hirsuitism
free testosterone is predominantly synthesized in the ovary
DHEA-S - 95% from adrenal
hirsuitism - testosterone level (esp free) and DHEA-S levels
- can tell the origin - most commonly of ovarian origin
PCOS
FSH is suppressed and LH is increased
LH - responsible for hormone synthesis in theca interna
- 17-ketosteroids (DHEA and androstendione) –> testosterone
- testosterone travels to granulosa cells - converts testosterone into estradiol, using aromatase
obesity - aromatase
- testosterone –> estradiol (strong estrogen)
- androstendione –> esterone
estrogens confer increased risk of endometrial hyperplasia and endometrial carcinoma
ovarian cysts - FSH prepares the follicle, suppressed FSH means follicle degenerates
seen on pelvic exam, US
dysmenorrhea
primary - too much PGF - PG increases contraction of uterine muscular
secondary cause - endometriosis
- Asherman syndrome –> infertile
dysfunctional uterine bleeding - due to hormone imbalance (not an anatomic reason)
- anovulatory cycles - most common cause of abnormal bleeding from menarche to 20 years of age
- persistent estrogen, not enough progesterone - endometrium sloughs off when stroma can no longer hold it - inadequate luteal phase
- irregular shedding of endometrial
Rokitansy-Kutser-Hauser syndrome
mullerian agenesis
amenorrhea
first step - pregnancy test
primary amenorrhea - Turner syndrome
- no bar body
- defects in lymphatics - swelling of hands and feet in a newborn, webbed neck (cystic hygroma - dilated lymphatics in neck)
- fourth metacarpal is underdeveloped - knuckle knuckle dimple knuckle
(- note - knuckle knuckle dimple dimple is pseudohypoparathyroidism)
- pre-ductal coarctation
- menopause before menarche - no follicles in ovary (streak ovary), susceptible to dysgerminomas
- loss of ovarian follicles by age 2
- high LH and FSH levels
adenomyosis
does not predispose to cancer
v. s. endometriosis
- *ovary, pouch of Douglas
endometrial adenocarcinoma
55 yo post-menopausal woman
bleeding after the onset of menopause
leiomyoma
NOT a precursor for leiomyosarcoma
ovarian masses
most common cause of an ovarian mass = follicular cyst
- rupture common cause of sudden onset pain - sterile cyst fluid can cause peritonitis
BUT if you can palpate an ovary in a woman over 55 - cancer until proven otherwise
cancer < 35 yo benign, >35 yo malignant
surface derived - serosal surface, most common ovarian tumor
- serous cystadenoma - benign
- serous cystadenocarcinoma - malignant, Psammoma bodies
- bilateral
germ cell types (identical to male tumors)
- cystic teratoma - most common overall germ-cell tumor, benign, struma ovarii
- choriocarcinoma - (synctiotrophoblast is outer layer…)
- complete mole
- 50% of choriocarcinomas –> choriocarcinoma
- 25% from spontaneous abortion
- 25% from normal pregnancy
- no chorionic villi, mets to lungs, responds excellently to chemotherapy
sex-chord stromal tumors - hormone producing tumors
- fibroma (most common, benign) - MEIG syndrome - ovarian fibroma, ascites, and right-sided pleural effusion
- syndrome goes away when you take out the ovary - granulosa cell tumor - hyper-estrogenism
- Sertoli-Leydig cell tumor
breast lesions
nipple - lactiferous duct - major duct - terminal lobules, stroma
-glands lining the ducts are estrogen sensitive
most common cause of a mass in the breast in a women < 50 = fibrocystic change (estrogen responsive, lumpy-bumpy, mobile)
- sclerosing adenosis in terminal lobules - benign part of fibrocystic change
- woman over 50 - infiltrating ductal carcinoma
mobile tumor in women under 35 - fibroadenoma - stroma is neoplastic –> ducts look slit-like
Based on location
- nipple - Padget’s disease (rash on nipple)
- lactiferous duct - intraductal papilloma, most common cause of blood nipple discharge in a woman under 50
- major duct - most of the cancers from this site
- terminal lobules - lobular carcinoma (bilateral)
retracted, hard nipple
- when breast cancers invade stroma –> fibroblastic and elastic tissue response
- painless, palpable mass in a woman over 50 = cancer
- painful, under 50 - inflammatory change
first step in management of palpable mass - FNA (ddx + solid or cystic)
- same for cold nodule in a thyroid - FNA
comedocarcinoma - caseous necrosis
- ERB2 oncogene - aggressive cancers
peau de orange - inflammatory breast cancer (cancer goes to lymphatics)
- dimpled skin - lymphatics are plugged with cancer –> fluid has leaked out –> increased fluid and interstitium +ligaments
radical mastectomy
lymphedema
cut long thoracic nerve (C5-C7) - innervates serratus anterior, attaches to ribs and anterior face, medial border of scapula
- winged scapula
1) deltoid and supraspinatus abduct the arm to horizontal
2) serratus anteror and trapezius - rotates scapula upward
estrogen and breast cancer
reproductive period - estrogen is abundant –> receptors are downregulated
- ERA and PRA negative cancers
post-menopausal women - low estrogen levels, upregulated receptors
- cancers are ERA and PRA positive
- give tamoxifen - weak estrogen, anti-estrogen on breast and pro-estrogen on endometrium
- tamoxifen can help with osteoporosis
pelvic muscles
levator ani (3 muscles - iliocox, pubocox, puborectalis) = pelvic floor
bulbospongiosus - anterior pelvic floor
transverse perineals - posterior
cystocele - posterior bladder wall caves in at the base
urethral hypermobility - incomplete closure of the urethra and bladder neck against the anterior vaginal wall –> stress incontinence
v.s. detrusor overactivity - due to sacral lesion, autonomic neuropathies
external urethral sphincter - pudenal nerve
- internal urethral sphincter - SNS
utero-sacral ligaments (lateral) - weakening of ligaments leads to uterine/vaginal apical prolapse (sinks out/down)
spermatic cord
inner - internal spermatic fascia - derived from transversalis fascia
middle - cremasteric fascia - from internal oblique muscle
outer - external spermatic fascia from external oblique muscle
dartos muscle
scrotal fascia
pre-eclampsia
HTN (after 20 weeks) and proteinuria/end-organ damage
abnormal placental vasculature –> placenta hypoxia and ischemia –> antiangiogenic/inflammatory factors released into maternal blood –> endothelial damage and dysregulation of vascular tone
Peyronie disease
excess collagen formation in tunica albuginea –> pain and curvature of penis
