PLE SEPT 2019

• CC acts by competing with endogenous circulating estrogens for estrogen-binding

sites on the hypothalamus, thereby blocking the negative feedback of endogenous
estrogen. GnRH is then released in a normal manner, stimulating FSH and LH,
which in turn cause oocyte maturation, with increased E2 production.
• Fibromas are the most common benign, solid neoplasms of the ovary. Their malignant potential is low,
less than 1%. These tumors make up approximately 5% of benign ovarian neoplasms and
approximately 20% of all solid tumors of the ovary.

• Meigs’ syndrome is the association of an ovarian fibroma, ascites, and hydrothorax. Both the ascites and
the hydrothorax resolve after removal of the ovarian tumor. The ascites is caused by transudation of
fluid from the ovarian fibroma; the incidence of ascites is directly related to the size of the fibroma.

• hydrothorax develops secondary to a flow of ascitic fluid into the pleural space via the lymphatics of the
diaphragm.

• clinical features of Meigs’ syndrome are not unique to fibromas, and a similar clinical picture is found
with many other ovarian tumors.
• Metformin has a direct role in inhibiting ovarian androgen steroidogenesis and
acts on the endometrium, which are probably the major mechanisms that help with
ovulation and pregnancy.
• Primary amenorrhea is defined as the absence of menses in a woman who has
never menstruated by the age of 15 years

• Another definition includes girls who have not menstruated within 5 years of
breast development, if occurring by age 10. Breast development (thelarche) should
occur by age 13 or otherwise requires evaluation as well
• Trichomoniasis - wet smear, trichomonads, NAAT

• Chlamydia trachomatis - NAAT (nucleic acid amplification test)

• Bacterial vaginosis is clinically diagnosed. The classic findings on wet smear are
clumps of bacteria and clue cells, which are vaginal epithelial cells with clusters of
bacteria adherent to their external surfaces. Leukocytes are not nearly as frequent
as epithelial cells underneath the microscope.
The four criteria for the diagnosis of bacterial vaginosis are

• (1) a homogeneous vaginal discharge is present;

• (2) the vaginal discharge has a pH of 4.5 or higher;

• (3) the vaginal discharge has an amine-like odor when mixed with potassium
hydroxide, the whiff test; and

• (4) a wet smear of the vaginal discharge demonstrates clue cells more than 20% of
the number of the vaginal epithelial cells
• Bacterial vaginosis is clinically diagnosed. The classic findings on wet smear are
clumps of bacteria and clue cells, which are vaginal epithelial cells with clusters of
bacteria adherent to their external surfaces (Fig. 23.16). Leukocytes are not nearly
as frequent as epithelial cells underneath the microscope.

• The four criteria for the diagnosis of bacterial vaginosis are (1) a homogeneous
vaginal discharge is present; (2) the vaginal discharge has a pH of 4.5 or higher;
(3) the vaginal discharge has an amine-like odor when mixed with potassium
hydroxide, the whiff test; and (4) a wet smear of the vaginal discharge
demonstrates clue cells more than 20% of the number of the vaginal epithelial
cells
• Because peak levels of LH occur 1 day before ovulation, measurement of LH by
urinary LH immunoassays is the best way to determine the optimal time to have
intercourse or an insemination.

• Tests that measure LH in a random daily urine specimen are usually more
convenient for planning natural or artificial insemination than tests that detect LH
in the first morning urine specimen.

• Ovulation most commonly occurs on the day following the detection of LH in a

random specimen (12 to 24 hours later), and it occurs on the day when LH is
detected in the first morning specimen, which contains urine formed during the
prior night
• Dilute acetic acid (3% to 5%) is applied to the cervix, and after 30 to 60 seconds
the cervix is again examined. Acetic acid dehydrates the epithelial cells and
dysplastic cells with large nuclei will reflect light and appear white.
VIA is a visual examination of the uterine cervix after application of 3-5% acetic
acid. If the cervical epithelium contains an abnormal load of cellular proteins, the
acetic acid coagulates the proteins conferring an opaque and white aspect of the
concerned area. A precancerous lesion has higher protein content when compared to
normal epithelium. As a consequence it becomes white (acetowhite) and is
considered to be “VIA positive”.
• Excessive adrenal production of glucocorticoids caused by increased ACTH
secretion (Cushing disease) or adrenal tumors produces the signs and symptoms of
Cushing syndrome. These findings include hirsutism and menstrual irregularity in
addition to the classic findings of central obesity, dorsal neck fat pads, abdominal
striae, and muscle wasting and weakness.
Addison's disease, called primary adrenal insufficiency, the adrenal glands don't
make enough of a hormone called cortisol, or less often, a related hormone called
aldosterone.
• Cyproterone belongs to a group of medications known as steroidal
antiandrogens.Antiandrogens such as cyproterone block the effect of the hormone
called testosterone.

• Drospirenone is a progestin medication used for contraception

• Levonorgestrel is a synthetic progestogen that is used for contraception

• The combined hCG molecule is detectable in plasma of pregnant women 7 to 9
days after the midcycle surge of LH that precedes ovulation.

• serum hCG levels increase from the day of implantation and reach peak levels at
60 to 70 days. Thereafter, the concentration declines slowly until a plateau is
reached at approximately 16 weeks.
• Primary amenorrhea is defined as the absence of menses in a woman who has
never menstruated by the age of 15 years (Practice Committee, American Society
for Reproductive Medicine, 2008.)

• Another definition includes girls who have not menstruated within 5 years of
breast development, if occurring by age 10.

• Breast development (thelarche) should occur by age 13 or otherwise requires

evaluation as well.
There are two types of precocious puberty:

• central precocious puberty (gonadotropin-dependent) is the most common,

affecting more girls than boys. It’s triggered by the premature secretion of
gonadotropins from the brain.

• peripheral precocious puberty (gonadotropin-independent) is not triggered by the

early release of gonadotropin hormones in the brain, but by androgen and estrogen
production from other parts of the body.
• A number of investigators have described discriminatory β-hCG levels above
which failure to visualize an intrauterine pregnancy (IUP) indicates that the
pregnancy either is not alive or is ectopic.

• Barnhart and colleagues (1994) reported that an empty uterus with a serum β-hCG
concentration ≥ 1500 mIU/mL was 100-percent accurate in excluding a live
uterine pregnancy.

• Some institutions set their discriminatory threshold higher at ≥ 2000 mIU/mL

C/I desogestrel include: [

• Allergy to desogestrel or any other ingredients

• Active thrombosis (deep vein thrombosis or pulmonary embolism)

• Jaundice or severe liver disease

• Hormone-sensitive cancers (e.g., breast cancer)

• Unexplained vaginal bleeding

Desogestrel is not indicated for use in pregnancy. It is not contraindicated during

lactation and breastfeeding.
 Neoplastic Risks and Benefits

• Breast Cancer - Although OC use increases the risk of breast cancer by 25%, this
risk disappears after cessation of use. The absolute risk of breast cancer is low
given the young age of most OC users

• Cervical Cancer - Conflicting. Studies indicate that the risk of cervi- cal cancer,
both invasive and in situ, for OC users compared with nonusers increases with
increasing duration of OC use.
• Endometrial cancer - strong protective effect between OCs and endometrial
cancer.

• Ovarian cancer - reduce the risk

• Liver adenoma and cancer - lower for women with lower dose OC

• colorectal cancer - reduction in risk

• with some contraceptive method failures, the relative number of ectopic
pregnancies is increased.

• Examples include tubal sterilization, copper and progestin-releasing intrauterine

devices (IUDs), and progestin-only contraceptives
Parameters used to evaluate the semen include

• volume

• viscosity

• sperm density

• sperm morphology

• sperm motility
• paramesonephric ducts, which open directly into the peritoneal cavity, form the
fallopian tubes. The fused portion, or uterovaginal primordium, gives rise to the
epithelium and glands of the uterus and cervix.

• The vagina develops from paired solid outgrowths of endoderm of the urogenital
sinus—the sinovaginal bulbs.
• The major effect of the progestin component is to inhibit ovulation, but progestins
also contribute other contraceptive actions such as thickening of the cervical
mucus and thinning of the endometrium.

• The major effects of the estrogen are to maintain the endometrium and thus
prevent unscheduled bleeding as well as to inhibit follicular development through
a synergistic effect with the progestin.
Cullen's sign  

bluish discoloration around the umbilicus sometimes occurring in intraperitoneal

hemorrhage, especially following rupture of the fallopian tube in ectopic pregnancy.
A similar discoloration is seen in acute hemorrhagic pancreatitis.
Grey Turner sign is ecchymosis or discoloration of the flanks occurring because of
abdominal pathology. Classically it is associated with severe acute necrotizing
pancreatitis often in association with Cullen’s sign (periumbilical ecchymosis) but it
is not specific to that.
• Those without a demonstrable lesion and a low gonadotropin level were
previously thought to have primary pituitary failure (hypogonadotropic
hypogonadism)
• Gonadal Failure (Hypergonadotropic Hypogonadism)

• Failure of gonadal development is the most common cause of primary amenorrhea

- Turner’s syndrome
PCOS
• Congenital adrenal hyperplasia (CAH) is an inherited disorder caused by an
enzymatic defect (usually 21-hydroxylase [21- OHase] or, less often, 11β-
hydroxylase), resulting in decreased cortisol biosynthesis.

• As a consequence, adrenocorticotropic hormone (ACTH) secretion increases and

adrenal cortisol pre- cursors produced proximal to the enzymatic block
accumulate. These are converted mainly to 17-hydroxyprogesterone and
androstenedione, and androstenedione in turn is converted to testosterone, which
produces signs of androgen excess
• Premature ovarian failure (POF) or premature ovarian insufficiency (POI), which
is the more recently used term, is defined as hypergonadotropic ovarian failure
occurring prior to age 40.
• ACCRETA - Attaches to the endometrium

• INCRETA - Invades the myometrium

• PERCRETA - Penetrates beyond

• PTH is an important contributor to the bone remodeling process. High levels of
PTH can activate osteoclasts and cause excessive bone breakdown

• Vitamin D is essential for maintaining the calcium in your bones. Vitamin D helps
you absorb calcium through your intestines.

• Calcitonin is a hormone that is produced and released by the C-cells of the thyroid
gland. Its biological function in humans is to have a relatively minor role in
calcium balance. Overall effect of calcitonin is to lower the concentration of
calcium in the blood when it rises above the normal value
• intrauterine gestational sac is reliably visualized with transvaginal sonography by
5 weeks, and an embryo with cardiac activity by 6 weeks

• embryo should be visible transvaginally once the mean sac diameter has reached
20 mm—otherwise the gestation is anembryonic

• Cardiac motion is usually visible with transvaginal imaging when the embryo
length has reached 5 mm
• fertility is reduced by 6% between ages 25 and 30

• 14% between ages 30 and 34

• 31% between ages 35 and 39

• to a much greater extent after age 40.

• koilocyte is a squamous epithelial cell that
has undergone a number of structural
changes, which occur as a result of
infection of the cell by
human papillomavirus.
Koilocytes may have the following cellular changes:

• Nuclear enlargement (two to three times normal size).

• Irregularity of the nuclear membrane contour

• A darker than normal staining pattern in the nucleus, known as hyperchromasia.

• A clear area around the nucleus, known as a perinuclear halo or perinuclear

cytoplasmic vacuolization.