REPRODUCTIVE for step 1 Lauren Meshkov, MS-3 [email protected]

REPRODUCTIVE for step 1

Lauren Meshkov, [email protected]

Tips Memorize non-deducible info Predict board-style ?’s (2-3 step thinking) Make connections between subjects Who cares about other people!

Overview• Menstruation and hormones• Pregnancy Pathology (eclampsia, moles)• Sex Chromosome disorders• Psuedo-Hermaphrodites• Questions

GnRH (pulsatile)

FSH

LH surgeFollicles grow

hCG preggo

Menses Vocab

• Oligomenorrhea = infrequent period• Polymenorrhea = period all the time• Amenorrhea = no period at all

• Menorrhagia = heavy flow• Metrorrhagia = frequent and irregular period• Menometrorrhagia = heavy, frequent, & irreg

“Doc, I haven’t had my period in months!

PREGNANCY TEST!

If negative, consider…• 1o Amenorrhea (Never had period)• 2o Amenorrhea (Had it, but now it’s gone)

• Hypothalamus Anorexia, weight loss/exercise

• Pituitary Prolactinoma, Psych Drugs (DA), Hypothyroidism (TRH), Sheehan’s

• Ovaries PCOS*, Premature ovarian failure, Turner’s, Menopause

• Uterus Adhesions (Asherman’s), Mullerian Agenesis

• Vagina Imperforate hymen

Boards PCOS

Clinical: Overweight, hirsutism, amenorrheic, insulin resistance, infertilityLabs: High LH/FSH ratio, high testosterone (cycle of estrogen aromatization in peripheryImages: Polycystic ovariesTx: Stimulate ovulation to regulate hormones. COCP, GnRH agonist pulsatile, Clompihene

Pregnancy Pathology• Moles – Big uterus, hCG, “snowstorm” “cluster of grapes”

• Pre-eclampsia – HTN (140/90, 160/110), proteinuria 3+/5+, seizures– Tx: Deliver baby ASAP

• Placental problems– Placenta Abruptio = detaches, painful bleeding– Placenta Accreta = Adheres to myometrium, bleeds– Placenta Increta = Invades myometrium, bleeds– Placenta Previa = Low-lying placenta

1 egg + 2 spermFetal parts

Empty egg + 1 spermChoriocarcinoma risk (easy chemo tx)Huge uterus

Partial (69XXY) Complete (46XY)

Gyn Onc and Breast

• Ovarian tumors– Teratoma in young women– Serous epithelial in older women – There is no screening test!

• Breast pathology– Fibroadenoma in young women (rubbery, mobile)– Fibrocystic change in middle age women (cyclic)– Invasive CA dimples (Cooper’s ligament, in ducts)– Nipple discharge: Galactorrhea ok, bloody not ok!– Mastitis in breastfeeding (give Abx and continue feeding)

Sex Chromosome Disorders

• Klinefelter’s (boy who looks like a girl)

– Appearance: Small testes, female hair distr, long/lanky– Genetics: XXY – Hormones: Testost Estrogen FSH and LH

• Turner’s (girl with no period)

Appearance: Short, shield chest, webbed neck, edema– Genetics: XO– Hormones: Estrogen FSH and LH – Complications: Coarctation, bicuspid AV, streak ovary

Psuedo-HermaphroditesSRY gene

Sertoli Cells

Mullerian Inhib Factor

Testes determining factor

TESTES

DHT

Testosterone

Leydig Cells

Internal dvlpmt

Male External genitalia

5-a-reductase

No uterus, fallopian tubes, or ovaries

Sexual Hair Dvlpmt

Masculine at puberty

Androgen InsensitivitySRY gene

Sertoli Cells



TESTES

DHT

Testosterone

Leydig Cells

Internal dvlpmt

Male External genitalia

5-a-reductase


Sexual Hair Dvlpmt

Genetics: XY Internal: testes, no uterusExternal: vaginaHormones: high testosterone

high estrogenPuberty: no sexual hair

breast dvlpmt


Default Female Genitalia

5-alpha reductase deficiencySRY gene

Sertoli Cells



TESTES

DHT

Testosterone

Leydig Cells

Internal dvlpmt

External genitalia

5-a-reductase


Sexual Hair Dvlpmt

Genetics: XY Internal: testes, no uterusExternal: vagina/ambiguousHormones: normal or high LHPuberty: girl boy!


“Guevedoces” or “Penis at 12”

Default Female Genitalia

Question 1

• A 25 yo female reports no menstruation for the past 6 months. She states her period has always been infrequent, occuring at unpredictable times every 6-8 weeks. You note she is overweight and has dark hair on her arms, chin, and chest. Which medication would NOT work for her amenorrhea?

a) Clomiphene (SERM)b) Pulsatile Leuprolide (GnRH agonist)c) Continous Leuprolide (GnRH agonist)d) Combined oral contraceptive pills e) Weight Loss

Question 2

• A 59 yo female comes to your office complaining of intermittent vaginal bleeding. She is post-menopausal and her last period was 7 years ago. What are you most concerned for?

a) Lower genital tract lacerationb) Endometriosisc) Uterine Fibroidsd) Endometrial cancere) Leiomyosarcomaf) New onset menses

Question 3• A couple suffering male infertility comes into your

office desiring treatment. The husband asks about the use of exogenous testosterone. Which of the following is true?

a) Exogenous testosterone will increase sperm production

b) Exogenous testosterone will decrease sperm production

c) Exogenous testosterone will neither increase nor decrease sperm production

d) Exogenous testosterone will cause prostate cancer

Question 4• A 17 yo teenage girl comes in to your office upset that

she hasn’t gotten her period. She has tanner stage 4 breast development and tanner stage 1 pubic hair. What is the most likely reason for her primary amenorrhea?

a) Vaginal outflow tract obstructionb) No uterus or ovarian structuresc) Dysregulation of the HPA axisd) Underweighte) Pituitary adenomaf) Antipsychotic use

Question 5• A 29 yo female at 30 weeks gestation presents at your office

complaining of headache and sudden swelling of her hands and feet. Her urine dipstick shows 5+ protein and BP is 160/110. What is the best management of this patient?

a) Wait until 34 wks for fetal lung maturity, then deliverb) Check lecithin/sphingomyelin ratio to determine fetal lung

maturityc) Give steroids to hasten lung maturity, then deliverd) Deliver now, despite fetal lung immaturitye) Begin hydralazine until diastolic BP reaches 90 to prevent maternal

strokef) Give MgSO4 to prevent seizure

g) Abort the pregnancy, as this patient is developing HELLP syndrome

Question 6• A 72 yo male comes to the office to discuss his

erectile dysfunction after seeing a Viagra commercial. For which of the following reasons would sildenafil be contraindicated?

a) Patient takes inhaled corticosteroids for asthmab) Patient takes labetelol for hypertensionc) Patient takes metformin for diabetesd) Patient takes a multivitamin, including zince) Patient takes finasteride for prostate hyperplasiaf) Patient is on nitrates for heart disease

Question 7• A 23 yo male has a mass in his left testicle. It is not

translucent on inspection and you suspect malignancy. Biopsy shows Schiller-Duval bodies and labs show increased AFP. What is the most likely tumor?

a) Seminomab) Embryonal tumorc) Choriocarcinomad) Yolk sac tumore) Teratoma

Question 8• A woman comes into your office with bloody

discharge from her left nipple. What is the most likely diagnosis?

a) Fibroadenomab) Fibrocystic changesc) Phyllodes tumord) Intraductal papillomae) Ductal Carcinoma in Situf) Invasive lobular cancerg) Paget’s disease

Question 9• A 31 yo mother comes in 2 wks after delivering her

first child and complains of left breast tenderness. On exam, the breast is tender and red. What is the best management of this patient?

a) Stop breastfeeding and use formula insteadb) Stop breastfeeding, use formula, and begin

antibioticsc) No treatment needed, keep breastfeedingd) Keep breastfeeding and begin antibiotics

Question 10• A 12 yo girl comes in with her mother for an

annual check-up. In addition to her booster shots, you recommend the HPV vaccine. You tell her mother it protects against which of the following?

a) HPV 16 and 18 for cervical cancerb) HPV 6 and 8 for genital wartsc) HPV 36 for invasive cervical cancerd) Both answers A and Be) Both answers A and C

Question 11• A newborn baby is determined to have

ambiguous genitalia. The baby is genetically female (XX), has two ovaries, but also seems to have a small penis. What other findings would be seen in this patient?

a) Hypernatremia and Hypokalemiab) Hyponatremia and Hyperkalemiac) Hypernatremia and Hyperkalemiad) Hyponatremia and Hypokalemia

Question 12• A 16 yo girl is brought to you by her mother, who is

concerned she hasn’t began menstruating. On exam you note her short stature, widely spaced nipples, and webbed neck. What cardiac finding should you be wary of?

a) Patent Foramen Ovaleb) Preductal Coarctationc) VSDd) Tricuspid stenosise) Mitral Valve prolapse

Question 13• A woman comes in complaining of a whitish fluid draining

from her nipples. She also reports feeling sluggish lately and you notice she has brittle hair. Which lab test would likely reveal the cause of her galactorrhea?

a) Prolactin b) Estrogenc) Testosteroned) Oxytocine) TSHf) Dopamine

Documents

REPRODUCTIVE for step 1 Lauren Meshkov, MS-3 [email protected]