventional radiologist |
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Testicular germ cell tumors - details?
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~95% of all testicular tumors. Most often malignant. Can present as a mixed germ cell tumor. Differential diagnosis for testicular mass that does not transilluminate: cancer.
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Testicular germ cell tumors - Seminoma
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Malignant; painless, homogenous testicular enlargement; most common testicular tumor, mostly affecting males age 15-35. Large cells in lobules with watery cytoplasm and a "fried egg" appearance. Radiosensitive. Late metastasis, excellent prognosis.
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Testicular germ cell tumors - Embryonal carcinoma
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malignant; painful; worse prognosis than seminoma. Often glandular/papillary morphology. "Pure" embryonal carcinoma is rare; most commonly mixed with other tumor types. May be associated with elevated hCG and normal AFP levels when pure (increased AFP when mixed).
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Testicular germ cell tumors - Yolk sac (endodermal sinus) tumor
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Yellow, mucinous. Analogous to ovarian yolk sac tumor. Schiller-Duval bodies resemble primitive glomeruli (Increased AFP).
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Testicular germ cell tumors - Choriocarcinoma
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Choriocarcinoma of the testicle is exceedingly rare.
Malignant, increased hCG. Disordered syncytiotrophoblastic and cytotrophoblastic elements. Hematogenous metastases to lungs. May produce gynecomastia since hCG is an LH analog. |
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Testicular germ cell tumors - Teratoma
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Unlike in females, mature teratoma in males is most often malignant. Increased hCG and/or AFP in 50% of cases.
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Testicular non-germ cell tumors - details?
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5% of all testicular tumors. Mostly benign.
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Testicular non-germ cell tumors - Leydig cell
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Contains Reinke crystals; usually androgen producing, gynecomastia in men, precocious puberty in boys. Golden brown color.
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Testicular non-germ cell tumors - Sertoli cell
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Androblastoma from sex cord stroma.
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Testicular non-germ cell tumors - Testicular lymphoma
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Most common testicular cancer in older men. Not a primary cancer. Arises from lymphoma metastases to testes.
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Tunica vaginalis lesions
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Lesions in the serous covering of testis - present as testicular masses that can be transilluminated (vs. testicular tumors).
1. Hydrocele - increased fluid secondary to incomplete fusion of the processus vaginalis 2. Spermatocele - dilated epididymal duct |
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Penile pathology - Squmous cell carcinoma
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More common in Asia, Africa, and South America. Commonly associated with HPV, lack of circumcision.
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Penile pathology - Peyronie's disease
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Bent penis due to acquired fibrous tissue formation.
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Penile pathology - priapism
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Painful sustained erection not associated with sexual stimulation or desire. Associated with trauma, sickle cell disease (sickled RBCs get trapped in vascular channels), medications (anticoagulants, PDE5 inhibitors, antidepressants, alpha-blockers, cocaine.)
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Control of reproductive hormones - explain the control of female hormones
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Hypothalamus secretes GnRH (inhibited by GnRH antagonists, inhibited or activated by GnRH agonists depending on continuous vs. pulsatile infusion).
GnRH activates the anterior pituitary to secrete LH and FSH (activated by Clomiphene, inhibited by OCPs, danazol). LH acts on theca cells to cause desmolase to convert cholesterol into androstenedione (inhibited by ketoconazole, danazole). Testosterone and androstenedione are converted by aromatase to estradiol and estrone, respectively (inhibited by anastrozole and other aromatase inhibitors). Estradiol acts on Estrogen Response elements (inhibited by fulvestrant and activated or inhibited by SERMs depending on tissue). This leads to expression in estrogen-responsive cells. |
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Control of reproductive hormones - explain control of male hormones
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Hypothalamus releases GnRH (inhibited by GnRH antagonists, activated or inhibited by GnRH agonists depending on whether pulsatile or continuous infusion). GnRH causes anterior pituitary to secrete LH which acts on Leydig cells to produce testosterone (inhibited by ketoconazole, spironolactone).
Testosterone is converted to DHT by 5alpha-reductase (inhibited by finasteride) in various tissues (testes, adrenals, etc.). Testosterone and DHT travel into cells to form androgen-receptor complex and activate androgen response elements (inhibited by flutamide, cyproterone, spironolactone) --> expression of appropriate genes in androgen-responsive cells. |
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Leuprolide - Mechanism? Clinical Use? Toxicity?
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Mechanism - GnRH analog with agonist properties when used in pulsatile fashion; antagonist properties when used in continuous fashion (downregulates GnRH receptor in pituitary --> decreased FSH/LH).
Clinical Use - infertility (pulsatile), prostate cancer (continuous - use with flutamide), uterine fibroids. Toxicity - Antiandrogen, nausea, vomiting |
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Testosterone (methyltestosterone) - Mechanism? Clinical Use? Toxicity?
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Mechanism - Agonist at androgen receptors.
Clinical use - Treats hypogonadism and promotes development of secondary sex characteristics; stimulation of anabolism to promote recovery after burn injury; treats ER-positive breast cancer (exemestane). Toxicity - Causes masculinization in females; reduces intratesticular testosterone in males by inhibiting release of LH (via negative feedback), leading to gonadal atrophy. Premature closure of epiphyseal plates. Increased LDL, decreased HDL. |
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Antiandrogens - basics?
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5alpha-reductase
Testosteron --> DHT (more potent) |
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Antiandrogens - Finasteride
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A 5alpha-reductase inhibitor (decreases conversion of testosterone to dihydrotestosterone). Useful in BPH. Also promotes hair growth - used to treat male-pattern baldness.
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Antiandrogens - Flutamide
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A nonsteroidal competitive inhibitor of androgens at the testosterone receptor. Used in prostate carcinoma.
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Antiandrogens - Ketoconazole
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Inhibits steroid synthesis (inhibits desmolase).
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Antiandrogens - Spironolactone
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Inhibits steroid binding
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What are similarities between spironolactone and ketoconazole?
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Both are used in treatment of PCOS to prevent hirsutism. Both have side effects of gynecomastia and amenorrhea.
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Estrogens (ethinyl estradiol, DES, mestranol) - Mechanism? Clinical Use? Toxicity?
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Mechanism - Bind estrogen receptors.
Clinical use - Hypogonadism or ovarian failure, menstrual abnormalities, HRT in postmenopausal women; use in men with androgen-dependent prostate cancer. Toxicity - Increased risk of endometrial cancer, bleeding in postmenopausal women, clear cell adenocarcinoma of vagina in females exposed to DES in utero, increased risk of thrombi. Contraindications - ER-positive breast cancer, history of DVTs |
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Selective estrogen receptor modulators (SERMs) - Clomiphene
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Partial agonist at estrogen receptors in hypothalamus. Prevents normal feedback inhibition and release of LH and FSH from pituitary, which stimulates ovulation. Used to treat infertility and PCOS. May cause hot flashes, ovarian enlargement, multiple simultaneous pregnancies, and visual disturbances.
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Selective estrogen receptor modulators (SERMs) - Tamoxifen
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Antagonist on breast tissue; used to treat and prevent recurrence of ER-positive breast cancer.
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Selective estrogen receptor modulators (SERMs) - Raloxifene
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Agonist on bone; reduces resorption of bone; used to treat osteoporosis.
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Hormone Replacement Therapy (HRT)
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used for relief or prevention of menopausal symptoms (e.g., hot flashes, vaginal atrophy) and osteoporosis (increased estrogen, decreased osteoclast activity).
Unopposed estrogen replacement therapy (ERT) increases the risk of endometrial cancer, so progesterone is added. Possible increased CV risk. |
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Anastrozole/exemestane
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Aromatase inhibitors used in postmenopausal women with breast cancer.
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Progestins - mechanism? Clinical use?
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Mechanism - bind progesterone receptors, reduce growth, and increase vascularization of endometrium.
Clinical use - Used in oral contraceptives and in the treatment of endometrial cancer and abnormal uterine bleeding. |
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Mifepristone (RU-486) - Mechanism? Clinical use? Toxicity?
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Mechanism - competitive inhibitor of progestins at progesterone receptors
Clinical Use - Termination of pregnancy. Administered with misoprostol (PGE1). Toxicity - Heavy bleeding, GI effects (nausea, vomiting, anorexia), abominal pain. |
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Oral contraception (synthetic progestins, estrogen)
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Estrogen and progestins inhibit LH/FSH and thus prevent estrogen surge. No estrogen surge --> no LH surge --> no ovulation.
Progestins cause thickening of the cervical mucus thereby limiting access of sperm to uterus. Progestins also inhibit endometrial proliferation, thus making endometrium less suitable for the implantation of an embryo. Contraindications - smokers > 35 years of age (increased risk of cardiovascular events), patients with history of thromboembolism and stroke or history of estrogen-dependent tumor. |
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Ritodrine/terbutaline
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Beta2-agonists that relax the uterus; reduce premature uterine contrations.
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How to remember the mechanism of action for ritodrine?
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Ritodrine allows the fetus to "return to dreams" by preventing early delivery.
Beta2-agonist that relaxes the uterus, reduces premature uterine contractions. |
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Tamsulosin -
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a.k.a. Flomax
Alpha1-anatagonist used to treat BPH by inhibiting smooth muscle contraction. Selective for alpha1(a,d) receptors (found on prostate) vs. vascular alpha(1b) receptors. |
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Sildenafil, vardenafil - Mechanism? Clinical use? Toxicity?
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Mechanism - Inhibit cGMP phosphodiesterase, causing increased cGMP, smooth muscle relaxation in the corpus cavernosum, increased blood flow, and penile erection.
Clinical use - treatment of erectile dysfunction Toxicity - Headache, flushing, dyspepsia, impaired blue-green color vision. Risk of life-threatening hypotension in patients taking nitrates. |
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Danazol - Mechanism? Clinical use? Toxicity?
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Mechanism - Synthetic androgen that acts as partial agonist at androgen receptors.
Clinical use - endometriosis and hereditary angioedema Toxicity - Weight gain, edema, hirsutism, masculinization, decreased HDL levels |
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How to remember some of the details of sildenafil?
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"Hot and sweaty," but then Headache, Heartburn, Hypotension
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What can be prescribed to prevent calcium stone formation in the urine?
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Citrate - binds to ionized calcium to prevent salt formation
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What is the most concerning lifestyle choice when considering prescribing a patient with OCPs?
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Smoking habits. - smokers are at increased risk for cardiac events
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What prevents lactation in expecting mothers, given the elevated prolactin levels?
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Progesterone
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Where does lymph from the testes drain?
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Directly into para-aortic lymphatic vessels
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Where does lymph from the glans penis?
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Deep inguinal lymphatics
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What drains into the superficial inguinal lymph nodes?
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Nearly all cutaneous lymph from the umbilicus to the feet with the exception of the testes (para-aortic), glans penis (deep inguinal) and skin over the posterior calf (deep inguinal).
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Enerococci have developed a surface enzyme that can transfer acetyl groups onto exogenous molecules. Which antibiotic class does this grant it resistance to?
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Aminoglycosides
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If a down syndrome baby is found to have trisomy 21 and DNA analysis shows two different-length chromosomes inherited from the mom, did the nondysjunction happen in meiosis I or meiosis II?
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Meiosis I - one sister chromatid from each tetrad needs to go in the same cell...this woudl happen if the tetrads did not split until Meiosis II
If it happened in meiosis II this would imply that meiosis I happened normally - in this case you would not have two different sized chromosome 21 fragments, you would have one double-thickness band because the sister chromatids would both go in the same oocyte. |
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Describe the course of the ureter from the UPJ to the VUJ.
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The ureter travels down in the retroperitoneum over the psoas muscle. Midway between the kidney and the pelvic inlet, the ureter passes under the gonadal artery and vein ("Water under the bridge") The ureters then gain access to the pelvis by traveling across the anterior surface of the external iliac artery and vein . At this point the ureter is medial to the gonadal vessels and lateral to the internal iliac artery. The ureters then course through the uterosacral ligament just deep to the uterine artery and vein before gaining access to the bladder.
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Which breast cancer subtype has central necrosis on pathology?
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Comedocarcinoma (DCIS)
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A woman at 12 weeks gestation has high blood glucose and triglycerides. What hormone is likely contributing most to this?
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human placental lactogen - causes maternal insulin resistance which causes hyperglycemia which allows blood glucose to be delivered to the fetus
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Low AFP on triple screen suggests what abnormality?
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Trisomy 21
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What artery supplies blood to the upper ureter?
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The renal artery
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Why is chlamydia resistant to ceftriaxone?
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It does not have peptidoglycan in its cell wall.
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Is it gardnerella or trichomonas if you have a positive whiff test with KOH prep?
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Gardnerella - Bacterial vaginosis
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Is family history a strong risk factor for cervical carcinoma?
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NOT considered an independent risk factor
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What is the sodium-cyanide/nitroprusside test used for?
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Detects sulfhydryl groups and is a rapid qualitative determinant of the presence of urine cystine.
Used to diagnose cystinuria, resulting from an inborn error of metabolism at the proximal convoluted tubule. The cyanide converts cystine to cysteine. The nitroprusside then bindes cysteine, causing a purple discoloration in 2-10 minutes. |
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What two hormones are elevated in patients with Klinefelters?
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FSH and Estrogen
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Sildenafil's net intracellular effect is similar to what other signalling molecules? 2 of them
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It causes increased levels of cGMP, similar to NO and Atrial Natriuretic Peptide - although they activate guanylyl cyclase while sildenafil inhibits the phosphodiesterase.
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What cells in the ovary produce progesterone?
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Theca cells
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If you see a gross specimen of a kidney from a 67yo man and it is enlarged - what should you be considering just based on gross observation?
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Urinary obstruction --> hydronephrosis - can see that the major calyces are enlarged just by gross inspection
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What landmark is used for lidocaine injection in a pudendal nerve block just prior to delivery?
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The tip of the ischial spine
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What is the most important cytokine mediator of sepsis?
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TNF-alpha (also IL-1 and IL-6)
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What should you be thinking if you see endometrial hyperplasia and an adnexal mass, in terms of the origin of the mass?
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Granulosa cell tumor --> secretes estrogen and you get endometrial hyperplasia
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If a 3 yr old cant absorb certain amino acids from his intestines, what else should be considered that is also probably going on?
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Abnormal reabsorption in the urine --> kidney stones -- these two processes share the same transport protein and so both would be affected usually
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Aside from meiotic nondysjunction, what other error may have occurred to cause a child to have Turner's syndrome?
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mitotic error with mosaicism -> some cells early in development lost one of the X chromosomes (after fertilization) and so there are two cell lines in the patients body
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What type of renal injury would you expect in a 21 yo with sickle cell anemia and one episode of hematuria?
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Papillary necrosis
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Where does lymph drain from the anus (below the pectinate line)?
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superficial inguinal lymph nodes
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Fever, maculopapular rash and oliguria after starting a beta-lactam = ?
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drug-induced renal interstitial nephritis
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What is the main method by which combination OCPs prevent pregnancy?
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Inhibit FSH/LH secretion from the anterior pituitary --> no LH surge --> no ovulation
This is the MAJOR way they work. |
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Which type of urinary tract stone is radiolucent?
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uric acid stone - the ONLY one that is radiolucent
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What are the four types of urine stones?
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Calcium oxalate/ calcium phosphate - 70-80% - radioopaque - colorless octahedron
Struvite (magnesium ammonium sulfate or triple phosphate) - 15% - radiopaque - rectangular prism Uric acid - 5% - Radiolucent - yellow or red-brown, diamond or rhombus Cystine - 1% - radiopaque - flat, yellow, hexagonal |
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If a woman is pregnant and begins developing a deep voice and hirsutism, and the baby has ambiguous genitalia and a normal sized uterus - what does the baby have?
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aromatase deficiency - if it were 21-hydroxylase deficiency the baby would also have severe hyponatremia, hypotension, and hyperkalemia and its not clear if the mom would become hirsute
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73yo man undergoes coronary angioplasty, afterwards he develops a blue toe and his Cr goes from normal to 2.4 - what is going on?
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atheroembolic disease of the renal artery - plaques dislodged from larger vessels are shooting everywhere
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A 32yo woman presents with fever and hematuria, renal biopsy shows hypercellularity with predominantly neutrophils in the tubules and interstitiam - what does she have?
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ascending bacterial infection
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What is the name for the process by which only paternal tissue forms and survives in a hydatidiform mole?
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Androgenesis
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What is the histologic pattern of a fibroadenoma of the breast?
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cellular, often myxoid stroma that encircles epithelium-lined glandular and cystic spaces.
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If you suspect a partial vs. complete mole and the prompt stresses that edematous villi were seen, which is it?
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Partial mole
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For a prompt to suggest a molar pregnancy, what would you need to see in the prompt to suggest that the mole had converted to choriocarcinoma?
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signs of metastases (lung mets maybe), and elevated beta-HCG
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If a prompt shows metastatic disease to lungs or bone or lymph or something else and the patient has polycythemia, what should you at least consider as a primary site?
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Kidneys - could be renal cell carcinoma with paraneoplastic EPO release
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What ligament supplies the ovarian vessels?
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Suspensory ligament of the ovary
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What are the inferior, lateral and medial border's of hesselbach's triangle? What type of hernia goes through it?
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Lateral - inferior epigastric vessels
Medial - rectus abdominus Inferior - inguinal ligament Direct inguinal hernia goes through it. |
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What cell type is importantly absent on histologic examination of choriocarcinoma?
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Chorionic villi
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What is an easy way to prevent urinary stone formation?
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drink lots of water/fluids
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Penicillins are analogs of what portion of the peptidoglycan molecule?
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D-ala-D-ala
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Biopsy of the endometrium would show what during the proliferative phase? the secretory phase?
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Proliferative - nonbranching, nonbudding uniform glands evenly distributed throughout a uniform stroma. Glands are tubular, narrow, and lined with pseudostratified, elongated, mitotically active epithelial cells.
Secretory - glycogen-rich lumen of the glands, edematous stroma, prominent spiral arteries extending to the surface |
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Name two other drugs that use the same mechanism as trimethoprim
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methotrexate and pyrimethamine
all three prevent the reduction of folic acid to tetrahydrofolate by inhibiting dihydrofolate reductase |
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What cellular process describes the mechanism by which sloughing of the endometrial lining occurs in menstruation?
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apoptosis - withdrawal of growth factor (progesterone) leads to apoptosis
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What is the mechanism of the "disulfiram like reaction"
|
Disulfiram is an aldehyde dehodrogenase inhibitor that causes acetaldehyde buildup when used with alcohol bc it also inhibits alcohol oxidizing enzymes.
Other drugs that cause disulfiram-like reaction work by similar mechanisms. |
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What is the most common cause of irregular periods in the first 5-10 years after menarche?
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anovulation
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If a male is found to have impaired sperm motility due to a dysfunction of the flagellar tail, what larger syndrome should you consider?
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Primary ciliary dyskinesia --> Kartagener's, bronchiectasis, recurrent otitis/sinusitis
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Explain the symptoms of prolactinoma.
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Amenorrhea - feedback inhibition of GnRH from the hypothalamus
Golactorrhea - direct stimulation of prolactin on the mammary glands |
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If a pregnant woman has high blood pressure and leg swelling, is this normal?
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No, she has pre-eclampsia - check a urine dipstick for proteinuria
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WBC casts are pathognomonic for what disease?
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Pyelonephritis - WBCs are precipitated by the Tamm-Horsfall protein secreted by tubular epithelial cells
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What is the most common cause of calcium nephrolithiasis? 50% of calcium stones are caused by this
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Idiopathic Hypercalciuria
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