What does the vulva refer to?
refers to all these external structures Vaginal orifice influenced by childbirth, exposing anterior vaginal wall
1. What artery supplies the the pelvic arterial flow?
2. And what artery branches from this?
1. Aorta-common iliac—external and internal iliac
2. Uterine artery as branch of internal iliac or hypogastric
What form the fallopian tubes and then fuse caudally to form uterus, cervix and upper vagina? 2
1. Mullerian or
2. paramesonephric ducts
1. What is a gartner's duct cyst?
2. What are the sites for this? 3
1. A Gartner's duct cyst (sometimes incorrectly referred to as vaginal inclusion cyst) is a benign vaginal cystic lesion that arises from the vestigial remnant of a mesonephric duct or Gartner's duct.
1. Later associated with uterine anomalies which caused what? 2
2. Exposed sons have increased risk of what? 3
3. Mothers have modest increase risk of what?
-increased pregnancy complications and infertility as well as
-increased risk of cervical and breast cancer
3. breast cancer
1. DES associated with what of vagina in DES exposed daughters in 1971 and use stopped in US?
Use continued in some other countries until early 1980’s. (Youngest exposed in US about 44 yo now.) Increase also in uterine anomalies (Tshaped uterus, hypoplastic uterus and uterine adhesions created increase infertility, ectopic preg and early preg loss. These daughters need yearly exams with cervical and 4 quadrant vaginal pap as well as careful vaginal palpation to screen for clear cell carcinoma. Mothers who took DES have mild-moderate increase risk of breast cancer (17%). Third generation effects equivocal.
1. clear cell carcinoma
What do the following pelvic types describe:
Ovulation requires a what?
surge of prostaglandin synthesis within the follicle
1. Hypothalamus loctaed where?
2. Hypothalamic-Hypophyseal Portal Circulation is the blood supply where?
1. Located at base of brain, just above junction of optic nerves
2. The blood supply of anterior pituitary originates in the hypothalamus
There are no direct nerve connections
State what the following are:
1. – gonadotropin-releasing hormone
2. – thyrotropin-releasing hormone
3. – somatotropin release-inhibiting factor (somatostatin or growth hormone inhibiting-hormone)
4. – corticotropin-releasing factor
5. – prolactin release-inhibiting factor = dopamine
Anterior pituitary (Adenohypohysis)
1. Derived from what?
2. Produces how many different hormones?
Posterior pituitary (Neurohypophysis)
1. Derived from what?
2. Transports what? 2
Anterior pituitary (Adenohypohysis)
1. Derived from ectoderm
2. Different cell types that produce 6 different hormones
Posterior pituitary (Neurohypophysis)
1. Derived from neural tissue
2. Transports oxytocin and vasopressin
Anterior Pituitary- Adenohypophysis
What are the 6 hormones that are released by this?
1. FSH – follicle stimulating hormone – gonadotrophs
2. LH – luteinizing hormone – gonadotrophs
3. TSH – thyroid stimulating hormone – thyrotrophs
4. Prolactin – lactotrophs
5. GH – growth hormone
6. ACTH – adenocorticotrophic hormone – MSH (melanocyte stimulating hormone – Addison’s disease)
1. Which hormones are released by Hypothalamic Neurohormone? 5
5. PIF (Dopamine)
What do the following signal for the anterior pit to release?
5. PIF (Dopamine)?
What are the target organs for the following hormones?
1. FSH and LH?
4. ACTH and MSH?
3. Skeletal system
Pulsatile secretion of GnRH from the (arcuate nucleus) hypothalamus
1. Stimulated by what?
2. Inhibited by what?
3. Influenced by what?
4. Low pulse frequency triggers what?
5. High pulse frequency triggers what?
1. Stimulated by norepinephrine
2. Inhibited by dopamine (PIF)
3. Influenced by endogenous opiods
4. Low pulse frequency triggers FSH
5. High pulse frequency triggers LH
1. GnRH reaches the anterior pituitary by what?
2. and stimulates secretion of what?
1. hypothalamic-pituitary portal vascular system
2. FSH (follicle stimulating hormone) and LH (luteinizing hormone)
1. First, low levels stimulate what and from where?
2. These androgens are converted to ________ in the granulosa cells
3. Stimulates secretion of what 2 from what?
1. secretion of androgens (testosterone and androstenedione) from the theca cells.
3. ESTROGENS (estradiol and estrone) by granulosa cells of ovarian follicles
Estrogen and LH: Ovulation
1. Initially, estrogen creates a negative feedback to the pituitary to__________ LH and FSH?
2. In late follicular phase, peak estradiol levels from the dominant follicle trigger what?
2. a midcycle surge of LH needed for ovulation and preparing the ovary to make progesterone
1. With ovulation, the dominant follicle becomes a progesterone-secreting cyst called the what?
2. and the ________ of menstrual cycle begins.
1. corpus luteum
2. luteal phase
1. Negative feedback on pituitary secretion of LH and FSH causes what?
1. decreasing E and P to be made in corpus luteum
1. If no conception, the lifespan of the corpus luteum is ____days.
2. Progesterone levels ____?
3. _______ period triggered
4. Negative feedback for FSH secretion stops and FSH levels start to do what?
4. to rise before onset of menses
If implantation occurs:
What from the zygote sustains the corpus luteum for 6-7 weeks until the placenta takes over?
HCG (human chorionic gonadotropin)
Describe the menstural cycle
DES causes what kind of shape uterus?
2. Which hormone dominates?
3. Development of what?
4. Culminates with what event?
5. How big will the dominant follicle be?
2. Estrogen Dominates
3. Development of Mature Follicle
4. Culminates with LH surge preceding ovulation
5. 20-25 mm in size
2. Requires what?
3. What hormone is dominant?
4. Elevated what?
5. What is the main event in this phase?
2. REQUIRES THAT OVULATION HAS OCCURRED
3. PROGESTERONE DOMINANT
4. ELEVATED BASAL BODY TEMPERATURE
5. FURTHER PREPARES UTERINE LINING (ENDOMETRIUM) TO RECEIVE FERTILIZED EGG
1. What confirms ovulation?
2. What does this look like on the corpus luteum?
3. Progesterone changes glandular structure. How?
4. ______ mm EMS
1. Following dominant follicle to CL confirms ovulation
2. Irregular, thin walled with internal echoes
3. (increased length and tortuosity)
Describe the functions of estrogen in the following organs:
4. Vagina? 2
1. pubertal development
2. stimulates cell growth (proliferative phase)
3. stimulates abundant, clear mucus at mid cycle
-growth and maturation of epithelium
5. helps to maintain density. Estrogen receptors in osteoblasts
1. __________ effects at level of hypothalamus
2. Increase of basal body temperature (BBT) by how much?
3. Cervical mucus changes how? 2
4. Breasts: stimulation of what contributes to fullness and tenderness? 3
5. Fallopian tubes: affected by progesterone how? 2
2. 0.5-1.0 F
3. thickens and decreases in amount
-decreases mucus and
-causes relaxation to speed transport of ovum
How can we track if ovulation occured?
1. Track length of menstrual cycles
2. Serial transvaginal ultrasounds to follow follicular development from dominant follicle to corpus luteum
3. Measure LH surge (OTC urine kits):
ovulation 36 hours after LH surge
4. Basal body Temp (BBT) rises 0.5-1.0 degree F
5. Measure serum progesterone at mid luteal phase
-Expect > 6 ng/ml
In which ways can you measure LH? 2
How long after ovulation does this occur?
-LH shows up in urine 12 hours after surge
-LH also increased with PCOS, POI and menopause
2. ovulation 36 hours after LH surge
1. Both male and female infants may have palpable breast tissue at birth. Some will have ____________- an effect of maternal hormones?
2. By ___ months of age, the breast tissue regresses
3. __________ : onset of breast development starts at age 12.5 in US in 95% of girls
4. Growth during pregnancy from hormones including what? 7
-thyroid hormones and
Reproductive Physiology-Breasts Composition
What are the parts? 7
2. Areola (pink or brown pigmented area around nipple)
3. Milk glands (lobules) that produce milk
4. Ducts - transport milk from the milk glands (lobules)
6. Connective (fibrous) tissue that surrounds the lobules and ducts
1. What os Paget's dz?
2. What will it look like? 4
1. Paget’s Disease: ductal carcinoma extending to skin
1. During pregnancy, breasts increase in size - increase in lobules = ?
2. The release of estrogen and progesterone from the ________ and prolactin from the __________ causes breast development
3. Breast milk production - inhibited during pregnancy by what?
1. alveoli lined by milk-secreting epithelial cells
2. placenta, anterior pituitary
3. the effect of progesterone on prolactin
1. ________ first 3-6 days
2. Milk production stimulated by _________.
3. ________ release stimulated by direct stimulation of the nipple
4. Milk ejection results from what?–
5. This is a neuro-endocrine reflex with release of _______?
6. Neuro-endocrine reflex disturbed by maternal tension resulting in what?
4. nipple stimulation
6. problems with nursing
Galactorrhea (non-physiologic milky discharge)
2. Medications that may cause this? 5
3. Disease processes that may cause this? 2
4. Injuries? 4
2. Medications -
-herbal supplements, and
-birth control pills
-nerve damage from injury
-Spinal cord injury
5. Stimulation of the breasts
The Menstrual Cycle
2. what is menarche?
3. What is menopause?
Majority between 24-35 days and are ovulatory
About 15% are 28 days
Less than 1% are < 21 or >35
2. Menarche: first menses
3. Menopause : final menses
The Menstrual Cycle
1. Follicular Phase begins with what and ends with what?
2. Ovulation occurs within ___ hours of LH surge
3. Luteal Phase begins with what and ends with what?
4. “Day 1” is what?
1. onset of menses, luteinizing hormone surge
3. LH surge, onset of next menses
4. first day of menses and the date used in LMP (last menstrual period)
Menstrual Cycle- Menarche
1. Age of first menses? (median age in US?)
2. Onset of puberty signals reactivation of the what? And how?
2. Hypothalamic-Pituitary-Gonadal Axis with pulsatile Gn-RH secretions
1. What is puberty?
2. Trend in US for changes in age?
1. Endocrine process that influences physical, sexual and emotional transition from childhood to adulthood. (Triggers for onset are not well defined)
2. In US, puberty starting 6-12 months earlier over last century
1. Sexual maturation extends an average of ____ years. Predictable events may vary in sequence and pace:
2. What happens over this phase? 6
-Breast development (thelarche): in US, begins by age 12.5 in 95%
-Pubic hair development (pubarche): preceded by increased adrenal androgen production (adrenarche)
-Maximal growth rate
-Menarche (further height limited to about 2.4 inches)
Onset is influenced by what? 4
1. Ethnic background: African American then Mexican American then White then Asian American (On average, black girls begin puberty 8-9 but can be normal as early as 6. White girls begin by age 10 but as early as 7 can be normal.)
2. BMI: higher = earlier onset of puberty
4. Possible role of environmental toxins acting as endocrine disruptors
Why would a higher BMI cause an earlier onset of puberty?
Possible effect of leptin (from adipocytes) on pulsatile GnRH secretion
Puberty-Role of Estrogens
1. Augments accrual of bone during puberty.
- What mediates the actions of estrogen, and the presence of both has been demonstrated in the growth plate? 2
2. Contributes to what at the end of puberty?
3. Stimulates what else?
1. Two estrogen receptors (alpha and beta)
2. growth plate fusion
3. breast development
Pubertal Growth Spurt-
Role of Growth Hormone? 3
1. Pulsatile release from pituitary
2. Both GH and sex steriods contribute to growth and epiphyseal fusion
3. Stimulates secretion of insulin-like growth factor (IGF-1)
Criteria for Dx? 4
1. Absent or incomplete sexual maturation by age at which 95% of girls started pubertal development:
2. Absence of secondary sexual characteristics by age 13
3. Absence of menarche by age 15-16
4. No menarche 5 years after onset of thelarche (breast development)
What are the most common causes of delayed puberty?
1. Hypogonadotropic hypogonadism: FSH & LH <10
2. Constitutional (physiologic delay) of HPO
3. Suppression of HPO axis by illness, malnutrition or excessive exercise
1. What is precocious puberty?
2. Caused by what?
3. Dx? 5
1. Onset of secondary sexual characteristics before age 6 in black girls and prior to age 7 in white girls (or > 2 SD from normal)
2. Caused by early sex hormone production
3. Evaluation goals: define cause, determine if tx necessary and minimize psychosocial impact
-Hx and exam (Tanner Staging)
-Xray of non-dominate wrist and hand for bone age (Premature closure of epiphyseal plates limits stature)
-MRI of brain
1. GnRH-dependent (central): Explain the PP?
2. 90% are caused by what?
3. Secondary causes? 4
4. Generally treated with what?
1. early activation of HPO with both breast and pubic hair development
2. idiopathic (dx of exclusion: MRI)
-CNS lesions (tumor, hydrocephalus, )
-Severe hypothyroidism : high TSH activates FSH receptor
4. GnRH agonist
Gn-RH independent (peripheral): Causes? 4
1. Autonomous functional ovarian cysts
2. McCune-Albright syndrome (rare genetic disorder)
3. Adrenal pathology:
4. Exposure to exogenous estrogens or xenoestrogens (endocrine disruptors which mimic estradiol)
What are the adrenal pathologies that affect precocious puberty? 2
1. Nonclassical Congenital Adrenal Hyperplasia (CAH)- May mimic PCOS due to accompanying hyperandrogenism
2. Adrenal tumors
1. Menstrual Cycle – Menopause: What is it?
3. Median age?
4. Primary ovarian insufficiency (premature ovarian failure) is what?
5. Confirmation of what is a common concern?
1. Permanent cessation of menses
2. Retrospective diagnosis: no period (amenorrhea) for 12 months without other explanation= postmenopause
3. Median age 51.4
4. Primary ovarian insufficiency (premature ovarian failure): cessation of menses prior to age 40
5. Confirmation of infertility is a common concern
Menstrual Cycle – Menopause
1. “Ovaries no longer listening to brain” =?
2. Represents depletion (or near depletion) of what?
3. FSH, although elevated, is seldom needed for dx unless confirmation of what is a concern?
1. oocytes resistant to FSH
Estrogen loss in Postmenopause
1. Urogenital atrophy
2. Increase in LDL and decrease HDL
3. Decrease in bone density
4. Vasomotor symptoms (Hot Flashes)
HOw does estrogen maintain bone density?
Estrogen acts to maintain the appropriate ratio between bone-forming osteoblasts and bone-resorbing osteoclasts in part through the induction of osteoclast apoptosis
Describe the stimulation and inhibition of LH and FSH?