REPRODUCTIVE for step 1

1. REPRODUCTIVE for step 1 Lauren Meshkov, MS-3 lmeshkov@med.miami.edu

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

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

4. GnRH (pulsatile) FSH Follicles grow LH surge hCGpreggo

5. 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

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

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

8. 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

9. Boards PCOS Clinical: Overweight, hirsutism, amenorrheic, insulin resistance, infertility Labs: High LH/FSH ratio, high testosterone (cycle of estrogen aromatization in periphery Images: Polycystic ovaries Tx: Stimulate ovulation to regulate hormones. COCP, GnRH agonist pulsatile, Clompihene

10. 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 Partial (69XXY) Complete (46XY) 1 egg + 2 sperm Fetal parts Empty egg + 1 sperm Choriocarcinoma risk (easy chemo tx) Huge uterus

11. GynOnc 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)

12. Sex Chromosome Disorders • Klinefelter’s(boy who looks like a girl) • Appearance:Small testes, female hair distr, long/lanky • Genetics: XXY • Hormones: TestostEstrogen 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

13. Psuedo-Hermaphrodites SRY gene Testes determining factor TESTES Leydig Cells Sertoli Cells Testosterone Internal dvlpmt MullerianInhib Factor Sexual Hair Dvlpmt Masculine at puberty 5-a-reductase No uterus, fallopian tubes, or ovaries DHT Male External genitalia

14. Androgen Insensitivity SRY gene Genetics: XY Internal: testes, no uterus External: vagina Hormones: high testosterone high estrogen Puberty: no sexual hair breast dvlpmt Testes determining factor TESTES Leydig Cells Sertoli Cells Testosterone Internal dvlpmt MullerianInhib Factor Sexual Hair Dvlpmt Masculine at puberty 5-a-reductase No uterus, fallopian tubes, or ovaries DHT Male External genitalia Default Female Genitalia

15. 5-alpha reductase deficiency SRY gene Genetics: XY Internal: testes, no uterus External: vagina/ambiguous Hormones: normal or high LH Puberty: girl  boy! Testes determining factor TESTES Leydig Cells Sertoli Cells “Guevedoces” or “Penis at 12” Testosterone Internal dvlpmt MullerianInhib Factor Sexual Hair Dvlpmt Masculine at puberty 5-a-reductase No uterus, fallopian tubes, or ovaries DHT External genitalia Default Female Genitalia

16. 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? • Clomiphene (SERM) • PulsatileLeuprolide (GnRH agonist) • ContinousLeuprolide (GnRH agonist) • Combined oral contraceptive pills • Weight Loss

17. 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? • Lower genital tract laceration • Endometriosis • Uterine Fibroids • Endometrial cancer • Leiomyosarcoma • New onset menses

18. 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? • Exogenous testosterone will increase sperm production • Exogenous testosterone will decrease sperm production • Exogenous testosterone will neither increase nor decrease sperm production • Exogenous testosterone will cause prostate cancer

19. Question 4 • A 17 yoteenage 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? • Vaginal outflow tract obstruction • No uterus or ovarian structures • Dysregulation of the HPA axis • Underweight • Pituitary adenoma • Antipsychotic use

20. 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? • Wait until 34 wks for fetal lung maturity, then deliver • Check lecithin/sphingomyelin ratio to determine fetal lung maturity • Give steroids to hasten lung maturity, then deliver • Deliver now, despite fetal lung immaturity • Begin hydralazine until diastolic BP reaches 90 to prevent maternal stroke • Give MgSO4 to prevent seizure • Abort the pregnancy, as this patient is developing HELLP syndrome

21. 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 wouldsildenafilbe contraindicated? • Patient takes inhaled corticosteroids for asthma • Patient takes labetelol for hypertension • Patient takes metformin for diabetes • Patient takes a multivitamin, including zinc • Patient takes finasteride for prostate hyperplasia • Patient is on nitrates for heart disease

22. Question 7 • A 23 yomale 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? • Seminoma • Embryonal tumor • Choriocarcinoma • Yolk sac tumor • Teratoma

23. Question 8 • A woman comes into your office with bloody discharge from her left nipple. What is the most likely diagnosis? • Fibroadenoma • Fibrocystic changes • Phyllodes tumor • Intraductalpapilloma • Ductal Carcinoma in Situ • Invasive lobular cancer • Paget’s disease

24. 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? • Stop breastfeeding and use formula instead • Stop breastfeeding, use formula, and begin antibiotics • No treatment needed, keep breastfeeding • Keep breastfeeding and begin antibiotics

25. 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? • HPV 16 and 18 for cervical cancer • HPV 6 and 8 for genital warts • HPV 36 for invasive cervical cancer • Both answers A and B • Both answers A and C

26. 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? • Hypernatremia and Hypokalemia • Hyponatremia and Hyperkalemia • Hypernatremia and Hyperkalemia • Hyponatremia and Hypokalemia

27. 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? • Patent Foramen Ovale • PreductalCoarctation • VSD • Tricuspid stenosis • Mitral Valve prolapse

28. 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 hergalactorrhea? • Prolactin • Estrogen • Testosterone • Oxytocin • TSH • Dopamine