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155 Cards in this Set

  • Front
  • Back
SEVEN UP

development of sperm
Seminiferous tubules
Epididymis
Vas deferens
Ejaculatory ducts
(Nothing)
Urethra
Penis
FSH
secreted from anterior pituitary (stimulated by GnRH) to stimulate the Sertoli cells to produce androgen binding protein and inhibin...sertoli cells are vital for sperm synthesis
LH
released from anterior pituitary to stimulate the Leydig cells to release testosterone (for sperm production)
Androgen binding protein
ensures that testonsterone in seminiferous tubules is high

secreted by Sertoli cells
Inhibin
inhibits FSH and is secreted by Sertoli cells
Testosterone
from Leydig cells; differentiates male genitalia, has anabolic effects on protein metabolism, maintains gametogenesis, maintains libido, inhibits GnRH, and fuses epiphyseal plates in bone
androstenedione
secreted by adrenal gland...least potent of androgens
DHT and testosterone are secreted by...
testis
5-alpha reductase
converts testosterone to DHT

inhibited by finasteride
Testosterone and androstenedione are converted to...
estrogen in adipose tissue and Sertolie cells by enzyme aromatase
function of androgens
differentiation of wolffian duct system into internal gonadal structures; secondary sex characteristics and growth spurt during puberty, closes epiphyseal plates; required for normal spermatogenesis; anabolic effects...increases muscle size, increase RBC production...increase libido
Sources of estrogen
Ovary (17 beta - estradiol)

placenta: estriol

blood: aromatization
Potency of estrogens
estradiol > estrone > estriol
In pregnancy...estrogen changes...
50-fold increase in estradiol and estrone

1000 fold increase in estriol (indicator of fetal well being)
Estrogen functions (long list)
1. growth of follicle
2. endometrial proliferation
3. development of genitalia
4. stromal development of breast
5. female fat distribution
6. hepatic synthesis of transport proteins (increase synthesis of sex hormone-binding globulin)
7. feedback inhibition of FSH and LH
8. LH surge (estrogen negative feedback on LH secretion switches to positive from negative just before LH surge)
9. increases myometrial excitability
10. increase HDL and decreases LDL
Theca cell
stimulated by LH to increase desmolase action...desmolase will convert cholesterol to androstenedione
Granulosa cell
next to the theca cell...androstenedione (made in theca cell) goes to the granulosa cells...aromatase (stimulated by FSH) converts the androgen to estrogens in the granulosa cells
Source of progesterone
corpus luteum, placenta, adrenal cortex, testes
Progesterone functions (long list)
1. stimulation of endometrial glandular secretions and spiral artery development
2. maintains pregnancy
3. decreases myometrial excitability
4. produces thick cervical mucus, which inhibits sperm entry into the uterus
5. increases body temperature
6. inhibits gonadotropins (LH and FSH)
7. uterine smooth muscle relaxation (preventing contractions)

(elevation of progesterone is indicative for ovulation...progesterone prepares for pregnancy)
Estrogen in menstrual cycle...
stimulates endometrial proliferation
Progesterone in menstrual cycle...
maintains endometrium to support implantation

...thus decreasing progesterone will decrease fertility
What phase in the menstrual cycle can vary in length?
follicular phase

luteal phase is usually a constant 14 days...ovulation day is menstruation day 14
Stuff about ovulation
estrogen surge day before ovulation

stimulates LH, inhibits FSH

LH surge causes ovulation (rupture of follicle)

increase temperature (progesterone induced)

ferning of cervical mucosa

oral contraceptives prevent the estrogen surge and thus the LH surge...ovulation does not occur
Mittelschmerz
blood from ruptured follicle causes peritoneal irritation that can mimic appendicitis
primary oocytes
begin meiosis I during fetal life and complete meiosis I just prior to ovulation (remain this way for years)

4N (stuck in prophase)
secondary oocytes
arrested in Metaphase until fertilization...

an egg MET a sperm

stratum granulosum (2N)...stuck in metaphase
If fertilization occurs...
the corpus luteum is rescued from regression by human chorionic gonadotropin...produced by the placenta
Implantation...
occurs 6 days after fertilization

trophoblasts secrete hCG...detectable in blood 1 week after conception and on home test in urine 2 weeks after conception
First trimester
corpus luteum (stimulated by HCG) is responsible for the production of estradiol and progesterone...peak levels of HCG occur at gestational week 9 and then decline
Second and third trimesters
progesterone is produced by the placenta

estrogens produced by interplay of fetal adrenal gland and the placenta...fetal adrenal gland synthesizes DHEA-S, which is then hydroxylated in the fetal liver...these are transferred to the placenta...
hCG function
maintains the corpus luteum (and thus progesterone) for the first trimester by acting like LH

elevated in women with hydatidiform moles or choriocarinoma
hormonal changes in menopause
decrease estrogen, waaay increase in FSH, increase in LH (no surge) and increase in GnRH
Hypospadias
abnormal opening of penile urethra on inferior (ventral) side of penis due to failure of urethral folds to close

more common than epispadias
Fix hypospadias to prevent...
UTIs!!!
Epispadias
abnormal opening of penile urethra on superior (dorsal) side of penis due to faulty positioning of genital tubercle
exstrophy of bladder is associated with
epispadias...you hit your eye when you pee with epispadias...on dorsal side
Klinefelter's syndrome
XXY
1:850

testicular atrophy, eunuchoid body shape, tall, long extremities, gynecomastia, female hair distribution

presence of inactivated X chromosome (Barr body)

common cause of hypogonadism seen in infertility workup
Klinefelter's syndrome...hormonal stuff
increase of pituitary hormones because of loss of feedback inhibition...

dysgenesis of seminiferous tubules leads to decrease in inhibin and increase in FSH

abnormal Leydig cell function leads to decrease in testosterone which leads to increase in LH and increase in estrogen

eunuchoid because dont close epiphyseal plates
Turner's syndrome
XO!!!

1:3000

short stature, ovarian dysgenesis (streak ovary), webbing of neck, preductal coarctation of the aorta, most common cause of primary amenorrhea, no barr body
Hormonal stuff in Turner's syndrome
XO

decrease estrogen leads to increase LH and FSH
Double Y males (XYY)

1:1000
phenotypically normal, very tall, severe acne, antisocial behavior (1-2% of XYY males)

normal fertility

observed with increased frequency among inmates of penal institutions
Female pseudo-hermaphrodite

XX
(pseudo-hermaphrodite: disagreement between the phenotypic...external genitalia...and gonadal sex...testes vs ovaries

ovaries are present, but external genitalia are virilized or ambiguous; due to excessive and inappropriate exposure to androgenic steroids during early gestation (like congenital adrenal hyperplasia or exogenous administration of androgens during pregnancy)
male pseudo-hermaphrodite

XY
testes present, but external genitalia are female or ambiguous; most common form is androgen insensitivity syndrome (testicular feminization)
True hermaphrodite
both ovary and testicular tissue present; ambiguous genitalia; very rare
Androgen insensitivity syndrome

46 XY
defect in androgen receptor resulting in normal appearing female

female external genitalia with rudimentary vagina; uterus and uterine tubes generally absent; develops testes (often found in labia majora; surgically removed to prevent malignancy)

levels of testosterone, estrogen and LH are all high
5 alpha reductase deficiency
unable to convert testosterone to DHT

ambiguous genitalia until puberty, when testosterone causes masulinization of genitalia

testosterone/estrogen levels are normal; LH is normal or increased; 'penis at 12' (when testosterone production begins at puberty, it stimulates growth of external male genitalia)
Hydatidiform mole
a pathologic ovum (empty egg...ovum with no DNA) resulting in cystic swelling of chorionic villi and proliferation of chorionic epithelium (trophoblast)

most common precursor of choriocarcinoma

high beta hCG

honeycombed uterus, cluster of grapes appearance

characteristically occurs in early months of pregnancy...eventuates to choriocarcinomas in 2-3% cases
Complete mole
46 XX and is COMPLETELY paternal in origin...2 sperm + empty egg (no maternal chromosomes)

NO associated fetus and commonly lead to an abnormally enlarged uterus
Partial mole
made up of 3 or more PARTS (triploid or tetraploid); may contain fetal PARTS

2 sperm + 1 egg

less likely to be associated with excessive uterine size
more about hydatidiform moles...
moles can lead to uterine rupture; treat with dilitation and curettage and methotrexate

monitor beta-hCG
Preeclampsia
triad of hypertension, proteinuria and edema

affects 7% of pregnant women from 20 weeks gestation to 6 weeks postpartum (before 20 weeks suggests molar pregnancy)
Eclampsia
hypertension, proteinuria and edema WITH SEIZURES

medical emergency!!!

treat with IV magnesium sulfate and diazepam
increased incidence of pre-eclampsia/eclampsia...
preexisting hypertension, diabetes, chronic renal disease and autoimmune disorders
Etiology of preeclampsia-eclampsia
placental ischemia (lack of trophoblastic invasion of spiral arteries in myometrium)
HELLP syndrome
can be associated with pre-eclampsia...hemolysis, elevated LFTs, low platelets
Clinical features and mortality with pre-eclampsia/eclampsia
mortality due to cerebral hemorrhage and ARDS

headache, blurred vision, abdominal pain, edema of face and extremities, altered mentation, hyperreflexia; lab findings show thrombocytopenia and hyperuricemia
Treatment of preeclampsia
delivery of fetus as soon as possible

otherwise bed rest, salt restriction, and monitoring and treatment of HTN
Painful bleeding
ABRUPTIO PLACENTAE

premature detachment of placenta from implantation site

PAINFUL uterine bleeding (usually during 3rd trimester)

fetal death

may be associated with DIC

increased risk with smoking, hypertension and cocaine use
Massive bleeding!
PLACENTA ACCRETA

defective decidual layer allows placenta to attach directly to myometrium

predisposed by prior C section or inflammation

may have massive hemorrhage after delivery
Painless bleeding
PLACENTA PREVIA!!!

attachment of placenta to lower uterine segment; may occlude internal os

PAINLESS bleeding in any trimester; prior C-section predisposes
Pain without bleeding
ECTOPIC PREGNANCY

most often in fallopian tubes, predisposed by salpingitis (PID)

suspect with increase in hCG and sudden lower abdominal pain

confirm with ultrasound

often clinically mistaken for an appendicitis
polyhydramnios
> 1.5 - 2 L of amniotic fluid

associated with esophageal/duodenal atresia, causing inability to swallow amniotic fluid, and with anencephaly
About 20% cases are due to maternal diabetes, which causes hyperglycemia of the fetus, hence fetal polyuria (fetal urine is a major source of amniotic fluid)
oligohydramnios
< 0.5 L of amniotic fluid

associated with bilateral renal agenesis or posterior urethral valves (in males) and resultant inability to excrete urine

can give rise to Potter's syndrome
Dysplasia and carcinoma in situ (cervical)
disordered epithelial growth

squamo-columnar junction!!!

begins at basal layer of squamo-columnar junction and extends outward

classified as CIN 1, CIN 2 or CIN 3, depending on the extent of dysplasia

associated with HPV 16 and 18


Vaccine: Gardasil (tetravalent)

may progress slowly to invasive carcinoma
Invasive carcinoma (cervical)
often squamous cell carcinoma

most frequently from preexisting CIN at the squamocolumnar junction; evloves through a series of increasing epithelial abnormalities proceeding from dysplasia to carcinoma in situ and then to invasive carcinoma

lateral invasion can block ureters, causing renal failure
Role of HPV
dysplastic cells frequently demonstrate koilocytosis!! (as in HPV induced conyloma acuminatum)
HPV sequences...
often integrated into genomes of dysplastic or malignant cervical epithelial cells

HPV types 16, 18, 31 and 33 are most common...
HPV viral protein E6
inactivates p53
HPV viral protein E7
inactivates Rb
Non-neoplastic endometrial glands/stroma in abnormal locations outside the uterus
endometriosis!!

ectopic endometrial tissue

causes may include retrograde dissemination of endometrial fragments through fallopian tubes during menstruation, with implantation on the ovary or other peritoneal structures...or blood-borne or lymphatic-borne dissemination of endometrial fragments
"chocolate cysts"...blood filled...
ectopic endometrial tissue

endometriosis!

in ovary or peritoneum

SEVERE MENSTRUAL RELATED PAIN

can be due to retrograde menstural flow
Adenomyosis
endometriosis within the myometrium
Endometrial hyperplasia
abnormal proliferation of the endometrial glands

usually caused by excess estrogen stimulation (can be caused by anovulatory cycles, polycystic ovary disease, estrogen secreting ovarian tumors like granulosa cell tumors and estrogen replacement therapy)

incresed risk for endometrial carcinoma
most commonly manifests clinically as post-menopausal vaginal bleeding
endometrial hyperplasia
Endometrial carcinoma
most common gynecologic malignancy

peak age 55-65 years of age

clinically presents with vaginal bleeding

typically preceeded by endometrial hyperplasia
risk factors of endometrial carcinoma
prolonged use of estrogen without progestins, obesity, diabetes, hypertension, nulliparity, and late menopause

Prognosis correlates with degree of myometrial invasion
Leiomyoma (fibroid)
most common of all tumors in females

MOST COMMON UTERINE TUMOR

often presents with multiple tumors with well-demarcated borders

increase incidence in blacks

benign SM tumor

malignant transformation is rare

estrogen sensitive - tumor size increases with pregnancy and decreases with menopause

usually develop subserosally or within the myometrium
Peak occurrence of leiomyomas

and clinical features
20-40 years old

may be asymptomatic or may cause abnormal uterine bleeding

severe bleeding may lead to iron deficiency anemia

does NOT progress to leiomyosarcoma
whorled pattern of SM bundles
leiomyoma!! (fibroid)
Leiomyosarcoma
bulky, irregular shaped tumor with areas of necrosis and hemorrhage

typically arising de nov (NOT from leiomyomas)...

increased incidence in blacks

highly aggressive tumor with tendency to recur; may protrude from cervix and bleed
incidence of gynecological tumors...
endometrial > ovarian > cervical!
worst prognosis of gynecological tumors...
ovarian > cervical > endometrial
Polycystic ovarian syndrome
increase LH, decrease FSH and increase testosterone

increase LH leads to anovulation, hyperandrogenism due to deranged steroid synthesis

increased risk of endometrial cancer
Clinical manifestations of polycystic ovarian syndrome
enlarged, bilateral cystic ovaries...amenorrhea, infertility, obesity and hirsutism

associated with insulin resistance

markedly thickened ovarian capsule; multiple small follicular cysts and cortical stromal fibrosis
Treatment of polycystic ovarian disease
weight loss, OCPs, gonadotropin analogs, clomiphene or surgery
Clomiphene
SERM!!

used mainly in female infertility due to anovulation (PCOS); inhibits action of estrogens
Follicular cyst
distention of unruptured graafian follicle

may be associated with hyperestrinism and endometrial hyperplasia
Corpus luteum cyst
hemorrhage into persistent corpus luteum

menstrual irregularity
Theca-lutein cyst
often bilatera/multiple

due to gonadotropin stimulation

associated with choriocarcinomas and hydaditiform moles
Chocolate cyst
blood containing cyst from ovarian endometriosis; varies with menstrual cycle
Dysgerminoma
malignant ovarian germ cell tumor

analagous to testicular seminoma

sheets of uniform cells

hCG is the tumor marker
Choriocarcinoma
ovarian germ cell tumor

rare, but malignant; can develop during pregnancy in mother or baby

large, hyperchromatic syncytiotrophoblastic cells

increase frequency of theca-lutein cysts

hCG is the tumor marker
Yolk sac (endodermal sinus tumor)
aggressive malignancy in ovaries (testes in boys) and sacrococcygeal area of young children

tumor marker: alpha-feto protein
Teratoma
90% of ovarian germ cell tumors

contains cells from 2 or 3 germ layers
Mature teratoma
'dermoid cyst'

most frequent benign ovarian tumor
Immature teratoma
aggressively malignant
Struma ovarii
teratoma

contains functional thyroid tissue

can present as hyperthyroidism

monodermal teratoma; cyst of a single element
Serous cystadenoma
ovarian non-germ cell tumors

20% of ovarian tumors

frequently bilateral, lined with fallopian tube-like epithelium

benign
Serous cystadenocarcinoma
50% ovarian tumors

malignant and frequently bilateral
Mucinous cystadenocarcinoma
multilocular cyst lined by mucus-secreting epithelium

benign
Mucinous cystadenocarcinoma
malignant
Pseudomyxoma peritonei
intraperitoneal accumulation of mucinous material from ovarian or appendiceal tumor

(assoicated with mucinous cystadenocarcinoma)
Brenner tumor
benign ovarian non-germ cell tumor

small islands of epithelial cells resembling bladder; transitional epithelium; interspersed within fibrinous stroma
Fibromas
ovarian non-germ cell tumors

bundles of spindle-shaped fibroblasts
Meigs' syndrome
triad of ovarian fibroma, ascites, and hydrothorax

pulling sensation in groin

(under fibromas heading)
Granulosa cell tumor
ovarian non germ cell tumor

secretes estrogen leads to precocious puberty in kids

can cause endometrial hyperplasia or carcinoma in adults
Call-Exner bodies
associated with granulosa cell tumor

small follicles filled with eosinophilic secretions

important diagnostic tool
Krukenberg tumor
GI malignancy that metastasizes to ovaries; causing a mucin-secreting signet cell adenocarcinoma

ovarian non-germ cell tumor
Squamous cell carcinoma of the vagina
2% go to cervical SCC
clear cell adenocarcinoma
vaginal carcinoma

exposure to DES
sarcoma botryoides
rhabdomyosarcoma variant

vaginal carcinoma

affects girls < 4 years old

spindle shaped tumor cells that are desmin positive
Benign tumors of the breast
fibroadenoma, intraductal papilloma, phyllodes tumor
Fibroadenoma
benign tumor of the breast

most common tumor < 25 years old

small, mobile, firm mass with sharp edges; increase size and tenderness with pregnancy

not a precursor to breast cancer
Intraductal papilloma
benign tumor of breast

tumor of lactiferous ducts

presents with serous or bloody nipple discharge
Phyllodes tumor
benign tumor of the breast

large, bulky mass of CT and cysts

tumor may have 'leaf-like' projections

some may be malignant (cystosarcoma phyllodes)
Malignant tumors of the breast (carcinomas)
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
What is the single most importnat prognostic factor for malignant tumors of the breast
axillary lymph node involvement
Noninvasive malignant breast tumor
ductal carcinoma in situ

early malignancy without basement membrane penetration
Invasive ductal
most common malignant tumor of the breast

no specific type

firm, fibrous mass

worst and most invasive

common
Invasive lobular
often multiple, bilateral, orderly rows of cells

malignant tumor of the breast
Medullar carcinoma of the breast
1.2 - 10%

fleshy, cellular, lymphocytic infiltrate

good prognosis
Comedocarcinoma
1.6%

malignant tumors of breast

ductal, caseous necrosis
Inflammatory carcinoma of the breast
lymphatic involvement; red, swollen; peau d'orange

(breast skin resembles an orange peel)
Paget's disease of the breast
invasive carcinoma of the breast

eczematous patches on nipple

paget cells: large cells with clear halo; suggests underlying carcinoma

also seen on vulva

(invade epidermis)
Risk factors of breast cancer
gender, age, early 1st menarche (before 12 years old), delayed first pregnancy (later than 30 years old), late menopause (>50), family history of 1st degree relative with breast cancer at young age

risk is NOT increased by fibroadenoma or nonhyperplastic cysts
Fibrocystic disease
most common cause of 'breast lumps' from age 25 to menopause

presents with diffuse breast pain and multiple lesions, often bilateral

usually does NOT indicate increased risk of carcinoma
Blue dome
cystic part of fibrocystic disease...fluid filled cyst
Sclerosing fibrocystic disease
increased acini and intralobular fibrosis
Epithelial hyperplasia of fibrocystic disease
increase in number of epithelial cell layers in terminal duct lobule

increased risk of carcinoma with atypical cells

occurs in women > 30 years old
Acute mastitis
breast abscess

during breast-feeding

increase risk of bacterial infection through cracks in the nipple...staph aureus is the most common pathogen
Fat necrosis
benign painless lump; forms as a result of injury to breast tissue
Gynectomastia
results from hyperestrogenism (cirrhosis, testicular tumor, puberty, old age), Klinefelter's syndrome, or drugs (estrogen, weed, heroin, psychoactive drugs, SPIRONOLACTONE, DIGITALIS, CIMETIDINE, ALCOHOL, AND KETOCONAZOLE)
Drugs that cause gynecomastia
spironolactone, digitalis, cimetidine, alcohol and ketoconazole
BPH
HYPERPLASIA

may be due to age related increase in estradiol with possible sensitization of the prostate to the growth promoting effects of DHT

nodular enlargement of the periurethral (lateral and middle) lobes of the prostate gland...compressing the urethra into a vertical slit
BPH may lead to...
distention and hypertrophy of the bladder, hydronephrosis, and UTIs

not considered a pre-malignant lesion

increase in free prostate-specific antigen!!

most frequent cause of urinary tract obstruction
Prostatic adenocarcinoma
posterior lobe (peripheral zone!!)

digital rectal examination (hard nodule) and prostate biopsy

prostatic acid phosphatase (PAP) and PSA are useful tumor markers

osteoblastic metastases in bone may develop in late stages...lower back pain and an increase in serum alkaline phosphatase and PSA
increase total PSA with decrease in fraction of free PSA
prostatic adenocarcinoma
Cryptorchidism
failure of testes to descend into scrotum

lack of spermatogenesis because of increase in body temperature

associated with increased risk of germ cell tumors (especially seminoma and embryonal carcinoma)

prematurity increases risk of cryptorchidism
Seminoma
testicular germ cell tumor

malignant

painless 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

analogous to dysgerminoma ovarian tumor
Embryonal carcinoma
testicular germ cell tumor

malignant; painful; worse prognosis than seminomas

often glandular/papillary morphology

can differntiate to other tumors
Schiller-Duval bodies
Yolk sac (endodermal sinus) tumor

analogous to ovarian yolk sac tumor

primitive glomeruli (increase alpha feto protein)

peak incidence in infancy and early childhood
Choriocarcinoma (testicular cancer)
malignant

increased hCG

cells that look like syncytiotrophoblast and cytotrophoblasts
Teratoma in males
testicular germ cell tumor

most common testicular cancer in older men
Leydig cell tumor
benign, contains Reinke crystals

usually androgen producing, gynecomastia in men, precocious puberty in boys
Reinke crystals
Leydig cell tumors
Sertoli cell tumor
benign; androblastoma from sex cord stroma
Testicular lymphoma
most common testicular cancer in older men
Varicocele
dilated vein in pampiniform plexus

can cause infertility

'bag of worms'
Hydrocele
serous, fluid filled; persistence of continuity of tunica vaginalis

secondary to fluid secondary to incomplete fusion of processus vaginalis
Spermatocele
dilated epididymal duct

(mostly intratestcular)

sperm containing cyst
Erythroplasia of Queyrat
red velvety plaques

usually involving the glans

otherwise similar to Bowen's disease
Bowenoid papulosis
multiple papular lesions

affects younger age group than other subtypes

usually does not become invasive

resembles condyloma accuminatum, HPV 16
Bowen's disease
gray, solitary, crusty plaque, usually on the shaft of the penis or on the scrotum; peak incidence is 5th decade of life; progresses to invasive SCC in < 10% cases
SCC of penis
rare in circumcised men

uncommon in US and Europe, more common in Asia, Africa and South America

commonly associated with HPV (16, 18, 31 and 33)
Peyroine's disease
bent penis due to acquired fibrous tissue formation