What is HMGcoA Reductase?

What does it do?

HMGcoA Reductase is the rate limiting enzyme in the mevalonate pathway that synthesizes Cholesterol and other isoprenoids.

It converts HMGcoA (3-hydroxy,3-methylglutaryl coA) to Mevalonic Acid.

Statin drugs are HMGcoA reductase inhibitors

Why is HMGcoA important to the  Repro System?

Becasue if you have a problem with HMGcoA Reductase, You will have inapropriate cholesterol  synthesis.  

This will result in inapropriate Reproductive Hormone Synthesis.

T/F

Cholesterol itself provides (-) feedback to HMGcoA reductase.

True

What is Desmolase?

What does it do?

Where does it do it?

Desmolase is a mitochondrial CYP450 enzyme.

Desmolase cleaves terminal 6 C from Cholesterol to make Pregnenolone

This is done in the Mitochondria

conversion of pregnenolone into progesterone, androgens and estrogens occurs in the ER.

In a patient with either too much or too little steroid, 

How do you know if the problem is Primary Synthesis

or if the problem is Peripheral conversion from one type to another?

What is MIS?

What cells make it and where?

What does it do?

Mullarian Inhibitory Substance

Made by the Sertolli cells of the Embryonic Testes

MIS stimulates the degeneration of the Mullarian duct system thus leading the embryo to male phenotype.

Where would you find Leydig cells?

How do they assist embryoloic pheotypic differentiation?

Leydig cells are found in the male testes

In embryologic development they stimulate the wolffian ducts to differentiate into the  seminal vessicles, epididymis, vas defferens, and ejaculatory duct.

What is SRY?

What happens to the Embryo in its presence?

What happens to the Embryo in its abscense?

Sex Determining Region on the Y chromosome

In its presence.... substances will be made that couse the Urogenital ridge to form Testes (7 weeks gestation)

In its abscence... the Urogenital ridge will form Ovaries (11 weeks gestation)

What Causes the following Embryologic structures to become either Male or Female external genatalia?

Genital Tubercle

Urogenital Groove

Labialscrotal Folds

Androgen - Male Genetalia

If there are testes present,  they will secrete Androgens and these Androgens will cause differentiation into scrotum and penis

No Androgen - Female Genetalia

If there are ovaries present, there will be Little Androgen

and the structures will deffentiate into, clitoris, vagina, urethra, labia.

T/F

Proper differentiation of Male Genetalia Requires the most potent form of Androgen:

5 alpha dihydrotestosterone.

True

What enzyme deficiency causes 90% of CAH?

21-alpha Hydroxylase

What does the enzyme 21-alpha Hydroxilase do?

What gene encodes it?

21-alpha hydroxylase is a key enzyme for both Cortisol and Aldosterone Synthesis.

CYP21A gene

In what ethnic group are CYP21A mutations or deletions more common.

What Congenital Condition does this make them more likely to get?

Ashkenazi Jews

Congenital Adrenal Hyperplasia CAH

What is Classical Virilizing Adrenal Hyperplasia?

Severe form of CAH due to 21-alpha hydroxylase defficiency

Females have ambiguous genetalia due to high levels of Androgens (testosterone) in utero

What is Simple Virilizing Adrenal Hyperplasia?

Mild form of 21-alpha Hydroxylase deficiency.

Identified later inchildhood:  Precotious pubic hair, cliteromegally, accelerated growth and maturation.

What is Nonclassic Adrenal Hyperplasia?

Super mild form of 21-alpha Hydroxylase deficiency.

Identified in adolescence or later with:   Oligomennorhea, infertility,  or Hirsutism (male hair patterns).

What is the effect of low Cortisol from 21-alpha Hydroxylase deficiency?

Without Cortisol... there is no neg feedback mechanism acting on the Hypothalamus to stop Corticotrophic Releasing hormone....    Thus there is also too much ACTH being secreted from the Anterior Pituitary.

ACTH in excess causes hyperplasia of the Adrenal Cortex.

How does 21-alpha Hydroxylase deficiency cause Salt Wasting?

What is salt wasting?

21-alpha Hydroxylase defiencincy leads to a defieciency in Aldosterone ADH because it can't be made.  Thus you're kidneys don't conserve Na+.... you Pee out all your Salt.

Salt wasting presents as:  Adrenal Crisis w/in first 4 weeks of life.   Severe electrolyte and water imbalance.  (classical virilizing Adrenal Hyperplasia).

Cushings Dz = too much Cortisol

Addison's Dz = too little Cortisol

What clinical signs would make you consider CAH?

Deficient Cortisol and Aldosterone with excessive Progesterone and 17 alphahydroxyprogesterone.

Hyperpigmentation in genitaliae and areolae

Hyponatremia and Hyperkalemia in a new born

In a patient with classic virilizing adrenal hyperplasia,

How do we treat her ambiguous genetalia?

Clitoral Recession Early

Vaginoplasty after puberty.

How do we treat Patients with CAH

who experience precocious puberty and compromised adult height?

We try and hold off puberty with long acting GnRH

We then try to stimulate their growth with Growth Hormone Treatment.

T/F

Steroids must be bound to Proteins in Plasma in order to bind to steroid receptors on tissue.

False

Only Unbound Steroids can bind to receptors

T/F

Albumin has a high affinity for all steroids.

False

It will bind all steroids but its affinity for them is low.

What is SHBG?

Sex Hormone Binding Globulin.

It has a High Affinity for: Androgens and Estrogens

It has a Low Affinity for: Progestagins and Cortisol

Explaine why BIOACTIVE steroids include both

Free Steroids and

Albumin-bound Steroids?

Because remember.... Albumin has a Low affinity for Steroids.   They readily dissociate from Albumen and can therefore be included with free steroid in the total BIOACTIVE steroid count.

In assessing whether a patient has excess Androgenism,

which value is more useful:

Total Plasma Androgens

Total Plasma SHBG

Total Plasma SHBG

What does the Free Androgen Index Tell You

And how do you calculate it?

It gives you a quick assesment of Bioavailable Testosterone

FAI = Total Testosterone/ SHBG

T/F

Steroid Receptors are Intracellular?

True

What Are Hormone Resopnse Elements?

They are neucleotide secquences on DNA that are recognized by nuclear receptors such as steroid receptors and receptors for thyroid hormone, vit A and, vit D.   In the case of Steroids... the steroid binds the receptor and the receptor is activated so that it can recognize the HRE and start trascription.

What is Androgen Insesitivity Syndrome?

It is a genetic disorder in which the Androgen Receptors are in some way falty.  It affects Males and may result in infertility

There are 3 broad catecores: 

CAIS, PAIS, MAIS

Describe the Parameters of the Following:

CAIS

PAIS

MAIS

CAIS is complete androgen insensitivity syndrome and results in completely normal Female Genitalia

PAIS is partial androgen insensitivity syndrome and results in ambiguous genitalia

Mais is mild androgen insensitivity syndrome and results in normal male genitalia

T/F

Unexplained Male Infertility may be due to MAIS.

True

True or False

CAIS presents with complete female reproductive organs but a XY genotype.

False

CAIS men have normal undescended testes that secrete normal amounts of testosterone ect.   They also make mormal amounts of MIS Mullerian-inihibiting Substance and thus don't form a utrerus, falopian tubes, or upper vagina

What is expected in terms of gender vrs sex in CAIS patients.

Usually even though their sex is male, they assume a female gender.

T/F

AIS disorder is recessive sex linked

True

T/F

Males who take Anabolic/Androgenic Steroids (AAS)... their testes tend to shrink.

True

this is because they don't need to make testosterone... the patient is loading up on it and this provides neg feedback to the testes.

What is the half life of Testosterone

and what does this suggest for medical use?

90 sec

not very usefull.... doesn't hang around for long (here is where synthetic forms such as AAS come in)

How has the bioavailability of AAS been increased

and what are the complications of this?

Methylating or ethylating (alkylating) the 17-alpha positions  slows the hepatic degredation of AAS

However it also increases the Hepatotoxicity.

What happens if you Esterify AAS?

Esterification slows release.  

An ester group will make the AAS less water soluble and

more fat soluble...thus slower release

What are the Approved Uses of AAS?

Hypogonadism

Hereditary Angioedema

Osteoporosis

Anemia

Muscle Waisting

Severe Burns

What is Hypogonadism and what forms of AAS are used in treatment?

Hypogonadism is failure of the gonad to produe adequate amounts of testosterone despite apropriate amounts of LH and FSH from the anterior Pituitary.

Transdermal preps of testosterone (ANDROGEL)

Intramuscular testosterone esters (testosterone enanthate or cypionate)

What is Hereditary Angioedema and why does AAS help?

Abnormality of the immune system

disfuctinonal C1 Esterase Inhibitor

Swelling of face and abdominal cramping

Anabolics (stanozolol) are used to treat

Whats the deal with Oxymetholone (Anadrol)?

The Deal is,  It stimulates EPO in the kidneys and thus can treat anemia

It is cheaper than EPO  but you cant give it to patients with kidney failure

Why would severe burns benefit from AAS?

In a severe burn you get exaggerated muscle catabolism and bone deposition is inhibited

both of these are improved by AAS

why would an athlete prefer oral steroids?

excreted faster..... avoid being caught 

but... more SE

What are the 3 strategies of Steroid use in the Athelete?

Cycling

Stacking

Pyramiding

What are the Risks of AAS?

Hepatic Cysts

Hepatic Carcinoma

Especially orally (17-alpha alkyl AAS)

The injectible Testosterone Esters seem to be okay on Liver

What are the effects of AAS on Serum Lipoprotiens?

Cholesterol Increases

HDL decreases

What are the signs of AAS  Abuse?

Rapid increase in body mass

Mood swings

Irational behavior

aggresion

Irriability

Depression

Acne

shrinking testes

low sperm count

gynecomastia

virilance in females

Which test is better?

Conventional PAP

or

Thin Prep PAP

Thin Prep PAP

What does a Class 1 PAP smear indicate?

A Negative Smear

(Negative for Squamous cell Carcinoma)

What does a Class 2 PAP smear indicate?

Atypia

(abnormality in a cell)

What does a Class 3 PAP smear indicate?

DYSPLASIA

Mild dysplasia CIN 1,  LGSIL

Moderate dysplasia CIN 2,  HGSIL

What does a Class 4 PAP smear indicate?

Severe Dysplasia

CIN 3,  HGSIL

Carcinoma In SITU (no invasion)

CIN 4, HGSIL

What does Class 5 PAP smear Indicate?

Squamous Cell Carcinoma

Name 4 Organisms you want to look out for on a PAP:

Trichomonas

Herpes

Actinomyces

Candida

What does LSIL stand for?

HSIL?

Low grade Squamous Intraepithelial Lesion

High grade Squamous Intraepithelial Lesion

What is an ASCUS Pap?

what does it stand for?

what does it indicate?

ASCUS pap is the most common abnormal PAP finding.

It means :  Atypical Squamous Cells of Undetermined Significance.

It could indicate several things:

Benign reactive Metaplasia

LSIL

Undersampled HSIL or CA

HPV testing is 95% sensitive for diagnosing underlying cancer in Patients with

ASCUS PAP

T/F

If a patient has a ASCUS PAP, you can rule out HSIL

FALSE

What are the Low Risk HPV's?

HPV 11, 16, 42, 43, 44

what does CIN 1 stand for?

what does CIS stand for?

Cervical Intraepithelial Neoplasm 1

Carcinoma In Situ

What is the purpose of a Colposcopy?

When would you do it?

To Examine the Cervix and Lower Genital Tract Epithelium under Magnification.

ASCUS x 2 with 2nd > or =.

ASCUS with HPV +

ASC-H

HSIL

LSIL
AGC and No endometrial Pathology

Why do a Colposcopy?

Gross visible palpable mass

abnormal cervical cytology

cant get good cytology do to inflamation

diethylstilbestrol exposure DES

Unexplaned discharge

Unexplained bleeding

Hx of neoplasia

surveilance

What does SERMS stand for?

Selective Estrogen Receptor Modulators

What is the average age of Menarche?

12

What is the average age of Menopause?

50

How many menstrual cycles does the average American Woman have and whate are the health risks?

400

Increased risk of Breast and Uterine Cancers due to Cyclical proliferation.

What is the predominant Estrogen in Human Females?

Estradiol 17 Beta

What are the "good" effects of Estrogen?

Prevents Osteoporosis

increases HDL

Decreases LDL

Neuroprotective and enhance cognition

What is ERalpha ?

What gene makes it?

What tissues express it?

Estrogen Recepotr alpha

ESR1

Endometrium, Breast, Breast Cancer, Ovarian Stroma, Hypothalamus

What is ERbeta?

What gene encodes it?

What tissues express it?

Estrogen Receptor beta

ESR2

Kidney, Brain, Bone, Heart, Lung, Intestine, Prostate, Endothelial cells.

T/F

Estrogen inhibits most Cancers that develop in the Breast and Uterus.

False

Estrogen further stimulates most of these Cancers. (70% and they are called estrogen receptor positive cancers)

T/F

SERMS  agonize some ER and antagonize other ER.

TRUE

What is Tamoxifen?

What are all the things it does?

1st SERM

Antagonist: to Breast ER

Used to treat ER+ Breast cancer

Agonist:  Uterine, Bone, Cardiovascular tissue

! Increases risk of Thrombus !

Increases risk of Endometrial cancer

May be used to prevent Breast Cancer in High Risk Patients but risky

What is Raloxifene?

How does it work?

What does it do?

SERM

Used to prevent Osteoporosis in postmenopausal women

Estrogen Antagonist in Uterus

Reduces risk of breast cancer

Fewer uterine cancers and blood clots than tamoxifene

What is Toremifene Citrate?

How is it used?

How is it like Tomoxifene?

How is it different from Tomoxifene?

SERM

Used to treat malignant breast cancer.

It is a bone and cholesterol metabolism agonist like Tomoxifene

It is a breast and uterus antagonsit unlike Tamoxifene

How do you get Estrogen in Men?

You aromatize Testosterone

Vaginal Adenosis

Remnant of columnar endocervical-epithelium extending further into the vagina that may persist.

Red granular areas contrasting with normal pale pink vaginal mucosa

Adenosis is very high in pt's with DES exposure in Utero

What type of carcinoma can be associated With DES asociated Adenosis?

Clear Cell Carcinoma

What is the 2nd most common Cancer among Women Worldwide?

Cervical Carcinoma

What 4 organisms may cause more significant acute or chronic Cervicitis?

Why do we want to treat this?

Gonococci

Chlamydiae

Mycoplasmas

Herpes simplex virus

They can cause Upper GI disease,

Complications during Pregnancy,

Sexual Transmission,

Atypia

Endocervical Polyps

Benign, exophytic growths, can cause irregular "spotting",  mucoid lesions,  dilated mucin secreting endocervical glands

What cells do HPV infect?

What tissue locations?

Immature Basal Cells of Squamous Epithelium.

Thus,  it can infect in the tranzitional zone of the cervix where you have sqamous metaplasia,  or where there is a tear in the tissue so that the basal layer is exposed.

T/F

HPV replication occurs in the maturing squamous cell.

True

What cellular changes does HPV replication cause?

What is a cell called that is infected with HPV?

Nuclear atypia, and perinuclear halo

Koilocytes

HPV may also infect glandular cells or neuroendocrine cells of the cervical mucosa.... 

what malignancies can develop from this,

and why are they uncomon?

adenocarcinoma

adenosquamous carcinoma

neuroendocrine carcinoma

HPV does not replicate well in these cells

LSIL's

associated with productive HPV infection.

no significant disruption of the host cell cycle

most regress spontaneously

will not progress directly to invasicve carcinoma so not viewed as premalignant

Do Theca cells have LH receptors or FSH receptors and what hormone do they make?

They have LH receptors

They make Androgen

Do you have LH receoptors or FSH receptors on Granulosa cells and what hormones do they make?

Initially you have only FSH receptors and the Granulosa cells make Estrogens from the theca cell androgens (when FSH binds to the receptor, aromatase enzyme is activated)

Later you have LH receptors on the Granulosa cells also, they will need LH stimulation to make progesterone later as the corpus luteum

How does Estrogen effect LH and FSH?

Initially estrogen inhibits LH and FSH. Estrogen levels are high and then lower.  Then the estrogen seems to prime the anterior pituitary.   After priming, an estrogen surge causes an LH, FSH surge.

What is the enzyme of Ovulation?

What does it do?

Hyaluronidase

degrades CT etc keeping the ovum in.

What is the role of Human Chorionic Gonadoptropin Hormone?

Who makes it?

How do we use it?

It is made by the implanting ovum

it maintains the Corpus Luteum as LH starts to decline.

The Placenta takes over progesterone synthesis later.

Vaginal Ring/ Nuva Ring

Most popular

contains Estradiol and progestin

inhibits ovulation

Copper IUD

One of most effective

Painful initially

Incresed bleeding and cramping during menses

Name the Contraceptive choices that are

"effective" only

Fertility awareness

cervical cap

Spermicide

List the contraceptive choices that are

"moderately effective"

Condom

Diaphragm

Sponge

List the contraceptive choices that are

"very effective"

(all the hormonals)

Vaginal ring

Pill

Patch

injectable

What is the major con of Injectible hormonal contraceptive, and how often do you need it?

Late return of fertility

take it every 3 months

List the contraceptive choices that are

"most effective"

Copper IUD

Implants

Sterilization

What are some important aspects of the sponge?

Not good for multiparous women

you can get it over the counter

some STI protection

How does suckling act as a contraceptive

Suckling disrupts GRH

baby has to suckle often

What are some risks of Combined Estrogen-progestin contraceptives?

Thromboembolis, Stroke, MI

What are some cons of Progestin only contraceptives?

No defense against cysts

Breakthrough bleeding

T/F

Implant contraceptives contain/emit hormones

True

Implant Contraceptives

What is their MOA

How long can they be left in

What are their side effects/risks

They emit Estranogestril

They can be left in for 3 years

They cause irregular bleeding

They increase the risk of thromboemboli

What is the MOA of Progesterone IUD's

What are its SE

How long can it stay in

It does NOT stop ovulation, it prevents capacitation, increases cervical mucus and changes the endometrial lining.

There is pain on insertion.  It improves menses, may have a menorrhea in one year... Imediate return to fertility.  strings may be felt.

It can be left in for 5 years

Plan B

must take within 5 days of intercourse

Progestin only

Stops Ovulation

Sterilization for men

Vasectomy

office proceedure

very easy, very safe, relatively inexpensive

Name the 2 important Vulva disorders

describe them

describe how they differ

Lichened Sclerosis: thin epidermis, hyper keritanosis, parchment pale gray thin.  Present with puritic, painful, scaly, opaque, plaque like mucosal lesions

Squamous hyperplasia:  thickened epithelium with hyper keritosis.  increased mitotic activity. Present with puritic, painful, scaly, opaque, plaque like mucosal lesions

one is thick the other is thin.

Vulvar Carcinomas

Type 1:  HPV associated,  seen in younger people, associated with other lesions as well

Type 2:  Not HPV associated.  associated with lichened sclerosis.  worse prognosis than type 1. p53 mutation

Cervical HPV infection

High risk HPV infection is associated with both LSIL and HSIL.  It is also associated with CA (16,18)

Low risk HPV infection is associated with LSIL only.  It is associated with Warts... 11, 6

T/F

squamous metaplasia is occuring regularly in the transformation zone

True

What is a Condyloma?

It is a type of Low grade intraepithelial lesion

Gential warts from hpv are condyloma acumunada

What are the common progressions of LSIL and HSIL?

LSIL are most likely to regress (60%)

LSIL are lest likely to progress to HSIL (10%)

HSIL are most likely to persist (60%)

HSIL are least likely to progress to CA (10%)

What does DUB stand for?

What does it represent?

Disfunctional Uterine Bleeding

Abnormal bleeding NOT caused by any underlying organic abnormality

What causes abnormal uterine bleeding in the prepucescent female?

Precocious puberty

can be hypothalmus, pituitary, or ovary related

What are the causes of abnormal uterine bleeding in the

ADOLESCENT

Anovulatory cycle

Coagulation disorders

What are the causes of Abnormal Uterine Bleeding in the

Reproductive Female

Complications of Pregnancy

Organic lesions

DUB (anovulatory cycle, inadiquate Luteal phase)

What are the causes of abnormal uterine bleeding in the

Perimenapausal Woman

DUB (anovulatory cycle, irregular shedding)

Organic lesions

What are the causes of abnormal uterine bleeding in the

Post menapausal women

Endometrial atrophy

Organic lesions

What bug primarily dominates normal vaginal and cervical flora

and why is this a good thing

Lactobacillus

this is good because they secrete lactic acid keeping the vaginal pH below 4.5.  this low pH suppresses other bugs.... also, at this low pH the Lactobacilli will make H2O2 which is bacterocidic... another defense mech.

Dyspareunia

Painful intercourse

What is included in the definition of Sexual Dysfunction

persistant or recuring decrease in sex drive

aversion to sexual activity

can't become aroused

can't achieve orgasm

Dyspareunia

What if sexual function is not distressing to a woman but is to her male partner?

She gets the diagnosis of DSMIV

what percent of women worldwide experience sexual dysfunction?

40%

What are the most common reported sexual dysfunctions?

low desire(#1)

unable to achieve orgasm (#2)

Where is sexual dysfunction most common

Where is it lease common?

Most: Southeast Asia

Least: North Europe

what is the percentage of female sexual dysfunction in the US

43%

T/F

Sexual Dysfunction can be an indication of both serious medical conditions and marital discord

True

How Can LOW estrongen

(hypoestorgenization)

cause sexual disfuction

Decreased Lubrication

Decreased vasocongestion during arousal

decreased libido and resonsivity

T/F

Adrenal Androgens decrease throughout a woman's reproductive life

True

Do Androgens play a role in female sexual dysfunction?

NO

What is PCOS?

PolyCystic Ovary Syndrome

it is an endocrine dz

women produce alot of Androgens

infertal, obese, anovulatory,

Strong correlation with insuline resistance and obeisity

T/F

Post meopausal women may get some benefit from testosterone... to increase sexual function

True

Why are Sexual disorders classified in the DSM-IV?

Because they disrupt interpersonal relatioships and cause psycological distress

What are the 6 specific Sexual Dysfunction diagnosis

Hypoactive sexual desire disorder

Sexual aversion disorder

Female sexual arousal disorder

Female Orgasmic disorder

Dyspareunia

Vaginismus

25% of pts with SD have depression

T/F

SSRI's and benzodiazepines affect libido

True

What 2 GYN pathologies can cause Sexual dysfunction?

Endometriosis

Uterine Fibroids (especially anterior or fundal)

both conditions may cause deep dyspareunia

What Endocrine Conditions can cause Sexual dysfunction?

Diabetes --- decreased sensation

Hyperprolactinemia --- decreased drive, lubrication, orgasm, pleasure etc.

Renal failure + dialysis ---- anovulation and the burdon of a serious medical illness

HTN --- beta blockers can cause SD

Cancer and cancer treatment

What types of Pelvic floor or Bladder dysfunctions can cause SD?

Urinary incontinance

Prolapse

Intersticial cystitis

---high rates of dyspareunia

Adenomyosis

Thickening of the endometrium into the myometrium

Progestin only pills

mini pills

Patch has increased risk of clots over pill

erectile disfunction for 3 months before you worry

what can cause erectile dysfunction

psychological

peyronie dz (scar tissue, penis errects around it... curving)

H2 Receptor blockers (heart burn)

marajunana

cigarettes

Hydrachlorothiazide... diuretic

15 % of impotent men have undiagnosed DM

overnight... all of a sudden i coulndn't get an erection

think hyperprolactinemia

bublocavernosus reflex

evidence of neurological deficiet related erectile dysfunction if not present.

squeez head of penus and anal sphinter contracts.

What tests to order for ED

Serum testosterone

glucose

thyroid function (classic but low yield)

what do you do for ED

Hormone replacement with testosterone

(low dose testosterone with phosphodiesterase inhibitor (viagra) blood flow doubles)

Vacume pumps are very safe (prefers to any over aproach)

vascular surgery not a good idea

Prostaglandin E 1 is very safe

Phosphodiesterase inhibitors

How do phosphodiesterases work

Powerful smooth muscle relaxers

cGMP relaxes the courpoura muscle and blood flow enters the space

Phosphodiesterase 5 breaks down cAMP cGMP so that your erection goe's away

these drugs block the break down of phosphodiesterase

you can get priapism  ... prolonged erection.

phosphodiesterase inhibers... who they are they

viagra

cialis

maine side effect of phosphodiesterase inhibitors

temporary inability to distinguis blue and green

what is the ONE contraindication for phosphodiesterase inhibitors?

If patient taking Nitroglycerin

too much irreverisible vasodilation.

Premature ejaculation

one min after vaginal penetration

or occurs too early to even aproach what your partner would want to do at least half the time

zoloft is aproved.... can take a few hours before hand

Nicotene may inhibit sexual arousal in women

Bellknocker defect of the testicle

testicle is twisted... so more likely to progress to complete torsion... and ischemic damage

Testicular cancer

60% are seminomas

all age gorups are suseptible

retic-crystals (its a leydig cell, a non-germ cell tumor of the testicle)

if  you suspect testicular cancer

you do a physical exam

you transilluminate it... to distinguish between a solid neoplastic mass and a hydrocil cyst which would illuminate.

get a blood test to see if HCGBeta (which is comonly secreted by some cancers such as seminomas)

3 kinds of Seminomas

get blood tests to distinguish

alpha fetal protian

HCG beta

Seminoma treatment

they are very radiosensitive

so radiation works well

Chemo works in most cases of NON-seminomas

cryptic orchidism

vrs retractile testicle

cryptic orchidism doesnt densend manually at all

the retractile testicle can be descended manually but then pops back in.

True cryptorchidism has a high incidence of testicular cancer

all chemotherapies for non-seminoma testicular cancers work by disrupting DNA

choriocarcinomas are more common in females

however it can occur in males and this one has the hightes amount of alpha fetal protein... true choriocarcinoma has 5% survival rate.

#1 cancer of female genital tract

endometrial cancer

function cysts of ovary

follicular cysts

luteal cysts

thecolutean cysts

the are functional cysts because they are part of the normal process of menstruation.

CA 125 in endometrial cancer diagnosis

it is elevated in over 50% of patients with endometiral cancer.

excess bleeding into the corpus leuteum causes a:

corpus leuteal cyst

Complications from ovarian teratoma are

torsion of the ovary, rupture of the teratoma

conservative fibroid treatment

monitor because less than 1 % malignancy rate

triad of

unilateral pain

pos HCG test

mass

is classically associated with ectopic pregnancy but more often is due a certain cyst during early pregnancy

corpus luteal cyst

common themes

of

Ovarian dz

pain

pelvic mass

endocrine abnormality

US most acurate way to evaluate the ovaries

often hard to distinguish between benign and malignant

treatment is more often surgican than medical

benign cystic teratomas are also called

dermoids

most common treatment for endometrial cancer is

total hysterectomy plus BSO, bilateral salpingo ooferectomy

which functional cyst is most commonly b/l

thecolutean cyst

long term OCP use or the myrena OUD provide protection from this type of cancer

endometrial cancer

teretoma

fibroma

mucinous cyst adoma

serous cyst adoma

brenner cell

these are all benign neoplasms of the ovary

how do you treat uterine fibroids

Oral contraceptives

corpus luteal cysts are more imortant clinically then folicular cysts

follicular cysts usually occur in this populaiton

young menstruating women

Uterine lyomyoma

another name for uterine fibroids

endometrioma

neoplastic growth of the ovarium endometrium

what is the most common ovarian cyst

follicular cyst

slow growing at 2 mm per year is the most common ovarian neoplasm in prepubertal girls

teratoma

endometrioma

endometrium that has migrated where it shouldn't be and is now reasonding to hormone (endometirosis).  it becomes and endometrioma when it form a cyst

surgical removal

follicular cysts  are lined with granulosa cells and therefore secrete estrogen

treatment for adenomyosis

Surgury

teratomas cause torsions

mymectomy (fibroid ectomy) --- takes out portion of endometrium

hystorectomy --- takes out whole uterus

most endometrial cancers of this type

adenocarcinoma

adnexal torsion

involves the ovary and the falopian tupe

fibroids more common in 4 and 5 decade

can use GnRH agonsist to shrink fibroids before surgical excision.

Bacterial vaginosis

white non inflamatory discharge

culture

clue cells

pH > 4.5

should be treated even if asymptomatic

Syphilus

chancare.... non painful skin lesion

Treponemum pallidum

Benzathine penicillin G

Genital Herpes Simplex

painful ulceration

only 22% are symptomatic

Gonorrhea

Urethritis male

urogenital infection in the female

Gonorrhea and Chlamydia infect together

Purulent urethral discharge

Cefixime and Ceftriaxone

Non-gonococcal Urethritis

mostly Chlamydia trachomatis

urethral discharge is not usually purulant as gonorrhea

mild dysuria, mucoid dishcharge

Elemental body stage of chlamydia... very resistant to heat and drying.. infections

Reticualte body stage --- it divides

Pediculosis Pubis

Crabs

can see with naked eye (one in a bottle) lice or nits on pubic hair

Permethrin

Lindance shampoo

Scabies

mite

"the itch"

cannot see

horrendous itching

rash and puruitis for sev weeks

can survive off host for several days

Permetherin cream

Norwegian scabies

Much harder to treat!

Adenocarcinoma

less frequent than squamous cell

if invasive: abnormal bleeding

HPV 18

stage 2... beyond cervix

stage 4.... other organs

Chronic endometritis

PID --- bacterial infection

IUD increase risk

you should see neutorphils and lymphocytes in the endometirum

but never plasma cells (these mean endometritis

Endometrial Hyperplasia

premalignant condition

caused by prolonged estrogen stimulation

endometrial architexture is simple(dilated glands) or complex (dilated glands and glandular crowding)

cytology:  w/ or w/o atypia

Atypia indicates premalignant and may progress to endometiral carcinoma

Leiomyoma

Benign tumors of uterus

benign smooth muscle tumor

very common

can be submucosal, intramural, subserosal, pedunculated

Endometiral Carcinoma

malignant tumor of uterus

middle aged to menopaus

abnormal bleeding

from prologed estorgen stim

almost always endometrioid adenocarcinoma but can allso be squamous cell

Serous Endometiral Carcinoma (very aggressive p53 mutation)

Malignant mixed mullerian tumor (MMMT) (aggressive...both glandular and stromal malignant components.... big bulky polypoid lesion

Leiomyosarcoma

NOT from a fibroid

arisis DE NOVO

look for mets in lungs