Term
| After puberty there are approximately 400,000 primordial follicles present, what is it about these ovum that cause fertility to decrease with age? |
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Definition
| Ova are highly vulnerable to damage and only undergo ovulation when their development coincides perfectly with the menstrual cycle. |
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Term
| The follicular phase of menstruation occurs during what time? |
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Definition
|
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Term
| What does LH act in developing follicles to induce testosterone production? |
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Definition
|
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Term
| What cells convert testosterone to oestrogen under FSH influence? |
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Definition
|
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Term
| How do granulosa cells inhibit further FSH production? |
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Definition
| By producing inhibin creating a negative feedback to the piuatry |
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Term
| What do oestrogens stimulate? |
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Definition
| Endometrial lining growth, follicle development and changes in cervix secretion to allow for sperm entry |
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Term
| What occurs at days 14 of the menstrual cycle? |
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Definition
|
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Term
| What happens to oestrogen and LH levels during the follicular phase? |
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Definition
| Increasing [Oestrogen] leads to ↓LH secretion by acting on α-receptor as a negative feedback. |
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Term
| What happens to oestrogen and LH levels prior to ovulation? |
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Definition
| Oestrogen levels pass threshold activating oestrogen-receptor-β and overriding α-receptor therefore begin to Stimulate ↑LH production |
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Term
| The peak of LH levels in the menstrual cycle leads to what? |
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Definition
| The release of the ovum as follicle ruptures and increased testosterone levels therefore discouraging further follicle development |
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Term
| What happens to the ruptured follicle post ovulation? |
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Definition
| Becomes corpus luteum, theca cells undergo atrophy and granulosa cells undergo hypertrophy. |
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Term
| The luteal phase of menstruation occurs during what time? |
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Definition
|
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Term
| LH stimulates what from the corpus luteum? |
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Definition
| Progesterone production rsulting in growth and preservation of the endometrium and a change in cervical secretions to stop sperm entry |
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Term
| What causes luteolysis of the corpus luteum? |
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Definition
| Approximately 14 days post ovulation, LH decreases (progesterone negative fedback) and oxcytocin/prostaglanding production increases. |
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Term
| Progesterone withdrawal in days 1-7 of the menstrual cycle results in what? |
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Definition
| Constriction of the endometrial arterioles and invasion of endometrium by leukocytes resulting in menstruation. |
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Term
| What is primary dysmennorhoea? |
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Definition
| Painful periods beginning within 1-2 years of menarche. No underlying pathology. |
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Term
| What is secondary dysmennorhoea? |
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Definition
| Painful periods after years of normal periods. May be caused by Endo/adenometriosis, fibroids, PID, IUDs. |
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Term
| What is the most common cause of menorrhagia and how is it diagnosed? |
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Definition
| Dysfunctional uterine bleeding. Diagnosis of exclusion |
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Term
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Definition
| Benign tumour of uterine smooth muscle. Grow in response to oestrogen/progesterone |
|
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Term
| What symptoms would you expect with a submucosal fibroid? |
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Definition
| Menorrhagia and may also reduce fertility. |
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Term
| What symptoms would you expect with an intramural fibroid? |
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Definition
| May produce menorrhagis, most common fibroid. |
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Term
| What symptoms would you expect with a subserous fibroid? |
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Definition
|
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Term
| Name the symptoms and signs of fibroids |
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Definition
Symptoms
Menorrhagia +/-Dysmenorrhoea - Submucosal+/-intramural most likely to cause
Dyspareunia - May occur depending on site
Infertility - May prevent implantation/cause miscarriage, particularly in subserous
Abdominal Fullness, Painful Defaecation, Urinary Frequency/Obstruction
Signs
Abdominal Mass - Slow growing, and rarely felt by pt unless v. large |
|
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Term
| Define endometriosis and adenometriosis |
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Definition
Adenomyosis - Endometrial tissue in muscle layer of uterus
Endometriosis - Endometrial tissue outside uterus |
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Term
| With endometriosis, is dysmennorhoea or menorrhagia a more common symptom? |
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Definition
|
|
Term
| What are chocolate cysts? |
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Definition
| Ovarian cyst caused by endometrial bleeding into cyst during menstruation. |
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Term
| How would endometriosis cause infertility? |
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Definition
| Scarring uterosacral ligaments or fallopian tubes. |
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Term
| What pharmacological treatments are there for endometriosis? |
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Definition
| Analgesia (NSAIDs, paracetamol), progestogens (maintain endometrium), GnRh analogues. |
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Term
| What surgical treatments are there for endometriosis? |
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Definition
| Ablation/excision of ectopic endometrium. Total hysterectomy and bilateral salpingo-oophrectomy |
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Term
| In a presentation of menorrhagia what investigations should be carried out? |
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Definition
FBC - To check for Anaemia
Swabs - High Vaginal & Endocervical - To check for PID (e.g. Chlamydia/gonorrhoea)
Consider USS - To check for fibroids, endometriosis, free fluid in peritoneum if ↑ suspicion
CT/MRI
Refer for Endometrial Biopsy - To exclude endometrial cancer. |
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Term
| What factors would make you more suspicious of endometrial cancer in a patient with menorrhagia? |
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Definition
| Persistent intermenstrual bleeding, >45YO and failure of other treatments. |
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Term
| What is the first line treatment for menorrhagia? |
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Definition
| Mirena coil, consider iron if anaemic. |
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Term
| What is the second line treatment for menorrhagia? |
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Definition
|
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Term
| What short term management should be considered for a patient with menorrhagia? |
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Definition
| Norethisterone- synthetic progesterone whihc rapidly stops bleeding. |
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Term
| In a patients with menorrhagia what treatments would you consider to reduce and control the bleeding? |
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Definition
Tranexamic acid- antifibrinolytic, given during menstruation to reduce bleeding.
Mefenamic acid- NSAID, given contiuously, not as effective as tranexamic. |
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Term
| Name a GnRH analogue and describe how it would work to treat menorrhagia. |
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Definition
| Leuprorelin, triptorelin. Mimic GnRH action on hypothalamus negative feedback therefore reducing LH, FSH and oestrogen and causing amenorrhoea. Should only be used for 6-12 months due to side effects caused by drop in oestrogen. |
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Term
| What surgical treatments are available for menorrhagia and when should this only be considered? |
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Definition
Endometrial ablation (20% require repeat after 5 years) and hysterectomy.
Should only be considered once the patients family is complete. |
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Term
|
Definition
|
|
Term
| What pH is seminal plasma and why? |
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Definition
| 7.5, slightly alkaline, in order to buffer vaginal acidity. |
|
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Term
| What is seminal plasma made up of? |
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Definition
| White cells, sugars, prostaglandins, proteins and sperm. |
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Term
| How many sperm cells are found in 1 typical ml of seminal fluid and how many of these are normal? |
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Definition
| >15million/ml only 5% normal. |
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Term
| What is the function of the acrosome in a sperm cell? |
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Definition
| Contains enzymes to digest through the zona pellucid. |
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Term
| What is the function of the head if a sperm cell? |
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Definition
| Contains nuclear material |
|
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Term
| What is the function of the midpiece of a sperm cell? |
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Definition
| 'Engine room' contains mitochondira to power flagellum |
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Term
|
Definition
| Must undergo capaciatation in fallopian tubes for approx. 24 hours before penetrationg the zona pellucida (Ca2+ influx to cell must occur) |
|
|
Term
| Prior to ovulation how is the ova stored? |
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Definition
| In suspended meiosis half way through the first meiotic division. |
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Term
| How does the ovum move from the ovary to the fallopian tube? |
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Definition
| Collected by the mobile fimbrial ends chemotactically attracted to the ovum upon rupture of the follicle and therefore ovulation. |
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|
Term
| Where does fertilisation usually occur? |
|
Definition
| Ampulla of fallopian tube |
|
|
Term
| What are the four most common causes for subfertility? |
|
Definition
Sperm Dysfunction (30%)
Ovulation Disorder (25%)
Tubal Disease (20%)
Endometriosis (10%) |
|
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Term
|
Definition
| The absence of sperm in the ejaculate. This can be caused by failure of sperm production or the inability of sperm to reach the urethra. |
|
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Term
|
Definition
| Decreased sperm concentration |
|
|
Term
| What is asthenozoospermia? |
|
Definition
|
|
Term
| What is teratozoospermia? |
|
Definition
|
|
Term
| How do you treat infertility caused by sperm dysfunction? |
|
Definition
IVF & Intracytoplasmic sperm injection
Donor insemination |
|
|
Term
| What can cause hypothalmic pituitary dysfunction leading to subfertility? |
|
Definition
| Eating disorders, excessive excercise, adenoma, prolactinoma and drugs |
|
|
Term
| How can polycystic ovary syndrome cause subfertility? |
|
Definition
| Increased androgens leads to decreased or absent ovulation. |
|
|
Term
| How can polycystic ovary syndrome be treated? |
|
Definition
Oestrogen antagonists e.g.Chlomiphine citrate
Synthetic FSH- stimulates ovulation |
|
|
Term
| What may cause tubal disease resulting in subfertility? |
|
Definition
Infection e.g chlamydia
Inflammatory process 2ry to endometriosis?
Trauma/Surgical damage |
|
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Term
| How can tubal disease resulting in subfertility be treated? |
|
Definition
Cuff salpingostomy- hole cut allowing for ovum to pass through
Ablation of endometriosis
IVF |
|
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Term
| Describe the technique of intrauterine insemination |
|
Definition
| Ovulation monitored or aided (βhCG may be given to trigger ovulation), washed and prepared sperm injected into uterus. |
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Term
| Describe the technique of in-vitro fertilisation |
|
Definition
oOva (usually 8-10) extracted via transvaginal USS-guided needle
oSperm selected (e.g. via motility tests), washed, prepared & injected into ovum
oZygote cultured for 2-5 days, and successful embryos inserted into uterus via catheter |
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Term
| What is the role of Human Chorionic Gonadotrophin (hCG)? |
|
Definition
Maintains the corpus luteum and therefore maintains progesterone levels.
Pregnancy marker, level doubles every 24 hours in 1st trimester. |
|
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Term
|
Definition
| Developing embryo and syncitiotrophoblast. |
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Term
| What percentage of recognised pregnancies miscarry? |
|
Definition
| 20%, 80% of these in the first trimester. |
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Term
| What risk factors increase the chance of miscarriage? |
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Definition
| Increasing maternal age, stress and threatened miscarriage (vaginal bleeding without cervical dilatation) -~50% may miscarry |
|
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Term
| What are the signs/symptoms of miscarriage? |
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Definition
Vaginal bleeding/passage of tissue.
Abdominal pain/cramping (middle or bilateral with no cramping)
Dilated cervical Os |
|
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Term
| What investigations would you carry out if suspecting a miscarriage? |
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Definition
β-hCG Assays, confirm pregancy, doesnt rule out ectopic pregnancy.
USS, transvaginal to find foetal heartbeat. |
|
|
Term
| What is the most common management approach for miscarriage? |
|
Definition
| Watch and wait, most complete spontaneously. |
|
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Term
| Why would you use mifepristoneand what is it? |
|
Definition
| Competitive progesteron receptor antagonsit. Primes for clearance of miscarriage/scheduled abortion by softening endometrium and dilation/softening of the cervix. |
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|
Term
| Why would you use misoprostol and what is it? |
|
Definition
| Synthetic PGE1 analogue. Softens cervix and causes contractions. Induces labour and clearance. |
|
|
Term
| Where is the most common site for ectopic pregnancies? |
|
Definition
| 95% occur in fallopian tubes. |
|
|
Term
| What risk factors increase the risk of ectopic pregnancy? |
|
Definition
Previous PIC, ectopic or tubal surgery.
Smoking
Increasing maternal age |
|
|
Term
| Clinical features of ectopic pregnancy normally occur in the first 5-8 weeks. What are these? |
|
Definition
Pain (usually unilateral)
Tenderness (dyspareunia and cervical excitation)
Amenorrhoea
Vaginal bleeding
Nausea, vomiting and GI symptoms. |
|
|
Term
| If you are suspecting an ectopic pregnancy, what investigations should you carry out? |
|
Definition
βhCG Assays - To confirm pregnancy & monitor development
Trans-Vaginal USS - To locate pregnancy
Laparoscopy - To locate & remove pregnancy |
|
|
Term
| In a pregnancy of unknown location, why would you sue methotrexate? |
|
Definition
| Folate antagonist, therefore prevents DNA/RNA/protein synthesis in rapidly dividing cells. |
|
|
Term
| Which two non pharmacological methods might you use in a pregnancy of unknown location? |
|
Definition
Conservative approach, monitor via weekly scan and 2xweekly hCG assay, 50% resolve.
Salpingectomy |
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