Reproductive System

Etiology of Incresed Exposure to Estrogen

  • Nulliparity
  • Early menarche
  • Late menopause

Side Effects of Unopposed Estrogen

  • ↑ Thromboembolism
  • ↑ Breast cancer
  • ↑ Endometrial cancer
  • ↑ Bone mineral density

Etiology of Peripheral Precocious Puberty

  • Congenital adrenal hyperplasia
  • Adrenal tumors
  • Gonadal tumors
  • McCune-Albright syndrome
  • Exogenous sex hormone

Etiology of Abnormal Uterine Bleeding (AUB) {PALM-COEIN}

  • Pregnancy
  • Polyps
  • Adenomyosis
  • Leiomyoma
  • Malignancy
  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrium
  • Iatrogenic
  • Not yet classified

Classification of Amenorrhea

  • Primary: no menarche by age 15 years
  • Secondary: no menses for ≥ 3 cycles / ≥ 6 months

Etiology of Primary Amenorrhea

Etiology Breast Uterus Ovary
Outflow obstruction + + +
Anorexia nervosa + + +
Mullerian agenesis + - +
Androgen insensitivity syndrome (AIS) + - -
Constitutional growth delay - + +
Hypogonadotropic Hypogonadism - + +
Turner syndrome - + +
Swyer syndrome - + -

Etiology of Secondary Amenorrhea

Etiology GnRH LH & FSH SH
Pregnancy ↓ ↓ ↑
Menopause [Ovarian failure] ↑ ↑ ↓
Resistant ovary [Savage] syndrome ↑ ↑ ↓
Hypogonadotropic Hypogonadism ↓ ↓ ↓
Polycystic ovary syndrome (PCOS) ↑/↓ ↑/↓ ↓/↑
Asherman syndrome - - -
Outflow obstruction - - -

Indicators of Ovarian Reserve

Indicator Normal
FSH :: follicular phase 2 ~ 8
Anti-Mullerian hormone (AMH) 1 ~ 5
Antral follicle count (AFC) 5 ~ 10

Presentation of Menopause {HAVOCS}

  • Hot flashes
  • Atrophy of the vagina
  • Osteoporosis
  • Cardiovascular disease
  • Sleep disturbances

Treatment of Menopause

  • Topical estrogen
  • Hormone replacement therapy (HRT)
  • SSRIs & SNRIs
  • Calcium & Vitamin D supplements

Side Effects of Hormone Replacement Therapy (HRT)

  • ↑ Thromboembolism
  • Breast cancer
    • ↑ if estrogen + progesterone
    • ↓ if estrogen alone
  • Endometrial cancer
    • ↓ if estrogen + progesterone
    • ↑ if estrogen alone
  • ↓ Fractures

Hormones Changes in PCOS

Hormone Changes
GnRH ↑/↓
LH ↑
FSH ↓
LH/FSH ↑
Progesterone ↓
Testosterone ↑
Estrogen ↑

Rotterdam Criteria for Diagnosis of PCOS

  • Anovulation
  • Hyperandrogenism
  • Polycystic ovaries

Treatment of PCOS

  • Ovulation induction
    • Estrogen modulators :: Clomiphene
    • Aromatase inhibitors
  • Combined hormonal contraception
  • Androgen antagonists
  • 5α-Reductase inhibitors
  • Metformin ± Statins
  • Lifestyle modification

Non-surgical Treatment of Pelvic Organ Prolapse (POP)

  • Kegel exercise
  • Topical estrogen
  • Pessary

Pathogens of Genital Tract Infection

Pathogen Presentation Treatment
Neisseria gonorrhoeae Discharge :: greenish-yellow
Pelvic inflammatory disease (PID)		 3° Cephalosporins
Macrolides
Haemophilus ducreyi Painful chancroid -
Klebsiella granulomatis Granuloma inguinale Macrolides
Doxycycline
Treponema pallidum Painless chancre
Condyloma lata		 Penicillin
Chlamydia trachomatis Discharge :: greenish-yellow
Lymphogranuloma venereum (LGV)
Pelvic inflammatory disease (PID)		 Macrolides
Doxycycline
Gardnerella vaginalis Discharge :: grayish & fishy Metronidazole
Candida albicans Discharge :: white & curdy -Conazoles
Trichomonas vaginalis Discharge :: greenish-yellow & frothy Metronidazole
HPV Condyloma accumulata
Verruca vulgaris		 -
HSV Paniful ulcers -

Comparison Between Testicular Torsion and Epididymitis

  Testicular Torsion Epididymitis
Prehn sign - +
Cremasteric reflex - +
Blood flow ↓ ↑

Medications for BPH

Mechanism Medication
α1 antagonists Tamsulosin
Terazosin
Doxazosin
Prazosin
5α-Reductase inhibitors Finasteride

Reproductive Tumors

Epithelial Tumors

  • Serous cystadenoma
    cystadenocarcinoma
  • Mucinous cystadenoma
    cystadenocarcinoma
  • Endometrioid carcinoma
  • Clear cell carcinoma
  • Mixed cell carcinoma
  • Transitional cell carcinoma [Brenner tumor]
  • Carcinosarcoma [Malignant mixed Mullerian tumor (MMMT)]

Stromal Tumors

Female Male Markers
Theca cell tumor [Thecoma] Leydig cell tumor -
Granulosa cell tumor Sertoli cell tumor Inhibin
Fibroma Fibroma -

Germ Cell Tumors (GCT)

Female Male Markers
Dysgerminoma Seminoma ALP & LDH
Choriocarcinoma Choriocarcinoma hCG
Endodermal sinus tumor (EST) Endodermal sinus tumor (EST) AFP
Embryonal carcinoma Embryonal carcinoma hCG & AFP
Teratoma Teratoma hCG & AFP

Triad of Meigs Syndrome

  • Ovarian fibroma
  • Pleural effusion
  • Ascites

Types of Endometrial Cancer

Type 1 2
Histology Endometrioid Non-endometrioid
Risk factors Estrogen -
Prognosis Favorable Poor

Bethesda System for Pap Smear Results

  • Squamous cell abnormalities
    • Atypical squamous cell (ASC)
    • Low-grade squamous intraepithelial lesion (LSIL)
    • High-grade squamous intraepithelial lesion (HSIL)
    • Squamous cell carcinoma
  • Glandular cell abnormalities
    • Atypical glandular cell (AGC)
    • Adenocarcinoma in situ (AIS)
    • Adenocarcinoma

Management of Abnormal Pap Smear Results

Result Age (years) HPV Management
- < 30 ±/? Routine screening
- > 30 -/? Routine screening
- > 30 + Repeat screening in 1 year
ASC-US < 25 - Routine screening
ASC-US < 25 +/? Repeat screening in 1 year
ASC-US > 25 - Repeat screening in 3 years
ASC-US > 25 ? Repeat screening in 1 year
LSIL < 25 ±/? Repeat screening in 1 year
LSIL > 25 - Repeat screening in 1 year
Consecutive
Otherwise		 Any ±/? Colposcopy ± Biopsy

Management of Cervical Intraepithelial Neoplasia (CIN)

CIN Management
I Repeat screening in 1 year
II
III		 Cryotherapy
Laser ablation
Conization
Loop electrosurgical excision procedure (LEEP)

Management of Seminoma

  • Radical orchiectomy
  • Radiotherapy
  • Chemotherapy

Contraception Methods

  • Barrier contraception
  • Combined hormonal contraception
    • Oral contraceptive pills (OCPs)
    • Contraceptive patch
    • contraceptive ring
  • Depot medroxyprogesterone
  • Progestin subdermal implant
  • Intrauterine devices
    • Progestin intrauterine device
    • Copper intrauterine device

Side Effects of Combined Hormonal Contraception

  • ↑ Thromboembolism
  • ↑ Breast cancer
  • ↓ Endometrial cancer
  • ↓ Ovarian cancer

Contraindications to Combined Hormonal Contraception

  • Age ≥ 35 years
    Smoking ≥ 15 cigarettes/day
  • History of thromboembolism
  • Active breast cancer
  • Liver failure
  • Migraines with aura

Contraindications to Intrauterine Device (IUD)

  • Pregnancy
  • Unexplained vaginal bleeding
  • Endometrial cancer
  • Cervical cancer
  • Pelvic inflammatory disease (PID)

Indications for Assisted Reproductive Technology (ART)

Intrauterine Insemination (IUI)

  • Cervical factors
  • Male factors
  • Donor sperms

In Vitro Fertilization (IVF)

  • Tubal factors
  • Donor eggs
  • Genetic screening
  • Failed intrauterine insemination (IUI)

Controlled Ovarian Hyperstimulation

Suppression of Spontaneous Ovulation

Protocol Timing
GnRH agonist long protocol Last luteal phase
GnRH agonist short protocol Menstruation
GnRH antagonist protocol Leading follicle > 14 mm

Ovulation Induction

  • (Follicles > 18 mm) ≥ 2
  • Estradiol per co-dominant follicle > 200 pg/mL
Mechanism Medication
GnRH agonists Leuprolide
hCG agonists Choriogonadotropin

Breast Imaging Reporting and Data System (BI-RADS)

Category Interpretation Management Likelihood of cancer
0 Inconclusive Repeat -
1 Negative Routine 0
2 Benign Routine 0
3 Probably benign Every 6 months < 2%
4 Suspicious Biopsy 2 ~ 95%
5 Highly suggestive Biopsy > 95%
6 Biopsy-proven - -

Breast Tumors

Epithelial Tumors

  • Fibrocystic change
  • Intraductal papilloma
  • Ductal carcinoma in situ (DCIS)
    Invasive ductal carcinoma (IDC)
  • Lobular carcinoma in situ (LCIS)
    Invasive lobular carcinoma (ILC)
  • Medullary carcinoma

Stromal Tumors

  • Fibroadenoma
  • Phyllodes tumor

Molecular Subtypes of Breast Cancer

Subtype Receptors Mutations
Luminal A PR & ER -
Luminal B PR & ER -
HER2-enriched HER2 -
Basal-like - BRCA
Claudin-low - BRCA
Interferon-rich - BRCA

Types of Flaps for Breast Reconstruction

  • Transverse rectus abdominis myocutaneous (TRAM) flap
  • Latissimus dorsi (LD) flap
  • Deep inferior epigastric perforator (DIEP) flap
  • Superficial inferior epigastric artery (SIEA) flap
  • Gluteal flap
  • Transverse upper gracilis (TUG) flap
  • Profunda artery perforator (PAP) flap