1
Q
name the parts of the hip bone
A
2
Q
name the parts of the pelvic girdle
(anterior view)
hint:
* ischium: (2)
* pubic: (2)
* ischium + pubic: (2)
* ilium: (4)
A
3
Q
name the parts of the pelvic girdle
(posterior view)
A
4
Q
differences bet male and female pelvis
A
- weight: bones of male are heavier
- shape of pelvic cavity: male’s one is narrow and deep
- pelvic inlet: male’s one is heart-shaped
- subpubic angle: male’s one is more acute
- coccyx: male’s one is less flexible and more curved
5
Q
what structures form the borders of the pelvic outlet
A
- pubic symphysis
- coccyx
- inferior ramus
(or ischiopubic ramus) - sacrotuberous ligament
6
Q
what structures form the borders of the pelvic inlet
A
- pubic symphysis
- promontory and ala of SACRUM
- illiopectineal/arcuate lines
7
Q
ligaments in pelvic wall
A
- sacrospinous ligament: bet sacrum and ISCHIAL spine
- sacrotuberous ligament: bet sacrum and ISCHIAK tuberosity
8
Q
functions of ligaments in pelvic wall
A
- provide stability to pelvis
- form passageways (greater and lesser sciatic foramens) for neurovascular bundles to pass through and enter the gluteal, thigh and perineal regions
mainly connecting pelvis to glutes and perineum
9
Q
muscles that make up the pelvic wall
A
- piriformis
- obturator internus
note: piriformis exits via GREATER sciatic foramen and attaches to the FEMUR
10
Q
(anatomical facts about the pelvic diaphragm/floor:
* muscular partition (i.e. its muscles) consist of (…) and (…)
* innervated by (…) and (…)
* males: (…) hiatus
females: (…) hiatus
A
anatomical facts about the pelvic diaphragm/floor:
* muscular partition (i.e. its muscles) consist of levator ani and coccygeus
* innervated by perineal branch of S4 and pudendal nerve (S2-S4)
* males: 2 hiatus (urethral opening + anal canal)
females: 3 hiatus (extra vaginal opening)
note:
* the perineal branch of S4 does NOT pass through any foramens,
enter pelvis directly
* pudendal nerve exits through greater sciatic foramen and re-enters through lesser sciatic foramen (recap!)
11
Q
what is the lateral origin of the levator ani
(i.e. where does it attach to laterally)
A
tendinous arch,
which is the thickened fascia of the obturator internus muscle
12
Q
functions of pelvic diaphragm
(or pelvic floor)
A
- support the pelvic viscera
- resist rise in intra-abdominal and pelvic pressure (e.g. coughing, lifting, straining) by counteracting with CONTRACTION of levator ani
- helps maintain continence via
puborectalis keeping the anorectal angle sharp → preventing leakage
and supporting anal sphincters
13
Q
what is the part of the pelvis which serves at the main weight-bearing point
(i.e. the part you sit down on)
A
ischial tuberosity
14
Q
anatomical facts abt pelvis:
* greater sciatic notch is located on (…) surface of (… portion of hip bone …)
* separated from lesser sciatic notch
(which is on (… portion of hip bone …))
by (…) (also on (… portion of hip bone …))
A
anatomical facts abt pelvis:
* greater sciatic notch is located on posterior surface of ilium bone
* separated from lesser sciatic notch
(which is on ischium)
by ischial spine (also on ischium)
15
Q
what structures pass through the greater sciatic foramen
1 muscle, 2 NAV,1 nerve
A
- piriformis
- superior and inferior gluteal NAV
- pudendal NAV (pudendal nerve + internal pudendal artery/vein)
- sciatic nerve
- superior and inferior gluteal NAV: motor innervation and blood supply to glute muscles
- sciatic nerve: motor AND SENSORY innervation to leg and foot muscles
pudendal nerve EXITS via greater sciatic foramen and RE-ENTERS via lesser sciatic foramen
16
Q
structures that pass through the lesser sciatic foramen
A
- obturator internus and nerve supplying it
- pudendal NAV (pudendal nerve + internal pudendal artery/vein)
- pudendal NAV: motor (and sensory) innervation and blood supply to perineum, sphincters and external genitalia
pudendal nerve EXITS via greater sciatic foramen and RE-ENTERS via lesser sciatic foramen
17
Q
what is the difference between diagonal conjugate and true conjugate
A
- diagonal conjugate: distance from sacral PROMONTORY to inferior portion of pubic SYMPHYSIS
⇒ what you can measure during a physical examination - true conjugate: distance from sacral PROMONTORY to closest point of pubic SYMPHYSIS
⇒ narrowest point fetus has to pass through
18
Q
clinical significance of diagonal and true conjugate
A
use in pelvimetry
* minus off 1.5cm from diagonal conjugate to estimate true conjugate
* if true conjugate < 10.5 cm
→ cephalopelvic disproportion
(clinically significant mismatch bet size and shape of fetus and maternal birth canal)
⇒ need Cesarean
19
Q
autonomic innervation of pelvis:
* sympathetic fibers: (…)
* parasympathetic fibers: (…)
* visceral afferent fibers:
1. above (…) follow (…) fibers (lumbar splanchnic) back to T10-L2 spinal segments
⇒ referred pain to lower abdomen, flank, lumbar
2. below (…): follow (…) fibers (pelvic splanchnic) back to S2-S4 spinal segments
⇒ referred pain to perineum and sacral dermatomes
A
- sympathetic fibers: lumbar splanchnic nerve
- ParaSympathetic fibers: Pelvic Splanchnic nerve
- visceral afferent fibers:
1. above pelvic pain line: follow sympathetic fibers (lumbar splanchnic) back to T10-L2 spinal segments
2. below pelvic pain line: follow parasympathetic fibers (pelvic splanchnic) back to S2-S4 spinal segments
20
Q
main artery supplying pelvis
= supplying all the pelvic organs
A
branches of internal iliac artery
21
Q
which lymph nodes drain the pelvis
= drain all pelvic organs
A
internal iliac lymph nodes
22
Q
which lymph nodes drain the structures in the perineum
split into 3:
1. majority
2. glans penis and clitoris
3. ovaries and testes
A
- majority drained by superficial inguinal lymph nodes
- glans penis and clitoris drained by deep inguinal lymph nodes
- ovaries and testes drained by para-aortic lymph nodes
23
Q
Perineum is divided into 2 triangles, urogenital triangle and anal triangle.
What separates them?
A
imaginary line between the 2 ischial tuberosities
24
Q
what are the contents of the urogenital triangle
A
- superficial perineal pouch
- deep perineal pouch
- external genitalia
- perineal membrane
- muscles (in the pouches)
25
what are the contents of the anal triangle
* anal canal
* 2 **ischiorectal fossa**:
**fat**-filled spaces lateral to anal canal
26
what is the urogenital diaphragm
| and what structures does it contain
* an area directly **inferior to the urogenital triangle**
* includes:
1. anterior part of pelvic diaphragm (and fascia in between)
2. deep perineal space
3. perineal membrane
4. superficial perineal space
5. colles fascia
27
structures in deep perineal space
* deep transverse perineal muscles
* urethra:
specifically **membranous** portion for males
* external urethral sphincter
* males: **bulbourethral glands** (NOT the duct tho)
females: part of **vagina**
28
what nerve is the external urethral sphincter controlled by
pudendal nerve
29
structures in superficial perineal space
* superficial transverse perineal muscles
* ischiocarvernosus, bulbospongiosus
* perineal branch of **pudendal** nerve
and perineal branch of **internal pudendal** vessels
* males: root of penis (bulb + cura)
females: root of **clitoris**
* females: Skene's (para-urethral) gland, greater vestibular gland
30
what does the ischiorectal fossa communicate with
| and the clinical implications
* deep post anal space, **posteriorly**
* potential space for the **spread of infections** from the anal canal or ischiorectal fossa
31
borders of ischiorectal fossa
32
ischiorectal abscesses:
* formed as ischiorectal fossa have (...)
* (local/systemic) antibiotics are used to treat it
and why
ischiorectal abscesses:
* formed as ischiorectal fossa have **poor blood supply**
⇒ predisposed to infection
* **CANNOT** be treated by **systemic** antibiotics
← again poor blood supply
* need **local** antibiotics and drainage
33
definition of perineal body
| what it is + location
tendon
located at **junction** of anus (NOT anorectal triangle)
and urogenital triangle
34
function of perineal body
serves as point of **attachment** for muscle fibers of
1. external anal sphincter and levator ani
2. deep and superficial transverse perineal muscles
3. bulbospongiosus muscle
## Footnote
NOT ischiocavernosus which is more **lateral** and anterior
35
anatomical facts about testes:
* located in (...), which is an (...) of anterior abdominal wall
* function: (...)
* supplied by (...) arteries
* drained by (...)
→ merge into (...)
⇒ drain into (...)
((...) vein drains **directly**, while (...) veins drains into (...) first)
* located in **scrotum**, which is an **outpoutching** of anterior abdominal wall
* function: produce **sperm**
* supplied by **testicular** arteries
* drained by **pampiniform venous plexus**
→ merge into a pair of **testicular** veins
⇒ drain into **IVC**
(**R** vein drains **directly**, while **L** veins drains into L **renal vein** first)
## Footnote
Testicular arteries arise DIRECTLY from abdominal aorta,
at level of **L2**
36
descent of testes:
1. where is it first located at
2. how does it descent
1. originate from **posterior** abdominal wall, **retroperitoneally**
2. **gubernaculum** anchors the **inferior** pole of the testis to scrotal SKIN
3. **peritoneum** evaginates to form **processus vaginalis**
(which creates the future **inguinal canal**)
4. pathway of descent: deep inguinal ring → inguinal canal → superficial inguinal ring → scrotal sac
5. processus vaginalis **obliterates** a few weeks before birth
(leaves behind a layer of peritoneum surrounding the testes = tunica vaginalis)
37
how is a **lower temp** maintained at testes
| lower than body temp by **2 - 4 ºC**
* cremaster muscle and dartos muscle:
(e.g. contraction → draws testes closer → reduce SA of scrotal skin exposed to cold ⇒ conserve heat)
* pampiniform plexus:
**countercurrent heat exchanger**
in which blood flow is in **opp direction** from testicular arteries
⇒ cooler venous blood **cools arterial blood** before it reaches testes
38
difference bet cremaster muscle and dartos muscle
| type of muscle + innervation
* cremaster: **skeletal** muscle,
innervated by **genitofemoral** nerve
* dartos: **smooth** muscle,
innervated by **sympathetic** fibers
39
what is the cremasteric reflex:
* stimulus
* afferent and efferent pathways
* spinal cord segments
* stimulus: gentle stroke on **inner thigh**
* afferent pathway: **illioinguinal** nerve
and *FEMORAL* branch of **genitofemoral** nerve
* spinal cord segments involved: **L1 and L2**
* efferent pathway: *GENITAL* branch of **genitofemoral** nerve
40
layers of testes
from superficial to deep:
1. skin
2. dartos fascia and muscle
3. colles fascia
4. external spermatic fascia
5. cremaster muscle and fascia
6. internal spermatic fascia
7. tunica vaginalis
## Footnote
how does it correspond to layers of abdominal wall:
1. skin → skin
2. **camper's** fascia → **dartos** fascia and muscle
3. **scarpa's** fascia → **colles** fascia
4. external oblique muscle → external spermatic fascia
5. **internal oblique** muscle → **cremaster** muscle and fascia
6. transversalis fascia → internal spermatic fascia
7. tunica vaginalis
transversus abdominis does NOT carry on
41
components of testes
(including bigger structures and cells)
* tunica ALBUGINEA:
(diff from tunica vaginalis)
dense **connective tissue** which serves as **outer covering** of testes
* **seminiferous** tubules:
structures in which **spermatogenesis** takes place,
contains **Sertoli cells**
* interstitial space (bet tubules):
contains **Leydig cells**
42
Sertoli cells:
* shape
* functions
* **columnal** cells
* functions:
1. (MOST IMPT) **support** and **nutrition** of spermatogenic cells
2. form **blood testis barrier**
3. secrete **androgen binding protein**
⇒ keep **high** local conc of **testosterone**
43
Leydig cells:
* function
* structures they contain
* function: **testosterone** synthesis,
produced in presence of **LH**
* contain **abundant SER** for steroid hormone (testosterone) synthesis
44
process of spermatogenesis:
* whole process takes (...) weeks
* process starts during (...), in which **spermatogonium** (germ cells) undergo (...)
→ become (...) spermatocytes
(23 chromosomes, 2C)
* (...) spermatocytes
(46 chromosomes, 4C)
then undergo (...)
→ become (...) spermatocytes
(23 chromosomes, 2C)
* 2º spermatocytes then quickly undergo (...)
→ become (...)
(23 chromosomes, C)
* (...) then undergo (...)
(= maturation/differntiation)
in (...)
to form (...)
* whole process takes **9-10 weeks**
* process starts during **puberty**, in which **spermatogonium** (germ cells) undergo **mitosis**
→ become **1º** spermatocytes
(23 chromosomes, 2C)
* 1º spermatocytes
(46 chromosomes, 4C)
then undergo **1st meiotic division**
→ become **2º** spermatocytes
(23 chromosomes, 2C)
* 2º spermatocytes then quickly undergo **2nd meiotic division**
→ become **spermatids**
(23 chromosomes, C)
* spermatids then undergo **spermiogenesis**
(= maturation/differntiation)
in **epididymis**
to form **mature spermatozoa**
## Footnote
memory tips!
* spermato**go**nium = **go**ing to become sperm cell
=> **germ cell**
* spermato*zoon* = *zoom*ing towards oocyte
=> *final mature form*
45
epididymis:
* location
* function
(overall, head, body, tail)
* located at **superior** and **posterolateral** side of each testes
* function: transports sperm from testes **to vas deferens** via
1. head: **receives** SPERMATOZOA **from efferent ductules**
2. body: **maturation** of SPERMATOZOA
(develop **motility**)
3. tail: **storage** of SPERMATOZOA until ejaculation
46
histology of epididymis
* **pseudostratified** COLUMNAR epithelium, consisting of
1. **prinicipal** cells
which has **stereocilia** to absorb water and residual bodies from testis
2. **basal** cells which **produce new cells**
47
Hydrocele:
* abnormal collection of (...) BETWEEN the 2 layers of the (...) of the testis
* 2 types: (...) and (...)
* abnormal collection of **serous fluid** BETWEEN the 2 layers of the **tunica vaginalis** of the testis
* 2 types:
1. Communicating:
where **processus vaginalis** remains **patent**,
and hydrocele **changes sizes** around the day
(usually smaller in morning, bigger at night)
2. NON-communicating:
where processus vaginalis is **closed**
48
what is a varicocele:
* definition
* cause
* appearance
* presenting features
* **enlargement** of **pampiniform** plexus
* due to **valve failure**
* bag of **worms** appearance
* presents with sharp to dull **discomfort**,
and **worsening** over the DAY
49
contents of spermatic cord
3x3
* arteries: *testicular* artery,
artery to *vas deferens*,
*cremasteric* artery
* nerves: genital branch of genitofemoral nerve,
sympathetic and parasympathetic fibers
* others: **VAS DEFERENS**, lymphatics (para-aortic), pampiniform plexus
## Footnote
* genital branch of genitofemoral: **motor** to cremaster,
**sensory** to *scrotum*
* sympathetic and parasympathetic: **vasomotor** and **visceral pain** to *testes and epididymis*
50
vas deferens:
* structure
* function
* **muscular** tube
⇒ strong **peristaltic contraction** to **expel** contents within a very short period
* functions to transport sperm cells FROM **epididymis**
to **prostatic urethra**
* joins with ducts of **seminal vesicles** to open into prostatic urethra
51
histology of vas deferens
* **pseudostratified** COLUMNAR epithelium
* epithelium and lamina propria are thrown into **multiple folds**
⇒ allowing **expansion**
## Footnote
smooth muscle layer consists of:
* inner AND outer longitudinal muscle
* thick middle circular layer
52
Testicular torsion:
* definition
* presenting feature
* a/w which abnormality
* **testicle** rotates
→ twisting **spermatic cord**
⇒ cutting off blood supply
* presents w/ ABSENCE of **cremasteric reflex** on affected side
* a/w **Bell Clapper abnormality**
⇒ treatment is **bilateral** orchidopexy
## Footnote
Bell Clapper abnormality:
* abnormally high insertion of tunica vaginalis on spermatic cord
⇒ **increased mobility** of testis
* even if torsion occurs on ONE side, other side usually has the **same abnormality**
⇒ thus surgeons fix BOTH testes to the scrotal wall (orchidopexy) to prevent future torsion
53
Cryptorchidism:
* definition
* a/w (...)
* should wait for (...) months in infants for descent before operating
* when testicle **HAS NOT** moved down into scrotum
* a/w risk of infertility, testicular cancer, hernia and torsion
* should wait for **6 months** in infants for descent before operating
54
prostate gland:
* divided into 3 zones: transitional, peripheral and central
1) BPH most commonly @ (...) zone
2) Prostate cancer most commonly @ (...) zone
* supplied by (...) and (...) arteries
(branches of INTERNAL ILIAC artery)
* drained by (...),
which communicates with (...)
=> possible prostate cancer metastasis to (...)
* divided into 3 zones: transitional, peripheral and central
1) BPH most commonly @ **transitional** zone
2) Prostate cancer most commonly @ **peripheral** zone
* supplied by **inferior vesicle** and **middle rectal** arteries
(branches of INTERNAL ILIAC artery)
* drained by **prostatic plexus**,
which communicates with **vertebral venous plexus**
(**VALVELESS**)
=> possible prostate cancer **metastasis to spine**
55
histology of prostate gland
* consists of tubuloacinar **glands**
* which are double layered:
1) **pseudostratified** COLUMNAR epithelium consisting of **secretory** cells
2) **basal** cells in basement membrane
* **corpora amylacea**,
which are conc prostatic fluid + glycoproteins + keratan sulfate,
may be seen in **lumen** of glands
56
composition of semen fluid
(components + %)
* **seminal vesicle** fluid (*70-80%*)
* **prostatic** fluid (*30%*)
* secretions from **bulbourethral** gland (minor)
57
components of **prostatic** fluid
and their functions
* ions:
zinc, citric acid, calcium and phosphate
→ sperm **health** and **motility**
* enzymes: **prostate-specific antigen** (PSA)
→ **liquifies semen** in ejaculate,
ALSO used as marker in **prostatic cancer / inflammation** (elevated)
58
secretions of bulbourethral gland
and their functions
pre-ejaculatory fluid
→ **NEUTRALISE ACIDIC** residue in urethra
(from urine)
AND **lubricates** urethra
## Footnote
recall: bulbourethral **gland** is located in **DEEP** perineal pouch,
but **duct** is in **SUPERFICIAL** perineal pouch
⇒ opens into **SPONGY** urethra
(NOT membranous urethra)
59
components of seminal vesicle fluid
and their functions
* FRUCTOSE
→ major **energy source** for spermatozoa
* Prostaglandins
→ **softens mucus of cervix**
⇒ reduce viscocity and make it easier for sperm to pass through cervix
60
facts about urethra:
* (...) is surrounded by the **internal** urethral sphincter
while (...) is surrounded by the **external** urethral sphincter
* (...) is the **broadest**, most dilatable part of the urethra
* spongy urethra is surrounded by (...)
* **pre-prostatic** urethra is surrounded by the **internal** urethral sphincter
while **membranous** urethra is surrounded by the **external** urethral sphincter
* **prostatic** urethra is the **broadest**, most dilatable part of the urethra
* *spongy* urethra is surrounded by **corpus *spongiosum***
61
what happens when there is a RUPTURE in the membranous urethra
vs in the spongy urethra
* membranous: blood flows into **pelvic cavity**
→ **bladder and prostate floating** in blood and urine
* spongy: blood flowing into superficial perineal pouch,
scrotum, around penis
and even **anterior abdominal wall**
## Footnote
* **Colles**’ fascia (superficial perineal fascia) is **continuous with Scarpa’s** fascia of the anterior abdominal wall
→ provides a pathway for urine and blood to spread over penis, scrotum, and **anterior abdominal wall**
* **perineal body** acts as a **posterior barrier**, so urine **CANNOT enter deep pelvis**
(think of a dam in a river channel)
62
erectile tissues in penis
* corpus **spongiosum**:
surrounds **urethra**,
has **more elastic tissue** to prevent urethral compression
* corpus **cavernosa**:
surrounded by **tunica albuginea**
63
parts of penis
* root: **proximal** part,
located in **superficial perineal pouch**
* body: free part bet root and glans
* glans: **bulbous expansion** of **CORPUS spongiosum**,
covered by **prepuce** (foreskin)
64
muscles in penis
* ischio*cavernosus*:
spirals over CORPORA *cavernosa*,
aids **movement** and **support** of erect organ
* bulbo*spongiosus*:
spirals over CORPORA *spongiosum*,
aids in **emptying urethra**
(expulsion of semen, last few drops of urine)
65
anatomical facts about penis:
* blood supply (artery + vein)
* innervation of muscles
| plus picture the overall structure of penis
* supplied by **DORSAL** artery
* drained by **deep dorsal** vein
* innervate by **PUDENDAL** nerve
## Footnote
note that dorsal artery
← internal pudendal artery
← internal iliac
(thus NOT a direct branch of internal iliac)
66
what is phimosis
inability to retract foreskin
67
mechanism of erection and ejaculation
"*Point* and **Shoot**"
* *erection* : *Parasympathetic* fibers are activated
(prostatic nerves plexus)
→ **relaxation** of smooth muscles in **trabeculae**
AND **dilation of arteries**
(dorsal artery)
→ **filling** of **cavernous spaces** with blood
→ blood-filled spaces **compress veins** against **tunica albuginea**
⇒ pool of blood in penis (erection)
* **ejaculation**: **Sympathetic** fibers are activated
(T11-L2)
→ closure of **internal urethral sphincter**
⇒ prevents **backflow of semen** into bladder
68
anatomical facts about ovaries:
* ligaments
* functions
* arterial supply
* venous drainage
* ligaments:
1. suspended (i.e. hanging off) **posterior** part of **BROAD ligaments**
2. **SUSPENSORY ligaments** of ovary contain ovarian vessels, lymphatics and nerves
* functions:
1. produce and release **ova** through **oogenesis**
2. produce and release hormones
(**estrogen, progesterone**)
* supplied by **ovarian** artery and ovarian branch of **uterine** artery
⇒ form an extensive **anastomosis**
* drained by L and R **ovary** veins
→ R ovary vein drains into **IVC** directly
whie L ovary veins drains into L **renal vein** first
## Footnote
note: suspensory ligaments of ovary is NOT considered a uterine supporting ligament as
* its role is mainly vascular
(a conduit for blood/lymph/nerve supply to ovary)
* it does not help support the uterus
69
histology of ovaries:
6 components
from outer to inner:
* germinal epithelium: **visceral peritoneum** over the tunica albuginea,
DOES NOT produce germ cells
* tunica albuginea: **surface** of ovary, basically condensed stroma
* cortex: contains **ovarian follicles** in **different stages of development**
* medulla: loose connective tissue with abundant **blood vessles, lymphatic vessels and nerve fibers**
* stroma: found **throughout ovary**,
functions as **structural support**
and microenvironment for **development and function**
* hilum: **entry and exit pt** for blood vessels
70
which part of the ovary is the most common site of origin for **ovarian cancer**
| recall **6** components of ovaries!
germinal epithelium
71
describe oogenesis:
1. (...): primordial germ cells undergo (...) to form **1º oocyte**
→ which undergoes meiosis and is halted at (...) at (...)
2. (...): completes meiosis I to form **2º oocyte**
→ continues on to meiosis II ,
resulting in ONE 2º oocyte halted at (...) during (...)
3. (...):
completes meiosis II to form (...)
1. **BEFORE birth**: **oogonium** (primordial germ cells) undergo **mitosis** to form **1º oocytes**
(23 chromosomes, 2C)
→ 1º oocytes
(46 chromosomes, 4C)
then undergo meiosis and are halted at **prophase of meiosis I** at **time of birth**
2. **menstrual cycle**: stimulation by **FSH** allows meiosis I to continue and be completed
→ form **2º oocyte**
(23 chromosomes, 2C)
→ continues on to meiosis II,
resulting in **ONE** 2º oocyte halted at **metaphase of meiosis II** during **ovulation**
3. **fertilisation**
(i.e. sperm penetrates oocyte):
meiosis II is completed
→ **ovum**
(23 chromosomes, C)
is formed
72
describe the ovarian cycle:
1. **primordial** follicle: **(...) oocyte** surrounded by **(...) layer(s)** of **(...) follicular** cells
2. **primary** follicle:
**(...)** stimulates the primordial follicle to (...)
AND (...) layer(s) of flattened cells
-> **(...) layer(s)** of (...) cells
(= (...) cells),
outermost (...) cells form (...) cells
3. **secondary** follicles:
a) follicular cells **continue proliferating** to form more layers
b) (...) cells secrete fluid
-> forms (...)
c) (...) cells also convert (...) -> (...),
while (...) cells produce (...)
4. **(...)/mature** follicle:
a) **antrum increases** in size
-> pushes oocyte (...) in follicle
b) (...): **innermost** layer of granulosa cells which (...),
adjacent to zona pellucida
c) (...):
**crowded** granulosa cells which **anchor oocyte** to follicle wall, **away from (...)**
5. **ovulation**:
(...) follicle **ruptures**,
releasing **(...) oocyte** along with (...) and (...)
6. **post-ovulation**:
a) ruptured follicle becomes (...) and produces (...)
b) if not fertilised, degenerates to form (...)
1. **primordial** follicle: **1º oocyte** surrounded by **single layer** of ***flattened* follicular** cells
2. **primary** follicle:
**FSH** stimulates the primordial follicle to **increase in size**
AND single layer of flattened cells
→ **multiple layers** of ***cuboidal/columnar* follicular** cells
(= **granulosa** cells),
outermost **stromal** cells form **theca** cells
3. **secondary** follicles:
a) follicular cells **continue proliferating** to form more layers.
b) **granulosa** cells secrete fluid
⇒ forms **follicular antrum**
c) **granulosa** cells also convert **androgens → estrogen and progesterone**,
while **theca** cells produce **testosterone**
4. **Graafian/mature** follicle:
a) **antrum increases** in size
⇒ pushes oocyte **eccentrically** in follicle
b) **corona radiata**: innermost layer of granulosa cells which **protects ovum**,
adjacent to zona pellucida
c) **cumulus oophorus**:
crowded granulosa cells which **anchor oocyte** to follicle wall, **away from fluid cavity**
5. **ovulation**:
mature/Graafian follicle **ruptures**,
releasing **2º oocyte** along with **zona pellucida** and **corona radiata**
6. **post-ovulation**:
a) ruptured follicle becomes **corpus luteum** and produces **progesterone**
b) if not fertilised, degenerates to form **corpus albicans**
73
fallopian tube:
* lies BETWEEN the 2 layers of the (...) of the (...)
* parts of the tube (lateral -> medial): (5)
* fallopian tube opens into (...) through (...)
* supplied by (...)
* functions:
1) transport (...)
2) transport (...)
* sterilisation method = (...)
* lies BETWEEN the 2 layers of the **upper margin** of the **broad ligament**
* parts of the tube (lateral → medial):
**fimbriae** (end processes of infundibulum)
→ **infundibulum**
→ **ampulla**
→ **isthmus**
→ **interstitium**
* fallopian tube **opens into peritoneal cavity** through infundibulum
* supplied by branches of **ovarian artery**
* functions:
1) transport **ova** from ovary
2) transport **fertilised** egg to uterus
* sterilisation method = **tubectomy**
## Footnote
note: **longest** end process (fimbriae) is **attached to ovary**
⇒ helps **“guide” the oocyte** into the tube at ovulation
74
histology of fallopian tube
* **simple** COLUMNAR epithelium
* consisting of
1. **ciliated** cells
(**lightly** stained):
aids **movement of ovum** towards uterus
2. **secretory** cells
(**dark** stained):
secrete **glycoprotein**
⇒ **nutrient** for ovum
75
uterus:
* structure: (...) is bet uterus and cervix
* position:
1) (...): bent over long axis of vagina
2) (...): bent over long axis of cervix
* innervated by (...), which carries
1) (...)
(sympathetic)
2) (...)
(parasympathetic)
* implantation site is (...) wall
* structure: INTERNAL **os** is bet uterus and **cervix**
* position:
1) anter**Verted**: bent over long axis of **Vagina**
2) ante**fleXed**: bent over long axis of **cerviX**
* innervated by **inferior hypogastric** PLEXUS, which carries
1) **lumbar** splanchnic nerve
(**sympathetic**)
2) **Pelvic Splanchnic** nerve
(**ParaSympathetic**)
* implantation site is **upper** and **posterior** wall
76
broad ligament:
* location (runs from where to where)
* function
* runs from **uterus** to **lateral wall** of pelvis
* function:
**not much support**,
but rather contain **uterine vessels, lymphatics and ovarian ligament**
77
cardinal ligament:
* definition
* functions
* thick connective tissue at **base of broad ligament**
* functions:
1) **MAJOR support** to uterus
2) contains UTERINE **artery**, as well as UTERINE **veins**
## Footnote
uterine artery ← internal iliac artery
uterine veins → internal iliac vein
78
facts about uterine artery:
* uterine artery anastomoses with
1) (...)
2) (...)
* runs through cardinal ligament,
with (...) passing UNDER it
* uterine artery **anastomoses** with
1) **other** uterine artery
2) superiorly with **ovarian** artery
* runs through cardinal ligament,
with **ureter passing UNDER it**
79
round ligament:
* development
* parts
* developed from **gubernaculum**
* parts:
1) **cranial** end developed into **ovarian** ligament
(medially wall of ovary
to lateral wall of uterus)
2) **caudal** end developed into **round** ligament of UTERUS
(uterus to **labia majora**)
## Footnote
pathway of round ligament of uterus:
begins at the **lateral** wall of the **uterus**
→ passes anterolaterally
and enters deep inguinal ring
→ runs through **inguinal canal**
→ exits via superficial inguinal ring
→ ends by **merging** with labia majora
80
histology of uterus: layers
* *endo*metrium (*innermost*):
**simple** COLUMNAR epithelium,
contains numerous **tubular glands**
* *myo*metrium (*middle*):
thick **smooth muscular** layer
* *peri*metrium (*outermost*):
**connective tissue**
81
histology of *endo*metrium
## Footnote
recall: *innermost* layer of uterus
from inner to outer:
* stratum **basale**:
more **cellular**,
remains **constant** through whole cycle,
**regenerates** endometrium for next cycle
* stratum **functionale**:
**proliferates, secretes** and **sheds** during menstrual cycle
* **simple** COLUMNAR epithelium
82
arterial supply of endometrium (5)
uterine artery
→ arcuate artery
→ radial artery
→ spiral and basal arteries
* **arcuate** artery supplies **myometrium**
* **spiral** arteries supply **functional endometrium**
and **respond to hormonal** changes
(e.g. drop in progesterone
→ constriction of arteries
→ ischaemia
→ shedding of endometrium
⇒ menses)
* **basal** arteries supply **basal endometrium** and is **NOT responsive** to hormones
83
changes in endometrium during menstrual cycle
* **proliferative** phase:
under influence of **estrogen**,
can be divided into
1) **early** proliferative:
tubular **glands** and **endothelial cells** proliferate
2) **late** proliferative:
glands **coil** and become **CLOSELY PACKED**
=> **thickening** of endometrium
* **secretory** phase:
under influence of **progesterone**,
glands even **more complexly** coiled
(**SAW TOOTH** appearance)
=> endometrium reaches **maximum thickness**,
secretions rich in **glycogen** and **glycoprotein**
## Footnote
* Glycogen = **energy** for embryo until placenta takes over
* Glycoproteins = adhesion + **immune protection** for implantation
84
function of myometrium
during pregnancy, it
* **increases** in size through **hypertrophy and hyperplasia**
* **muscular contractions** during labour to expel fetus,
with **reinforcement** of the contractions by **oxytocin**
## Footnote
also note that the contractions during labour reduce blood supply to placenta
=> thus precipitating its detachment
85
parts of cervix
(and their respective type of epithelium)
* *endo*cervix:
*connects* to **uterus**,
**simple** COLUMNAR epithelium
* *ecto*cervix:
projects ***into* vagina**,
non-keratinised **stratified** SQUAMOUS epithelium
* **transformation** zone
(squamocolumnar junction)
86
vagina:
* which part is expanded and why
* secretions?
* pH?
* **upper** end **expanded**
← receives uterine cervix
* **no secretory** glands or secretions,
but opening is **lubricated** by secretions from **Bartholin's** gland
(which lies in superficial perineal space)
* **acidic**
⇒ protect from **external pathogens**
87
which peritoneal pouch is MOST LIKELY to **accumulate fluid**
rectouterine (**Douglas**) pouch
88
blood supply, innervation and lymphatic drainage of vagina
* arterial supply: divided by **pelvic floor**,
1. ABOVE pelvic floor: **uterine** and **vaginal** artery
2. BELOW pelvic floor: **internal pudendal** artery
* nerve supply: divided into upper **4/5** and lower **1/5**,
1. UPPER 4/5: **inferior hypogastric** plexus
(**stretch** only)
2. LOWER 1/5: **pudendal** nerve
(**touch, temp**)
* lymphatics: divided into upper **4/5** and lower **1/5**,
1. UPPER 4/5: **iliac** (external + internal) nodes
2. LOWER 1/5: **superficial inguinal** nodes
89
histology of vagina
* non keratinised **stratified** SQUAMOUS epithelium
* which has cells with a large amt of **cytoplasm**
→ filled with **glycogen** which they produce
⇒ helps to **maintain pH**
## Footnote
how do they maintain pH?
cells slough off
→ glycogen is released into the lumen
→ normal vaginal flora (Lactobacilli) metabolize glycogen
→ produce lactic acid
⇒ thus maintaining acidic vaginal pH (~4–4.5)
90
external genitalia of female
* mons pubis: **hairy** skin and subcutaneous fat
in front of **pubic symphysis**
* labia majora: 2 **hair bearing EXTERNAL**
skin folds + subcutaneous tissue
* labia minora: 2 **hairless**
skin folds **within** labia majora
* vestibule: area **enclosed by labia minora**,
containing opening of **vagina and urethra**
* hymen: **covers** part of **vaginal** opening
## Footnote
another diff bet labia MAJOR and labia MINORA is their histology!
* labia majora: **KERATINISED** stratified squamous epithelium
* labia minora: **NON-keratinised** stratified squamous epithelium
91
erectile tissue in female
* corpora **cavernosa**:
one on each side of urogenital triangle,
form the **crura of the CLITORIS**
-> each crus attached to **ischiopubic ramus** and anchored to **perineal membrane**
* corpua spongiosum:
originates from perineal body
and splits into 2,
form the 2 **bulbs of the vestibule**
-> which join tgt to form **glans CLITORIS**
92
what is an episiotomy
surgicial incision of **perineum** on **inferoposterior** wall
→ **enlarge opening** for **baby** to pass through
⇒ thus preventing **multiple tears**
## Footnote
Layers incised
1. Skin
2. Subcutaneous tissue
3. Superficial and deep transverse perineal muscles
4. Part of levator ani
5. Posterior vaginal wall
93
lymphatic drainage of urethra
* UPPER **1/4**: **internal iliac** nodes
* LOWER **3/4**:
**superficial** inguinal nodes
94
What is the homologue of
* scrotum
(covering of reproductive organ)
* prostate
(accessory reproductive organ)
* bulbourethral (Cowper's) glands
(organ that secretes lubricating fluid during sexual arousal)
* labia **majora**
* paraurethral (Skene) glands
* greater vestibular (Bartholin's) glands
95
What is the most impt gene for sex differentiation?
and its gene pdt
sex region Y (**SRY**) gene on **Y chromosome**
→ encodes for testis determining factor (**TDF**)
## Footnote
* other pro-male genes: **S**OX9
(also begin with **S**)
* other pro-female genes: *F*OXL2, *W*NT4, *F*ST
(all either begin with F or W
= *F*emale or *W*omen)
96
describe development of internal genital organs
up until 6 weeks: BOTH **wolffian duct** (male internal organs) and **mullerian duct** are present
males: PRESENCE of **TDF**
→ formation of **Sertoli and Leydig** cells
→ a) **Sertoli** cells produce **Mullerian Inhibiting Substance** (MIS)
⇒ **regression of mullerian** duct
b) **Leydig** cells produce **testosterone**
⇒ **wolffian duct develops** into male internal organs
females: ABSENCE of TDF
→ NO Sertoli and Leydig cells
→ a) no Sertoli so no MIS
⇒ **mullerian duct develops** into female internal organs
b) no Leydig so no testosterone
⇒ **regression of wolffian** duct
97
breast:
* location
* lateral and medial borders
* posterior muscles
* layers
* **2nd to 6th** rib
* lateral border: **axillary** tail
* medial border: lateral border of **sternum**
* posterior muscles:
pectoralis major,
serratus anterior,
external oblique
* layers (superficial to deep):
1. nipple, areola, breast
2. **retromammary space, pectoral fascia**
3. pec major, pec minor, chest wall
98
arterial supply of breast
* branches of **axillary** artery:
superior *thoracic*, acromio*thoracic*, lateral *thoracic*
* perforating branches of **internal *thoracic***
* lateral branches of **posterior intercostal** arteries
99
lymphatic drainage of breast:
2 main groups
and where they drain into
* **superficial** lymphatics: **skin** of breast
⇒ drain into **axillary** lymph nodes
* **deep** lymphatics: everything else
(parenchyma, **nipple** and **areola**)
⇒ drain into **axillary**
or **internal mammary** nodes (**medial** quadrants)
* axillary nodes route:
anterior, posterior, lateral nodes
→ **central** node
→ **apical** node
⇒ **supraclavicular** node
* internal mammary nodes may result in **contralateral** spread
(i.e. to other breast)
100
histology of breast
* parts:
1. **glandular** elements: modified **apocrine sweat** glands
2. **stroma**:
connective tissue, adipose tissue
and cells (fibroblasts and plasma cells)
3. **STRATIFIED** SQUAMOUS epithelium at **nipple and areola**
* what forms the "wall" of each gland?
1. **luminal** cells: **innermost** layer of epithelium,
**PRODUCE milk**
2. **myoepithelial** cells:
**outermost** layer of epithelium,
**contract** for **MILK EJECTION** during lactation
3. basement membrane:
produced by myoepithelial cells
101
are mammograms more useful in younger or older female patients
older!
* **adipose replace fibrous** tissue in stroma with increasing age
⇒ older women have **more adipose** tissue,
and thus mammogram can **pick up masses** more easily
## Footnote
further explanation:
adipose tissue is radiolucent (darker)
⇒ calcifications and small masses (brighter) are detected more easily
102
stages of mammary gland:
inactive vs active
* inactive (non-pregnancy):
normal lobules and stroma
(**dense, irregular** interlobular connective tissue)
* active (pregnancy and lactation):
1. **more glandular** tissue and less connective tissue
2. glandular tissue: INCREASE in **epithelial and myoepithelial** cells
→ form more secretory alveoli
3. **interlobular** connective tissue: MORE **plasma cells**
→ secrete **IgA** into breast milk
103
describe 5⍺-reductase deficiency
* mutation of 5⍺-reductase gene
→ testosterone cannot be **converted** to DHT
⇒ absence of **DHT**
* genetic sex: **XY**
⇒ **testes** present
* has **testosterone**
⇒ development of **male internal genitalia**
* NO **DHT**
→ **NO** developement of **male EXTERNAL genitalia**
⇒ predominantly **female phenotype** *before puberty*
* has **testosterone**
⇒ development of **male secondary sexual characteristics** *after puberty*
104
describe Androgen Insensitivity Syndrome (AIS)
* mutation of **androgen receptor**
⇒ inability to respond to androgens (testosterone, DHT)
* genetic sex: **XY**
⇒ **testes** present
* NON-FUNCTIONAL **testosterone**
⇒ **NO** development of **male internal genitalia**
* NON-FUNCTIONAL **DHT**
→ **NO** development of **male external genitalia**
⇒ predominantly **female phenotype** *before puberty*
* NON-FUNCTIONAL **testosterone**
⇒ **NO** development of **male secondary sexual characteristics**;
testosterone receptors are unable to detect testosterone
→ **feedback** to produce **more** testosterone
→ **high testosterone**
→ converted to **estradiol**
⇒ development of **female secondary sexual characteristics** *after puberty*
105
puberty:
progress and its associated physical changes
1. *hypothalamus* **increases** secretion of **GnRH**
2. *anterior pituitary* responds by **progressive secretion** of **FSH and LH**,
associated with **increased** secretion of **GH**
⇒ **somatic growth**
3. **increased** secretion of **testosterone/oestrogen**
⇒ development of **secondary sexual characteristics**
occurs due to:
* males:
***L*H** -(act on)→ ***L*eydig** cells
→ production of **testosterone**,
**F*S*H** -(act on)→ ***S*ertoli** cells
→ **conversion** of testoterone to estradiol
* females:
**LH** -(act on)→ **Theca** cells
→ production of **testosterone**,
**FSH** -(act on)→ **Granulosa** cells
→ **conversion** of testoterone to estradiol
## Footnote
involves the
Hypothalamic - Pituitary - Gonadal Axis:
* Hypothalamus: GnRH
* Pituitary: FSH and LH
* Gonads: Sertoli, Leydig, Granulosa and Theca cells
106
describe Klinefelter syndrome
* genotype: **XXY**
=> **impairment** of **testes** function,
including **testosterone** production
* functional hypothalamus and pituitary
=> *INCREASE FSH and LH* levels
in response to **LOWER testosterone**
* thus *HYPERgonadotropic* **hypogonadism**
107
describe Kallmann syndrome
* mutations of multiple genes
-> failure in **GnRH** function (hypothalamus level)
=> *IMPAIRED FSH and LSH* production
* which will subsequently result in **IMPAIRED testosterone** production
* thus *HYPOgonadotropic* **hypogonadism**
108
difference between
primary and secondary
amenorrhoea
| amenorrhoea = absence of menstrual cycle
* primary: failure of **ONSET** of menstrual cycle by **age 16**
* secondary: **ABSENCE** of menstrual cycle for **6 months**
109
fertilisation:
* location
* process:
1. sperm undergoes (...) reaction in female genital tract
2. sperm binds to (...) of egg
-> (...) reaction is triggered
3. (...) break down
-> allowing entry of sperm
4. 2º oocyte resumes meiosis II
5. male and female (...) are formed
and fuse to form (...)
* usually occurs in **ampulla** of fallopian tube
* process:
1. sperm undergoes **capacitation** reaction in female genital tract
2. sperm **binds to zona pellucida** of egg
-> **acrosomal** reaction is triggered
3. zona pellucida and oocyte membrane **break down**
-> allowing **entry of sperm**
4. 2º oocyte **resumes meiosis II**
5. **male and female pronuclei** are formed
and **fuse** to form zygote
## Footnote
polyspermy is prevented via
oocyte preventing entry of more than one sperm via fast and slow block
110
when there are **changes in length** of menstrual cycle,
which **OVARIAN phase** is affected?
* **follicular** phase
← diff factors (e.g. weight loss, physical activity, stress levels) can affect **FSH secretion** and **follicular growth** rate
* **luteal** phase remains **constant**
← **lifespan** of corpus luteum is constant (∼ 14 days)
111
negative feedback in HPG axis
males: *testosterone*
⇒ **inhibitory** effect on BOTH hypothalamus and AP
females: *oestrogen*
⇒ **inhibitory and stimulatory** effect on BOTH hypothalamus and AP
AND *progesterone*
⇒ **inhibitory** effect on BOTH hypothalamus and AP
*inhibin*
⇒ **inhibitory** effect on PITUITARY
males: *follistatin*
⇒ **inhibitory** effect on PITUITARY
females: *activin*
⇒ **stimulatory** effect on
PITUITARY
| main impt ones are sex hormones and inhibin!
## Footnote
* effects of **estrogen**:
1. **majority** (= early-mid follicular + luteal): **inhibits** FSH (and LH)
⇒ prevent development of other follicles
2. ONLY in **midcycle** (= late follicular): **stimulates** LH (and FSH)
⇒ surge in LH for ovulation
* all the other hormones (NOT sex hormones) are produced by **sertoli** and **granulosa** cells in males and females respectively
112
describe menopause:
* age
* cause
* hormonal changes
* effects
* occurs at around **50** y/o
* due to the **depletion of oogenesis** (i.e. no responsive follicles left)
→ ovaries **decrease** production of **oestrogen and progesterone**
⇒ **increase** in **FSH and LH**
(loss of inhibitory effect from oestrogen and progesterone)
* leads to symptoms like
**osteoporosis**,
hot flashes, insomnia, depression
113
what is involved in implantation,
A) zygote
B) morula
C) blastocyst
C) blastocyst
* around **7-10 days** after ovulation
* via it binding to endometrium through **special receptor binding**
→ **trophoblastic** cells
(syncytiotrophoblast cells specifically)
secreting enzymes to **digest uterine cells**
⇒ blastocyst **invading** into endometrium
114
why does menstruation NOT occur when a woman is fully breastfeeding
| i.e. lactational amenorrhoea
**increased prolactin** levels
→ **inhibit** production and secretion of **GnRH**
→ **decreased oestrogen** lvls
→ no surge in LH
⇒ NO **ovulation**
| considered a **contraceptive** effect!
115
how can we classify testicular neoplasms
* seminomatous: originate from **spermatogenic** cells
(i.e. cells that form sperm)
* sex-cord stroma: originate from **supporting** cells of **seminiferous tubules**
* lymphomas: originate from **lymphoid** cells **infiltrating the testis**
116
seminomatous vs non-seminomatous
germ cell tumours
117
important serum markers in testicular neoplasms:
* **lactate dehydrogenase**,
raised in (2)
* alpha-fetoprotein (AFP),
raised in (...)
* beta human chorionic gonadotrophin (HCG),
raised in (...)
* LDH:
1. seminomas
2. lymphomas
* AFP: yolk sac tumour
* HCG: choriocarcinoma
likely MIXED germ cell tumour!
| if **> 1** serum marker is elevated,
## Footnote
* LDH is raised as
1. tumours **outgrow their blood supply**
→ **hypoxic** regions
→ cells rely less on aerobic metabolism and more on **anaerobic glycolysis**
⇒ which is catalysed by **LDH**
2. **reprogramming of energy metabolism**
(recall: hallmark of cancer!)
where cells **switch to aerobic glycolysis**
even in the presence of oxygen
(i.e. still have oxygen, but in pyruvate → lactate pathway)
⇒ which is catalysed by **LDH**
3. **high cell turnover**
→ more cell death/**necrosis**
⇒ **release** of **intracellular** enzymes (like **LDH**) into the bloodstream
* choriocarcinoma originates from placenta tissue (trophoblast cells)
118
characteristics of yolk sac tumour
| think of *SAC*!
## Footnote
recall: yolk sac tumour is a **germ cell** neoplasm,
specifically **non-seminomatous** in males!
* *S*chiller-Duval bodies
= central vessel surrounded by tumour cells
(basically the one that looks like a fried egg)
* *A*lpha-fetoprotein (AFP) levels raised
* *C*hildren (esp neonates up to 6 months)
119
pathophysio of BPH
* TOO MUCH **5-α reductase**
→ stimulate production of **growth factors**
→ INCREASED **proliferation** of **stroma cells**
and DECREASED **cell death**
⇒ **imbalance** bet the two
## Footnote
recall!
* 5-α reductase helps in conversion of
testosterone → DHT
* 1 of the functions of DHT is development and growth of prostate gland
120
histologic features of BPH
* **hyperplasia** of bilayered **glands**
* AND hyperplasia of **stroma**
* in *nodular* configuration
| ⇒ gross: **enlarged** prostate with *nodules*
## Footnote
* preservation of **BOTH layers**
indicate that it is **benign**
121
symptoms of BPH
compression of prostate on prostatic urethra
→ **obstruction**
⇒ *hesitation*
(← delay in initiating stream),
*weak stream*
and *straining*
(← **increased intra-abdominal pressure** to overcome obstruction)
→ **incomplete emptying**
⇒ *dribbling* and
subsequently *frequency*
(← residual urine remaining each time)
and *urgency*
(← compensatory **detrusor overactivity**)
## Footnote
also NOCTURIA
which has same mechanisms as **frequency** and *urgency*
← *reduced cortical inhibition* and **increased urine production** at night
122
management of BPH
* drugs:
1) **5-α reductase inhibitors**
2) **α blockers**
⇒ mainly work to **relax** smooth muscles in **prostate**
* lifestyle:
modifications that will **decrease urine production**
(less fluid, less alcohol/coffee)
## Footnote
alcohol and coffee are diuretics!
123
symptoms of prostatic cancer
* most commonly:
**NO SYMPTOMS**
* metastatic presentations: **back pain**
* constitutional presentations (e.g. LOW)
* LUTs: similar to BPH
## Footnote
back pain:
recall that prostate gland is drained by **prostatic plexus**,
which has a **VALVELESS communication**
with **vertebral venous plexus **
124
investigations for prostatic cancer
* digital rectal examination:
**hard, uneven** prostate
(↔ *firm, smooth* prostate in BPH)
* **PSA** levels: **elevated**
## Footnote
PSA levels are **more sensitive than specific**
bcos other conditions (e.g. BPH, prostatitis) could also present with elevated PSH
→ elevated PSH = NOT confirm have
→ does NOT rule *IN*
⇒ NOT *SP*ecific (*SPIN*)
125
oestrogen vs progesterone:
* effects on libido
* effects on cancer risk
* effects during pregnancy
* effects on lactation
* **libido**:
**estrogen increases**
(← derivative of testosterone),
progesterone decreases
* cancer risk:
**estrogen increases**,
progesterone decreases
* pregnancy:
**progesterone**
1) maintains **endometrium**
2) reduces **maternal immune response**
3) **decreases** contractility of **uterine smooth muscle**
while oestrogen
1) promotes **growth** of UTERUS and UTERINE **blood flow**
2) stimulate **breast cell proliferation** and fat deposition
(→ prepare for lactation)
* lactation:
estrogen stimulate **breast cell proliferation**
(i.e. more breast epithelial cells)
and **fat deposition**
(⇒ enlargement of breasts)
while progesterone **converts epithelial cells into secrety cells**,
BOTH **INHIBIT lactation**
126
what triggers lactation after birth
sudden **reduction** in **oestrogen and progesterone**
127
human chorionic gonadotropin (hCG):
* produced by (2)
* binds to (...) receptor on (...)
* function: (...)
* used in (...) test
* produced by **syncytiotrophoblasts**,
which are initially in implanting **blastocyst**
and later in **placenta**
* binds to **LH receptor** on **corpus luteum**
* function: maintain function of corpus luteum of secreting **progesterone**
* used in **urine pregnancy tests**
(detected via **immunoassay**)
## Footnote
for urine pregnancy tests,
* positive results can be as early as **6-8 days** after conception
* **false (+)** could be due to malignancy
(e.g. **hCG producing tumours** like choriocarcinoma)
128
human placental lactogen (hPL):
* produced by (...)
* function: (...)
* produced by **syncytiotrophoblasts** in **placenta**
(ONLY and not implanting blastocyst)
* function: supports **foetal nutrition**
129
prostaglandins during pregnancy:
* produced by (...)
* functions and MOA
* produced by **myometrium, decidua and chorion**
* functions:
1. stimulate **uterine contractions**
(via **increasing Ca2+** in **myometrial** cells
to increase **actin and myosin activation**)
2. **cervical ripening** and **dilation**
130
relaxin:
* produced by (...)
* functions and MOA
* produced by **placenta**
* functions:
bind to **relaxin receptors** on **smooth muscles** ⇒
1. **cervical ripening** and **softening of pubic symphysis**
2. increase cardiac output, renal blood flow and arterial compliance
(= basically **vasodilation**)
⇒ help with **expanded blood vol** and increased metabolic demands during pregnancy
## Footnote
can think of it can RELAXin helps one to
RELAX during pregnancy and childbirth
by helping body adapt and thus making things easier
131
oxytocin:
* produced by (...) and stored in (...)
* functions and MOA
* produced by cells of **SON and PVN** in **hypothalamus**
and stored in **posterior pituitary** gland
* main functions:
1. **uterine contractions**
(via binding to **oxytocin receptors** on **myometrium and endometrium**)
2. milk ejection
## Footnote
binding to receptors on endometrium has an **indirect** effect on uterine contractions:
binding
→ stimulates production of **prostaglandins**
⇒ further **enhance** uterine contractions
132
complications of placental infection
* intrauterine growth retardation
* premature delivery
* low birth weight
* congenital abnormalities
* deafness
133
symptoms of eclampsia
* seizures
← **cerebral** vasoplasm and endothelial dysfunction
* disseminated intravascular coagulation (DIC)
← activation of **coagulation**
## Footnote
pathophysio:
abnormal **trophoblast invasion**
→ spiral arteries remain narrow and high-resistance
instead of becoming large and low-resistance
→ placenta becomes hypoperfused and **ischemic**
→ **release of factors** into maternal blood by placenta
→ widespread maternal **endothelial dysfunction**
=> **HTN** (<- widespread **vasospasm**),
**proteinuria** and **edema** (<- increased vascular **permeability**)
[triad of pre-eclampsia]
134
complications of eclampsia
*HeLLP* syndrome:
1. *H*aemolysis
← **destruction of RBCs** as they pass through blood vessels obstructed by **clots**
2. *e*levated *L*iver enzymes
← **clots** obstructing renal blood flow and resulting in **liver injury**
3. *L*ow *P*latelets
← **platelets** used for **clot** formation
| life-threatening, an emergency!
135
describe different forms of abnormal placenta:
a) abruptio
b) percreta/increta/acreta
c) previa
1) abnormal **adhesion**
due to defective decidua
(missing Nitabuch's layer which fns to limit trophoblast invasion)
2) placenta **block** baby
as it implants low in the uterus
3) placenta **detaches** from uterus
* 1b
* 2c
* 3a
## Footnote
for abnormal adhesion,
* accreta = adhesion
* increta = infiltration
* percreta = penetration past myometrium into surrounding organs
136
hydatidiform moles:
* definition
* risk factors (3)
* types (2)
* caused by abnormal fertilisation
-> proliferation of trophoblasts
=> abnormal placental growth
* risk factors:
1. extremes of **pregnancies** (**super young/old**),
with **older** patients at higher risk of developing **malignant** complications as well
2. **previous** mole
(<-> previous normal pregnancies
(= term pregnancies and live births) reduce risk)
3. asians/africans/latin americans
* 2 types:
1. complete
2. partial
## Footnote
trophoblasts
* are outermost layer of cells on blastocyst
* produce hCG
137
complete vs partial mole
138
types of vaginal cancer
* clear cell adenocarcinoma
* rhabdomyo(sarco)ma
139
# vaginal cancer!
pathophysiology of clear cell adenocarcinoma
mother treated w/ **DES**
(= synthetic oestrogen)
-> **metaplasia** of stratified squamous epithelium into glandular structure in child
140
# vaginal cancer!
features of rhabdomyo(sarco)ma
* **grape**-like mass
* presents in **infants and children**
141
pre-cancerous lesion associated with cervix
cervical intraepithelial lesion (CIN)
142
# pre-cancerous lesion in cervix
risk factors for CIN
* sex
* HPV **16** & **18**
* co-infection with **HIV**
143
# pre-cancerous lesion in cervix
screening for patients w/ CIN
look for **HPV**
* ages 25-29: **pap** smear cytology,
every **3** years
* ages > **30**: HPV **DNA** immunohistochemistry,
every **5** years
144
types of cervical cancer
* Squamous Cell Carcinoma (SCC)
* adenocarcinoma
145
# cervical cancer
features of SCC
* most common cervical cancer!
* **cauliflower**-like growth
146
types of uterine cancer
* endometrial carcinoma
* leiomyo(sarco)ma
147
# uterine cancer
type I vs type II endometrial carcinoma:
* related gene
* which has poorer prognosis
* type I: EXCESSIVE **oestrogen**
-> hyperplasia
=> loss of **PTEN**
* type II: loss of **P53**,
poorer prognosis
## Footnote
recall!
* loss of PTEN = cells **resist apoptosis**
* loss of P53 = cells keep dividing despite **DNA damage**
148
risk factors for endometrial cancer
**oestrogen**-related:
* **OBESITY**
* peri/post-**menopausal**
* 2º to oestrogen-producing tumours
* oestrogen hormone therapy
149
# uterine cancer
symptoms for leiomyo(sarco)ma
related to its rapid **enlargement** DURING pregnancy
* pain
* haemorrhage
* bladder compression
* spontaneous abortion
150
salpingitis:
* inflammation of (...)
* almost always a component of **PID**
* most common cause: (...) — usually (...) and (...)
* acute infection -> inflammation -> (...) => (...)
resulting in:
1. (...)
2. (...)salpinx: tube fills with (...)
3. (...)salpinx: tube fills with (...)
4. infections spreading to (...) — (...),
then to (...) — (...)
and finally to (...) — (...)
salpingitis:
* inflammation of **fallopian tube**
* almost always a component of **PID**
* most common cause: **STDs**
— usually **chlamydia** trachomatis and neisseria **gonnorhoea**
* acute infection -> inflammation -> **adhesions** => **blockage** of tube
resulting in:
1. **ectopic** pregnancy
2. **hydro***salpinx*: tube *fills with* **serous fluid**
3. **pyo***salpinx*: tube *fills with* **pus**
4. infections spreading to **PERITONEUM** — peritonitis,
then to **liver CAPSULE** — **Fitz-Hugh-Curtis** syndrome
and finally to systemic circulation — **bacteraemia/septicaemia**
## Footnote
* other causes include objects & fomites, iatrogenic
* recall: FHC syndrome involves
NORMAL LIVER parenchyma,
but "violin-string" adhesions bet liver and abdominal wall,
presents w/ RUQ pain
151
how does actinomycotic salpingitis differ from the usual salpingitis
## Footnote
caused by actinomyces israelii (filamentous, branched, gram pos bacteria)
* results in **CHRONIC invasive** infection instead of an acute mucosal infection
* associated w/ **IUD** — intra-uterine device
152
treatment for salpingitis
* ceftriaxone
=> kills N. gonorrhoea
* azithromycin
=> stops growth of obligate *intracellular* C. trachomatis
153
cause of a single ovarian cyst
simple ovarian cyst
due to early maturation of **Graafian** follicle
and then **failure to rupture**
-> continuous accumulation of **serous fluid** in **antrum**
=> enlargement into cyst
## Footnote
usually 1-5 cm
154
what syndrome could **multiple** ovarian cysts be associated with
+ its symptoms
PolyCystic Ovarian Syndrome (PCOS)
* acne
* hirsutism
* obesity
* (sometimes) 1º amenorrhoea
## Footnote
pathophysiology:
1. increased LH: FSH ratio
-> theca cells are highly stimulated -> excessive amts of androgens
=> hirsutism and acne
2. insulin resistance
-> hyperinsulinemia
-> greater storage of fat
=> obesity
155
which marker can be used to monitoring **epithelial** ovarian cancer?
Cancer-Antigen (CA) **125**
<- can rmb as ovarian cancers have 3 categories:
thecal (1), granulosa (2) and epithelial (5)
## Footnote
not used for diagnosis as not very sensitive or specific
e.g. high CA-125 can also be seen in other conditions such as endometriosis, PID, HF, etc
156
types of epithelial ovarian cancer
* endometrioid
* clear cell
* serous
* mucinous
* Brenner
## Footnote
epithelial = **germinal epithelium**
which is pluripotent
and thus can differentiate into various types of epithelium
157
what type of epithelium does each
epithelial ovarian cancer have
| think abt the structures which they resemble
* endometrioid: **stratified**
<- endometrial **glands**
* serous: columnar, **ciliated**
<- **fallopian tube**
* mucinous: columnar, **mucin-producing**
<- endocervix/GI
* *B*renner: **urothelium**
<- organs in urinary tract, e.g. *B*ladder
158
compare gross features of the different types of epithelial ovarian cancers
159
compare histological features of the different types of epithelial ovarian cancers
160
which types of epithelial ovarian cancer are associated w/ endometriosis?
* endometrioid
* clear cell
* Brenner
161
types of granulosa ovarian cancers
* granulosa cell tumour
* Sertoli-Leydig cell tumour
162
# ovarian cancer
genetic mutation associated w/ granulosa cell tumour
FOXL2
163
# ovarian cancer
histological features of *granulosa* cell tumour
* **Call**-**exner** bodies:
"**Call** *granny* **exner**"
* Coffee-bean nuclei:
164
# ovarian cancer
symptoms of granulosa cell tumour
granulosa cells convert androgens -> oestrogen
-> increased conversion
=> increased oestrogen levels
* young girls: **precocious** puberty
(= EARLY puberty)
* reproductive-age women: menstrual irregularities, infertility
* post-menopausal women: abnormal uterine **bleeding**,
increased risk of **endometrial hyperplasia and CA**
## Footnote
these are the core symptoms of unopposed oestrogen!
which could be due to increased oestrogen lvls (this case)
or just a low progesterone relative to oestrogen
165
symptoms of Sertoli-Leydig cell tumour
**stromal** cells **differentiate** into sertoli and leydig cells
=> overall increased **testosterone** AND **oestrogen** levels
* masculinisation
(e.g. menstrual irregularities, amenorrhoea,
hirsutism, acne, deepening of voice
clitomegaly)
* some uterine bleeding and endometrial hyperplasia
166
inflammatory mastitis:
* usually occurs during (...)
* pathogenesis:
(...)
-> (...) enter through **cracked** nipples and proliferate in (...)
=> infection and inflammation
* treatment
* complication
* usually occurs during **breastfeeding** early postpartum
* pathogenesis:
abundant **milk** in secretory units
-> bacteria (esp **S. aureus**) enter through **cracked** nipples and proliferate in **stagnant milk**
=> infection and inflammation
* treatment: **CONTINUE breastfeeding**
* complication: **abscess**
167
most common benign non-proliferative epithelial lesions
fibrocystic change
168
pathophysiology (and thus symptoms) of fibrocystic change
* relative excess of oestrogen
-> **epithelial hyperplasia**
-> ducts become blocked and start ballooning out
=> formation of **cysts**
* cells lining cyst also undergo **apocrine metaplasia**
* chronic inflammation caused by trapped fluid
=> **fibrosis** (of STROMA)
169
what could increase risk of fibrocystic change resulting in malignancy
* **EPITHELIAL HYPERPLASIA**
* even more if w/ **atypia**
170
fibroadenoma:
* benign lesion in (...)
* present as a (...), well-defined (...) lump
* pathophysiology:
proliferation of (...)
=> compressed (...) surrounded by (...)
* benign lesion in **intraLOBULAR stroma**
* present as a **FIRM**, well-defined **MOBILE** lump
* pathophysiology:
proliferation of **glandular** AND **stromal** elements
=> **compressed ducts** surrounded by pink fibrous stroma
## Footnote
* if the breast is a tree,
lobule = "leaves" (where milk is actually made)
duct = "branches" (the pipes that carry the milk to the trunk/nipple)
* both are still lined by double layer of cells (luminal, myoepithelial)
171
intraductal papilloma:
* benign lesion in (...)
* present with (...),
(...)
* pathophysiology:
proliferation of (...)
=> formation of (...)
* benign lesion in **ducts**
* present with **dilated** ducts,
**bloody** nipple **discharge**
* pathophysiology:
proliferation of epithelial cells lining duct
=> formation of **papillae** w/ fibrovascular core and epithelial lining
## Footnote
epithelial includes both luminal epithelial AND myoepithelial
172
what condition is associated with **greenish** discharge
ductal ectasia:
benign condition where milk **ducts** beneath nipple **dilate** and often fill w/ fluid
173
what infectious agents can cross the placenta and cause congenital infection
| hint: TORCHeS VPZ
* **T**oxoplasmosis
* **O**thers (hep B, listeria, coxsackie virus)
* **R**ubella
* **C**MV
* **H**IV
* **H**erpes virus (HSV) **2**
* **S**yphilis
* **V**ZV
* **P**arvovirus B19
* **Z**ika
174
what infectious agents are detected during
routine antenatal screening tests for pregnant women
* **R**ubella antibody
* **H**IV antibody
* **S**yphilis antibody
* Hep *B* surface **ANTIGEN**
& Grp *B* strep (pathogen itself via **vaginal swab**)
## Footnote
* method most commonly used is Enzyme ImmunoAssay (EIA),
esp for syphilis
* Hep B and Grp B are only ones not rlly in TORCHHeS and thus are different
175
which types of antibodies give a neonate immunity
| from MGAE
* transported from maternal blood -> fetal circulation via **placenta** = Ig**G**
* secreted in **milk** = Ig**A**
## Footnote
thus if child has Ig**M** against a pathogen = active **infection**
176
vaginal discharge:
* bacterial (gonorrhoea, chlamydia)
* bacterial vaginosis
* fungal
* protozoa
* trichomoniasis
177
types of pre-invasive malignant neoplasms
* ductal carcinoma in-situ (DCIS)
* lobular carcinoma (LCIS)
| where proliferating tumour cels **fill up** ducts or lobules
178
DCIS:
* features (2)
* pattern
* ipsilateral/bilateral subsequent cancer?
* features:
1. central **necrosis**
2. **CALCIFICATIONS**
* pattern: comedo or cribiform
<- INTACT E-cadherin
* subsequent cancer is **ipsilateral** only
<- INTACT E-cadherin
## Footnote
* comedo: cells grow rapidly → central necrosis → debris in duct lumen
* cribiform: cells grow around punched-out spaces
179
LCIS:
* pattern
* ipsilateral/bilateral subsequent cancer?
* pattern: solid (uniform, loosely-packed)
<- **LOSS** of **E-cadherin**
* subsequent cancer can be ipsilateral or **bilateral**
<- LOSS of E-cadherin
180
which pre-invasive malignant neoplasm,
DCIS or LCIS,
results in greater risk of subsequent invasive neoplasm?
**D**CIS
| it's **D**angerous!
181
features of breast cancer
* palpable, hard **mass** (**upper outer** > subareolar)
* nipple changes: nipple **retraction**, nipple **discharge**
## Footnote
**peau d'orange** skin can occur but rarely
182
how do features of **inflammatory** breast cancer differ from the usual (non-inflammatory)
* hallmark sign: **"PEAU D'ORANGE"** skin
* breast appears **red, swollen and warm**
* NO discrete mass
## Footnote
* IBC is due to **lymphatics** being blocked by **tumour emboli**
* and is significantly **more aggressive**
183
risk factors for breast cancer
* peri**menopausal** age
* **obese**
* **ovarian** activity: early menarche/late menopause
* **previous** breast disease
* positive **family** history
184
what does triple test in screening of breast cancer involve
* **clinical** assessment: HX, PE
* **imaging**: **mammogram**, **US**
* pathology: **biopsy**
185
how often should screening for breast cancer happen
* **40**-49: every **year**
* >**50**: every **2 years**
186
tumour staging for breast cancer
* at which T (T1-T4) does tumour **extend to skin or chest wall**?
* N1, N2 and N3 involve which LNs respectively?
## Footnote
recall **TNM**:
**T** = **T**umour size
**N** = lymph **N**ode metastases
**M** = distant **M**etastases
* T**4**
* N1: **axillary**
N2: A OR **internal mammary**
N3: A and IM OR **supraclavicular**
187
# breast cancer
compare gross appearance of the different types of invasive ductal carcinoma
188
# breast cancer
compare histological features of the different types of invasive ductal carcinoma
189
# breast cancer
which type of invasive ductal carcinoma is associated with **BRCA-1** gene
medullary
190
what is the most common type (and subtype) of breast cancer
invasive **ductal** carcinoma
* most common subtype: **no special type**
191
# breast cancer
which type of invasive ductal carcinoma has the tendency to metastasise to **axillary** LNs
all invasive breast neoplasms can,
but very likely to is
**no special type**
192
invasive **lobular** carcinoma
* common?
* gross
* histo
* pathophysio
* 2nd most common breast cancer
* gross: **no palpable mass**,
instead just vague skin thickening or "fullness"
* histo: **diffuse** infiltration,
**SINGE-FILE** OR **"BULL'S EYE"** pattern,
minimal desmoplasia
* pathophysio: **LOSS** of **E-cadherin**
## Footnote
desmoplasia = stroma proliferation around tumour to trap it
193
Paget's disease of the nipple:
* pathophysio
* gross
* histo
* **underlying malignancy** (e.g. DCIS, IDC)
-> malignant tumour cells **migrate** from original site **through the ducts** and into the **epidermis** of the **nipple and areola**
W/O breaching BM
* gross: red, scaly/crusty patch on nipple
=> LOOKS like **eczema**
* histo: **large** atypical cells with **clear cytoplasm**
## Footnote
differentiate from eczema by the fact that eczema usually involves areola first and spares the nipple
194
hormone therapy for breast cancer:
* when can it be used
* drugs
* when patient is either **Estrogen** Receptor positive (**ER+**),
**Progesterone** REceptor positive (**PR+**)
or **HER2+**
* for ER+ and /or PR+ patients:
1) pre-menopausal: **SERM** (e.g. tamoxifen)
=> recall: acts as **estrogen antagonist** in **breast** tissue
2) post-menopausal: **aromatase inhibitors** (e.g. anastrozole, letrozole, exemestane)
=> prevent **conversion of androgens to estrogen** in fat and muscle
* for HER2+ patients: HER2 inhibitors
(e.g. humanized monoclonal antibody **trastuzumab (aka herceptin)**)
=> for breast cancers which overexpress **HER2 protein**,
which drives **aggressive growth**
## Footnote
goal of homone therapy for ER+ and PR+ patients is to** deprive cancer of estrogen**!
med
flashcards
Decks in class (23)
# Cards
-
embryology30
-
biochem1
-
immunology16
-
cvs pharm (DONT USE)9
-
blood86
-
cvs233
-
respi153
-
renal123
-
thorax anatomy181
-
lungs anatomy38
-
git355
-
foundation I10
-
biochem168
-
foundation II133
-
endocrine121
-
repro194
-
mskderm160
-
mskderm 2387
-
multisystem19
-
paediatrics24
-
PE42
-
approach to passing5
-
procedural skills4
