WHISM 2023 Reproductive System Revision Lecture PDF

WHISM 2023 Reproductive System Revision Lecture Nish, Paige, Natania Table of Contents Pelvis Male Anatomy & Histo Female Anatomy & Histo Physiology Microbiology Contraception & Clinical Skills  PELVIC ANATOMY True vs False Pelvis Greater pelvis is superior to the pelvic inlet and...

WHISM 2023 Reproductive System Revision Lecture Nish, Paige, Natania Table of Contents Pelvis Male Anatomy & Histo Female Anatomy & Histo Physiology Microbiology Contraception & Clinical Skills  PELVIC ANATOMY True vs False Pelvis Greater pelvis is superior to the pelvic inlet and lesser pelvis is located between the pelvic inlet and pelvic outlet Greater pelvis (false pelvis) → provides support of the lower abdominal viscera (e.g. ileum and sigmoid colon) Lesser pelvis (true pelvis) → contains the pelvic cavity and pelvic viscera Pelvic Inlet and Pelvic Pelvic Outlet outlet borders The junction between the true and false pelvis is the Posterior → tip of coccyx pelvic inlet. Outer bony edges of the pelvic inlet is the pelvic brim Lateral → ischial tuberosities + sacrotuberous ligament Pelvic Inlet borders Anterior → pubic arch Posterior → sacral promontory + sacral wings (ala) Lateral → arcuate line (inner surface of ileum) + pectineal line (inner surface of superior pubic ramus) Anterior → pubic symphysis Label the following: A B C F E D Hip Bone Structure of the Pelvic Ilium Girdle Pubis Ischium Main articulations in Pelvis: These bone form the acetabulum which Sacroiliac joints (x2) articulates with the head of the femur to Sacrococcygeal symphysis form the hip joint Pubic symphysis Pelvis has an anterior tilt → contributes to normal lumbar lordosis of spine Which of the following is a male pelvis and which is a female pelvis? Which of the following is a male pelvis and which is a female pelvis? Male Female Which of the following is false regarding the female pelvis? A) Wider ischiopubic rami angle B) Ischial spines are wider apart C) Oval and rounded D) Higher iliac crests Which of the following is false regarding the female pelvis? A) Wider ischiopubic rami angle B) Ischial spines are wider apart C) Oval and rounded D) Higher iliac crests (shorter iliac crests) Male vs Female Pelvis Main Ligaments Sacrospinous ligament ○ Sacrum → ischial spine Sacrotuberous ligament ○ Sacrum → ischial tuberosity Which of the following structures passes through the foramen labelled A A) Obturator vein B) Sciatic nerve C) Femoral artery A D) Triradiate cartilage B Which of the following structures passes through the foramen labelled A A) Obturator vein B) Sciatic nerve C) Femoral artery A D) Triradiate cartilage B What structures pass through the following foramina A) Obturator vein B) Sciatic nerve C) Femoral artery D) Triradiate cartilage C What structures pass through the following foramina A) Obturator vein B) Sciatic nerve C) Femoral artery D) Triradiate cartilage C Greater Sciatic Foramen Located superior to the sacrospinous ligament Divided into 2 foramina by the piriformis muscle Suprapiriform foramen ○ Superior gluteal a+v and n Infrapiriform foramen ○ Inferior gluteal a+v and n ○ Sciatic nerve ○ Pudendal nerve Lesser Sciatic Foramen Located inferior to the sacrospinous ligament Structures passing through ○ Obturator internus tendon ○ Nerve to obturator internus ○ Internal pudendal a+v ○ Pudendal nerve Through which opening does the pudendal nerve enter? A) Lesser sciatic foramen B) Greater Sciatic foramen C) Obturator foramen D) Suprapiriformis foramen Through which opening does the pudendal nerve enter? A) Lesser sciatic foramen → Pudendal nerve leaves pelvis via greater sciatic foramen and re-enters through lesser sciatic foramen B) Greater Sciatic foramen C) Obturator foramen D) Suprapiriformis foramen Obturator Foramen Formed by the ischial and pubic bones Structures passing through ○ Obturator a+v and n Pelvis during pregnancy The plane of least dimension = smallest space that the baby’s head must squeeze through During pregnancy, the corpus luteum will produce relaxin to relax the pelvic girdle during pregnancy During Childbirth ○ Sacrum, tilts anteriorly ○ Coccyx tilts posteriorly This increased lumbar lordosis, widens the pubic symphysis and leads to a wider plane of least dimensions While giving birth, a woman undergoes an episiotomy. She is incontinent of urine postpartum. Which muscle was most likely damaged during the episiotomy? A) Pubococcygeus B) Puborectalis C) Iliococcygeus D) Coccygeus E) Obturator internus While giving birth, a woman undergoes an episiotomy. She is incontinent of urine postpartum. Which muscle was most likely damaged during the episiotomy? A) Pubococcygeus B) Puborectalis → the “sling” C) Iliococcygeus D) Coccygeus E) Obturator internus Pelvic Floor Muscles Puborectalis = “sling” around anus ○ Helps with fecal continence ○ Tonically contracted; relaxed to defecate Levator ani = puborectalis + pubococcygeus + iliococcygeus (the 3 with the longest names!) ○ Raises pelvic floor Pelvic Floor Muscles Order the pelvic floor muscles from posterior to anterior: A) Coccygeus → iliococcygeus → puborectalis → pubococcygeus B) Iliococcygeus → coccygeus → pubococcygeus → puborectalis C) Coccygeus → iliococcygeus → pubococcygeus → puborectalis D) Pubococcygeus → puborectalis → iliococcygeus → coccygeus Order the pelvic floor muscles from posterior to anterior: A) Coccygeus → iliococcygeus → puborectalis → pubococcygeus B) Iliococcygeus → coccygeus → pubococcygeus → puborectalis C) Coccygeus → iliococcygeus → pubococcygeus → puborectalis *think coccyx = most posterior & pubis = most anterior* D) Pubococcygeus → puborectalis → iliococcygeus → coccygeus Pelvic Arteries Aorta ○ Common iliacs Internal Iliac Anterior division Posterior division External iliac Femoral artery Median sacral artery Divisions of Internal Iliac Which of the following is not a branch of the ANTERIOR division of the internal iliac artery? A. Uterine B. Obturator C. Internal pudendal D. Ovarian E. Superior gluteal F. Inferior gluteal Which of the following is not a branch of the ANTERIOR division of the internal iliac artery? A. Uterine B. Obturator C. Internal pudendal D. Ovarian E. Superior gluteal F. Inferior gluteal Divisions of Internal Iliac TIP: just learn the posterior division Posterior ○ Iliolumbar Posterior muscles: Psoas major muscle, quadratus lumborum muscle, cauda equina, iliacus muscle, iliac bone ○ Lateral sacral Piriformis ○ Superior gluteal → not the same as the nerve! Glutes/hip: Gluteus maximus, medius, minimus, piriformis, obturator internus, quadratus femoris, head of the femur, tensor fascia lata Question Whilst performing laparoscopic surgery on the posterior abdominal wall (having introduced your instruments through the anterior abdominal wall) you notice a tubular structure contracting when your instruments touch it. Upon further investigation you note that it is angled from lateral to medial along it’s superior to inferior course. What structure is this? A) Aorta B) Common iliac artery C) Ovarian artery D) Ureter E) Urethra Question Whilst performing laparoscopic surgery on the posterior abdominal wall (having introduced your instruments through the anterior abdominal wall) you notice a tubular structure contracting when your instruments touch it. Upon further investigation you note that it is angled from lateral to medial along it’s superior to inferior course. What structure is this? A) Aorta B) Common iliac artery C) Ovarian artery D) Ureter E) Urethra Pelvic Arteries - Special ones Bladder is supplied differently in males and females ○ Superior vesicular + Inferior vesicular artery in males or vaginal artery in females Superior and inferior gluteal arteries supply a mix of all gluteal muscles The ureter runs under the uterine artery ○ “Water (urine) under the bridge” What provides blood supply to gluteus maximus? A. Just the superior gluteal artery B. Just the inferior gluteal artery C. Branches from both the divisions of the internal iliac artery D. A branch of the anterior division of the internal iliac artery E. A branch of the posterior division of the internal iliac artery What provides blood supply to gluteus maximus? A. Just the superior gluteal artery B. Just the inferior gluteal artery C. Branches from both the divisions of the internal iliac artery D. A branch of the anterior division of the internal iliac artery E. A branch of the posterior division of the internal iliac artery What are the 3 vessels that supply the urinary bladder in either females or males? A. Superior vesicular (m/f) + inferior vesicular (m) + uterine (f) B. Superior vesicular (m/f) + inferior vesicular (m) + vaginal (f) C. Inferior vesicular (m/f) + uterine (f) + vaginal (f) D. Inferior vesicular (m/f) + inferior vesicular (m) + uterine (f) What are the 3 vessels that supply the urinary bladder in either females or males? A. Superior vesicular (m/f) + inferior vesicular (m) + uterine (f) B. Superior vesicular (m/f) + inferior vesicular (m) + vaginal (f) C. Inferior vesicular (m/f) + uterine (f) + vaginal (f) D. Inferior vesicular (m/f) + inferior vesicular (m) + uterine (f) What are the 3 vessels that supply the urinary bladder in either females or males? A. Superior vesicular (m/f) + inferior vesicular (m) + uterine (f) B. Superior vesicular (m/f) + inferior vesicular (m) + vaginal (f) C. Inferior vesicular (m/f) + uterine (f) + vaginal (f) D. Inferior vesicular (m/f) + inferior vesicular (m) + uterine (f) Varicocele = nutcracker syndrome Varicocele = dilated veins in scrotum ○ LEFT renal vein passes between the aorta and the SMA to drain into the IVC ○ The testicular/ovarian vein drains into the renal vein ○ If there is an aneurysm or atherosclerosis, the renal vein gets squashed, blocking drainage into IVC ○ This backed-up blood pools in scrotum as a varicocele “bag of worms” ○ Same thing can happen in a female but ovaries are too deep in the body to notice Lumbosacral Plexus Important nerve levels: ○ Femoral and obturator are L2, 3, 4 ○ Pudendal is S2, 3, 4 Each branch is somatic motor + sensory (except the “cutaneous” ones) A 25yo female presents with medial thigh pain on a monthly basis. This is MOST LIKELY explained by the ovary’s direct relationship to the: A. Lateral cutaneous nerve of the thigh B. Anterior cutaneous nerve of the thigh C. Genitofemoral nerve D. Ilioinguinal nerve E. Obturator nerve A 25yo female presents with medial thigh pain on a monthly basis. This is MOST LIKELY explained by the ovary’s direct relationship to the: A. Lateral cutaneous nerve of the thigh B. Anterior cutaneous nerve of the thigh C. Genitofemoral nerve D. Ilioinguinal nerve E. Obturator nerve Sensory innervation for lumbosacral plexus Generally match the names! Exceptions: ○ Obturator = medial thigh ○ Pudendal = genitals Lymphatics – The one time this is relevant! Scrotal cancer → enlarged superficial inguinal lymph nodes Testicular cancer → enlarged para-aortic lymph nodes ***Testicular cancer is harder to diagnose because you won’t notice the enlarged lymph nodes! Pudendal nerve “S2, 3, 4 keeps the poo off the floor” Pathway ○ Exits via greater sciatic foramen ○ Through Alcock’s (pudendal) canal ○ Wraps around the ischial spine Sensory supply ○ External genitalia (both sexes) ○ Skin around the anus, anal canal + perineum Motor supply ○ Various pelvic muscles ○ External urethral sphincter ○ External anal sphincter Question Question - Pudendal Nerve! D  MALE ANATOMY Which is the ischiocavernosus and which is bulbospongiosus? Penis Bulbospongios Ischiocavernos us us What is the correct sequence of events involved in the male sexual response? A. Sexual stimulation –> sympathetic nerve activation -> dilation of penile artery -> parasympaethic nerve activation -> emission -> ejaculation B. Sexual stimulation -> parasympathetic nerve activation -> dilation of penile artery -> sympathetic nerve activation -> emission -> ejaculation C. Sexual stimulation -> sympathetic nerve activation -> dilation of penile artery -> parasympaethic nerve activation -> ejaculation -> emission D. Sexual stimulation -> parasympathetic nerve activation -> dilation of penile artery -> sympathetic nerve activation -> ejaculation -> emission What is the correct sequence of events involved in the male sexual response? A. Sexual stimulation –> sympathetic nerve activation -> dilation of penile artery -> parasympaethic nerve activation -> emission -> ejaculation B. Sexual stimulation -> parasympathetic nerve activation -> dilation of penile artery -> sympathetic nerve activation -> emission -> ejaculation C. Sexual stimulation -> sympathetic nerve activation -> dilation of penile artery -> parasympaethic nerve activation -> ejaculation -> emission D. Sexual stimulation -> parasympathetic nerve activation -> dilation of penile artery -> sympathetic nerve activation -> ejaculation -> emission Erection 1. Sexual Stimulation: Erection typically begins with sexual arousal or stimulation. This can be psychological or physical 2. Neural Signaling: Upon sexual stimulation, the brain sends signals through the parasympathetic nervous system. These signals cause the release of neurotransmitters, particularly nitric oxide (NO), in the penile arteries and cavernous bodies. 3. Vasodilation: Nitric oxide relaxes the smooth muscle in the walls of the penile arteries and corpus cavernosum (spongy tissue within the penis). 4. Increased Blood Flow: As the smooth muscle relaxes, blood flow into the penis increases. This engorgement of the erectile tissue leads to the penis becoming erect. 5. Maintaining Erection: The rigidity of the penis is maintained by trapping the blood in the erectile tissue, largely due to the compression of the veins in the penis. 6. Completion of Sexual Activity: After ejaculation or when sexual stimulation ceases, the sympathetic nervous system becomes dominant, causing vasoconstriction and reducing blood flow to the penis. The erection gradually subsides. Erectile dysfunction 1. Vascular Factors: Conditions such as atherosclerosis (narrowing of arteries), high blood pressure, and diabetes can damage the blood vessels that supply the penis, leading to reduced blood flow 2. Neurological Factors: Damage or disruption to the nerves involved in the erection process can lead to ED. Conditions like multiple sclerosis, spinal cord injuries, or nerve diseases 3. Hormonal Factors: Hormonal imbalances, particularly low testosterone levels, can contribute to ED 4. Psychological Factors: Emotional and psychological factors, such as anxiety, stress, depression, and relationship problems, can lead to ED 5. Medications and lifestyle 6. Other Medical Conditions: ED can be a symptom of underlying medical conditions, including Peyronie's disease, priapism (prolonged, painful erection), or even side effects of certain surgeries or treatments (e.g., prostate surgery) What structure do sperm cells enter after leaving the seminiferous tubules in the testes? A. Epididymis B. Rete testes C. Efferent Tubules D. Vas Deferens E. Ejaculatory duct What structure do sperm cells enter after leaving the seminiferous tubules in the testes? A. Epididymis B. Rete testes C. Efferent Tubules D. Vas Deferens E. Ejaculatory duct Testes 1. Seminiferous tubules: sperm made from germ cells with help of sertoli cells 2. Leydig cells make T 3. Rete Testis (star): sperm collect here 4. Epididymis: ‘swimming school’ - sperm mature and learn how to work (Head -> Body -> Tail) 5. Vas deferens: smc-lined tube which contracts to propel sperm into ejaculatory duct 6. Ejaculatory duct (not shown): junction between seminal vesicle + VD (just posterior to prostate) 7. Prostatic urethra 8. Spongy urethra 9. External urethral meatus Which of the following abdominal wall layers does not extend into the scrotum? A. Scarpa’s fascia B. Internal oblique muscle C. Parietal peritoneum D. Transversus abdominis muscle Which of the following abdominal wall layers does not extend into the scrotum? A. Scarpa’s fascia B. Internal oblique muscle C. Parietal peritoneum D. Transversus abdominis muscle Scrotum Cremaster mm - Spermatic Cord Raises/lowers Contents Continuation of internal VD oblique from abd Testicular a Pampiniform Dartos mm - Wrinkles plexus (v) Continuation of Lymphatics Camper’s/Scarpa’s ANS nn Accessory organs Seminal vesicles Seminal fluid- fructose, prostaglandins, bicarbonate Bulbourethral glands Acts as a lubricant and cleaner for the urethra Secretes mucous prior to ejaculate moving through Prostate Produces proteolytic enzymes BPH (helps ejaculate to remain liquid), citric acid, PSA Prostate cancer  MALE HISTOLOGY Overview What is this? Lumen of vas deferens What part of repro tract is this? What is the arrow? Seminiferous Tubule; Leydig cells (makes testosterone) What is this? Name the epithelium? Prostate w/ cuboidal epithelium What is this? Name the epithelium? Epididymis; pseudostratified columnar w/ stereocilia  Male Histology 1. Seminiferous tubules → (straight tubules & rete testis) → 2. Epididymis → 3. Vas deferens → 4. Penis Seminiferous Tubules Spermatogonia → 1˚ spermatocyte → 2˚ spermatocyte → spermatid → spermatozoa → mature sperm (epididymis) Sertoli cells (faint nuclei) within the tubule provide support Leydig cells outside the tubule (interstitial) produce testosterone Epididymis Where sperm go to mature and hang out Pseudostratified columnar cells w/ stereocilia ○ I think of these cells as being super long You can see sperm in the lumen Smooth muscle to contract during ejaculation Straight Tubules & Rete testis Rete testis = lots of white space Vas deferens Pseudostratified columnar epithelium with stereocilia Smooth muscle ○ Longitudinal (int) ○ Circular (mid) ○ Longitudinal (ext)  Penis Superficial Nerves dorsal v. Cavernosum = caves where blood pools for erection Spongiosum = where urethra is Urethra has transitional epithelium Urethr a  Prostate Glands ++ Walnut-sized Smooth muscle Cuboidal epithelium Rule of thumb: secretory/glandular tissue is usually cuboidal epithelium  FEMALE ANATOMY Uterus Is the uterus: a) Anteverted and anteflexed b) Anteverted and retroflexed c) Retroverted and anteflexed d) Retroverted and retroflexed Uterus Is the uterus: a) Anteverted and anteflexed b) Anteverted and retroflexed c) Retroverted and anteflexed d) Retroverted and retroflexed Anteverted = rotated forwards Anteflexed = flexed towards anterior surface Where does fluid accumulate in the upright position (female)? a) Recto-uterine pouch b) Pouch of Douglas c) The peritoneal cavity d) Morrison's pouch Where does fluid accumulate in the upright position (female)? a) Recto-uterine pouch b) Pouch of Douglas c) The peritoneal cavity d) Morrison's pouch  Uterus Layers Outer serosa/adventitia Myometrium: thick layer of smooth muscle Endometrium: mucosa for implantation ○ If fertilisation does NOT occur = sloughs off Which part of the broad ligament surrounds the uterus itself? a) Mesometrium b) Mesovarium c) Mesosalpinx  Hypospadias vs Epispadias Tip: Think of dorsal/ventral for the penis as when it is erect Which part of the broad ligament surrounds the uterus itself? a) Mesometrium- surrounds the uterus, encloses the proximal part of the round ligament b) Mesovarium- doesn’t actually cover ovary surface, attaches to the hilum, covers neurovasculature c) Mesosalpinx- encloses fallopian tubes Fallopian tubes 4 key components Fimbriae: finger-like, ciliated projections which capture the ovum from surface of ovary Infundibulum: funnel-shaped opening near ovary Ampulla: where fertilisation occurs!!! Isthmus: connects ampulla to uterine cavity Fire is fun! = F I A Is Fun Which correctly matches a female pelvic ligament with an artery it contains? A. Cardinal ligament, ovarian artery B. Ovarian ligament, uterine artery C. Suspensory ligament, ovarian artery D. Uterosacral ligament, uterine artery Which correctly matches a female pelvic ligament with an artery it contains? A. Cardinal ligament, uterine artery B. Ovarian ligament, uterine artery C. Suspensory ligament, ovarian artery D. Uterosacral ligament, uterine artery The suspensory ligament secures the ovary to the lateral wall of the pelvis and carries the ovarian artery and vein. The uterine artery runs in the cardinal ligament found at the base of the uterus. Neither of the ovarian ligament or uterosacral ligament contain an artery. Ovaries Produce oocytes, produce oestrogen Arterial supply = paired ovarian aa. and uterine a. and progesterone in response to LH Venous = left ovarian v. ( > renal v) and right ovarian v. ( > IVC) and FSH Lymphatics = para-aortic nodes Cortex = developing follicles, medulla = loose connective tissue with vasculature Plus round ligament: uterus > labia major (through inguinal canal) Uterus vasculature During hysterectomy, what structure is most at risk of being damaged? a) Pudendal nerve b) Internal pudendal artery c) Uterine artery d) Ureter During hysterectomy, what structure is most at risk of being damaged? a) Pudendal nerve b) Internal pudendal artery c) Uterine artery d) Ureter Water under the bridge!- ureter runs under the uterine artery Uterine artery needs to be ligated  FEMALE HISTOLOGY Which part of the endometrium is shed during menstruation? A) Stratum basalis B) Stratum functionalis Which part of the endometrium is shed during menstruation? A) Stratum basalis B) Stratum functionalis Uterus 3 layers: ○ Endometrium Epithelium - simple columnar epithelium with ciliated cells Stratum functionalis - shed during menstruation Strum basilis - retained during menstruation ○ Myometrium Smooth muscle layer Facilitates contraction of uterus during labour/menstruation Responsive to oxytocin ○ Serosa/adventitia Outermost surface of uterus A single layer of epithelial cells line the lumen of the uterus, and invaginations of the stroma. The deep invaginations are called? A) Spiral arteries B) Myometrial crypts C) Endometrial glands D) Sawtooth or straight crypts E) Uterine villi A single layer of epithelial cells line the lumen of the uterus, and invaginations of the stroma. The deep invaginations are called? A) Spiral arteries B) Myometrial crypts C) Endometrial glands D) Sawtooth or straight crypts E) Uterine villi Ovaries Outside the tunica albuginea is simple squamous or cuboidal epithelium Tunica albuginea = thick connective tissue capsule Cortex → contains developing follicles at different stages of development Medulla → loose connective tissue with blood vessels and nerves Primordial Follicle A finite number of primordial follicles form in fetal ovary Consists of oocytes surrounded by single layer of squamous follicular granulosa Primary Follicle Late Phase Early Phase Follicular cells proliferate into stratified FSH stimulates a limited number of epithelium layer = zona granulosa primordial follicles to develop at start of Zona pellucida = thin band of menstrual cycle glycoproteins Consists of central oocyte surrounded Stromal cells around the follicle form the by a single layer of cuboidal follicular theca to prepare for secondary follicle cells Folliculogenesis Graafian Follicle Stage after first meiotic division but before ovulation Contains a 2N haploid oocyte Larger follicular antrum Oocyte surrounded by zona pellucida and layer of several cells called the corona radiata The structure indicated by the arrow will degenerate into what is known as a: A) Corpus luteum B) Corpus albicans C) Graafian follicle D) Secondary follicle  The structure indicated by the arrow will degenerate into what is known as a: A) Corpus luteum B) Corpus albicans C) Graafian follicle D) Secondary follicle The ruptured follicle turns into the corpus albicans. If fertilisation occurs, the corpus luteum will persist in the presence of hCG. If fertilisation does not occur, the corpus luteum remains active until levels of LH fall and will involute to form the corpus albicans. After Ovulation Corpus Luteum Corpus Albicans Centre contains the remains of a If fertilisation does not occur, corpus large blood clot luteum becomes corpus albicans What structure does the following image show? A) Uterus B) Ovary C) Fallopian tube D) Secondary follicle What structure does the following image show? A) Uterus B) Ovary C) Fallopian tube D) Secondary follicle Fallopian Tube 3 layers: ○ Mucosa - simple columnar epithelium with ciliated cells and secretory cells ○ Lamina propria - loose connective tissue ○ Muscularis - inner circular and outer longitudinal layers of smooth muscle  FEMALE GONADAL ANATOMY DIFFERENTIATIO N Differentiation- foetus  Gonadal differentiation SRY protein = male!!!! > development of Absence of SRY = female!!! > development testes of ovaries Dihydrotestosterone > external male genitalia Testosterone > internal male genitalia No testosterone Testes descend around week 8-10, finish At week 10: descending by week 35 (before birth) At week 10: Ovaries + Mullerian duct (uterus + tubes) Wolffian ducts > epididymis, vas deferens descend + seminal vesicles Cloaca > bladder, ascends Cloaca becomes bladder, urethra + penis Leydig cells produce androgens that induce Wolffian duct development into male urogenital structures Sertoli cells produce anti-Mullerian hormone preventing the development of female genital A) The testes and ovaries descend from their original position at the tenth thoracic level  FEMALE PUBERT ANATOMY Y C Puberty Hormones Hypothalamus: ↑ GnRH in nightly pulses ○ This is regulated by Kisspeptin Pituitary: ↑LH and FSH Results in ↑testosterone in males and ↑estrogen in females Ages Female: menarche 12.5 years (avg) ○ Start puberty 8-13yo ○ Finish puberty 16yo Male: ○ Start puberty 9-14yo ○ Finish puberty 18yo 5 Tanner Stages → breast and pubic hair growth Females Males Secondary Sex Characteristics  FEMALE OOGENESIS ANATOMY Secondary oocytes that develop during each cycle are arrested at which stage of meiosis? A. Metaphase I B. Anaphase I C. Prophase II D.Metaphase II Secondary oocytes that develop during each cycle are arrested at which stage of meiosis? A. Metaphase I B. Anaphase I C. Prophase II D. Metaphase II Before puberty, primary oocytes are arrested at prophase I. During each cycle, developing oocytes continue meiosis until they are arrested at metaphase II. If the oocyte is ovulated and encounters sperm, it will then finish meiosis II. MENSTRUAL FEMALE ANATOMY CYCLE Which of the following does not occur during the ovulatory phase of the menstrual cycle? A. Approximately one day prior to ovulation, LH will surge due to oestrogen forming a positive feedback loop B. Progesterone remains high throughout the ovulation and luteal phases C. Oestrogen will fall after ovulation D. The ruptured follicle will undergo luteinization to become the corpus luteum Menstrual cycle The menstrual cycle is controlled by feedback mechanisms: Moderately increased oestrogen: negative feedback to the HPG axis Significantly increased oestrogen: positive feedback to the HPG axis Inhibin: selectively inhibits the anterior pituitary from secreting FSH OVARIAN FEMALE ANATOMY CYCLE What are the major phases of the ovarian cycle? What are the major phases of the ovarian cycle? Follicular phase (day 1-14) (then ovulation) Luteal phase (day 15-28) Ovarian Cycle Follicular phase (d1-14): follicle growth with ovulation occurring at the end of this stage Day 1-5: start of new cycle, estrogen and progesterone low (little negative feedback at HPG axis) → increased in FSH & LH levels → follicle growth Day 7: a single follicle becomes dominant Day 7-12: plasma estrogen levels rise due to secretion by the dominant follicle + LH & FSH levels drop (negative feedback) Day 12-13: LH surge ○ High follicular estrogen → positive feedback to HPG axis Ovulation: day 14 Luteal phase (d15-28): period of corpus luteum activity Day 15-25: Corpus luteum forms producing estrogen & progesterone ○ In absence of fertilisation: corpus luteum regresses after 14 days → fall in hormones ○ If fertilisation occurs: human chorionic gonadotropin (HcG) from embryo maintain corpus luteum until placenta takes over Follicular phase Usually day 1-14 with progressive growth of the follicle 1. Primordial → oocyte surrounded by one layer of granulosa cells Present in the ovary since birth 2. Primary follicle → single cuboidal granulosa surrounding and zona pellucida forms 3. Secondary (pre-antral) follicle → zona granulosa becomes stratified and outer theca layer forms 4. Antral follicle → thicker zona granulosa and antral cavity 5. Atresia → non-dominant antral follicles undergo apoptosis 6. Mature → antrum continues to expand and granulosa cells form cumulus oophorus Was selected from the cohort of recruited follicles to become dominant, increasing in size up to 20mm A) Corpus luteum B) Secondary follicle C) Primordial follicle D) Graafian follicle Was selected from the cohort of recruited follicles to become dominant, increasing in size up to 20mm A) Corpus luteum B) Secondary follicle C) Primordial follicle D) Graafian follicle Contains nutriative fluid for the oocyte A) Corpus luteum B) Antrum of secondary follicle C) Lumen of oviduct D) Graafian follicle Contains nutriative fluid for the oocyte A) Corpus luteum B) Antrum of secondary follicle C) Lumen of oviduct D) Graafian follicle Expelled at ovulation via the stigma A) Oocyte B) Zona pellucida C) Follicular cells D) All of the above Expelled at ovulation via the stigma A) Oocyte B) Zona pellucida C) Follicular cells (corona radiata) D) All of the above Label the hormones F E A C B D Label the hormones Hormones FSH Increases until mid-follicular phase, then decreases aside from mid-cycle peak LH Constant in follicular phase and then decreases 18 hours before ovulation = LH surge Estrogen Increases rapidly in second week as dominant follicle secretes estrogen 2nd peak due to corpus luteum secretes some estrogen prior to degenerating Progesterone Increases rapidly with secreting corpus luteum before degenerating Inhibin B produced by small follicles and A by large follicles and corpus luteum Inhibin correlates with FSH and LH because inhibin exerts negative feedback on pituitary Which of the following does not occur during the ovulatory phase of the menstrual cycle? A. Approximately one day prior to ovulation, LH will surge due to oestrogen forming a positive feedback loop B. Progesterone remains high throughout the ovulation and luteal phases C. Oestrogen will fall after ovulation D. The ruptured follicle will undergo luteinization to become the corpus luteum Which of the following does not occur during the ovulatory phase of the menstrual cycle? A. Approximately one day prior to ovulation, LH will surge due to oestrogen forming a positive feedback loop B. Progesterone remains high throughout the ovulation and luteal phases C. Oestrogen will fall after ovulation D. The ruptured follicle will undergo luteinization to become the corpus luteum Which of the following is not a function of estrogen? A. Stimulating the myometrial cells of the uterus to form more oxytocin receptors B. Thinning the cervical mucus at the time of ovulation to allow sperm to pass C. Inhibiting prostaglandin induced contractions of the myometrium for successful implantation D. Initiating follicle maturation during the menstrual cycle Which of the following is not a function of estrogen? A. Stimulating the myometrial cells of the uterus to form more oxytocin receptors B. Thinning the cervical mucus at the time of ovulation to allow sperm to pass C. Inhibiting prostaglandin induced contractions of the myometrium for successful implantation - Progesterone D. Initiating follicle maturation during the menstrual cycle UTERINE FEMALE ANATOMY CYCLE Which phase of the uterine cycle is characterized by the development of a thick, glandular endometrium in preparation for potential implantation of a fertilized egg? A. Menstrual Phase B. Proliferative Phase C. Secretory Phase D. Ovulatory Phase Which phase of the uterine cycle is characterized by the development of a thick, glandular endometrium in preparation for potential implantation of a fertilized egg? A. Menstrual Phase B. Proliferative Phase C. Secretory Phase D. Ovulatory Phase The stratum functionalis of the endometrium plays a crucial role in which aspect of the uterine cycle? A. Nutrient storage for the developing embryo B. Hormone production to support ovulation C. Preparing the uterine lining for implantation D. Facilitating the release of the secondary oocyte The stratum functionalis of the endometrium plays a crucial role in which aspect of the uterine cycle? A. Nutrient storage for the developing embryo B. Hormone production to support ovulation C. Preparing the uterine lining for implantation D. Facilitating the release of the secondary oocyte Uterine Cycle Day 0-5: Menstruation ○ “sloughing off” of stratum functionalis ○ Low estrogen + progesterone Day 5-15: Proliferative phase ○ Regrowth of functionalis ○ Driven by estrogen Day 15-28: Secretory phase ○ Uterine wall prepares for implantation ○ ↑ glands, mucus, vessels, secretion of glycogen ○ Driven by progesterone from corpus luteum (+estrogen)  FEMALE FERTILISATION ANATOMY Fertilisation involves several important steps. Which of the following is correct A. The primary/fast block involves cortical granules lying beneath the egg fusing with the membrane to harden the zona pellucida B. During capacitation, sperm membranes become less permeable to Ca2+, causing an increase in motility of sperm C. Fertilisation occurs in the ovary D. The acrosomal reaction occurs after sperm bind to the zona pellucida E. Multiple sperm bind to the sperm binding receptors Fertilisation Fusion of egg and sperm in the ampulla of the fallopian tube to form a zygote Sperm transport: ○ Prostaglandins cause contraction of the uterus to propel sperm towards the fallopian tubes Capacitation: ○ Uterus and fallopian tubes wash away inhibitory factors that suppress premature activity of sperm ○ Membrane of the sperm becomes more permeable to Ca+, causing a significant change in flagellar activity and increased motility of the sperm - whipping movement Acrosomal Reaction and Sperm Penetration ○ Sperm release proteolytic enzymes (hyaluronidase) and break down hyaluronic acid holding together granulosa cells ○ Sperm binds to sperm receptors on zona pellucida → Ca+ influx into the sperm → acrosomal reaction (release of all enzymes in the acrosome of the sperm), forming holes in the zona pellucida ○ Sperms membrane binds to the oocytes sperm binding receptors → egg transmembrane protein Cp9 and sperm protein lzumo facilitate fusion ○ Sperm contents are released into the oocyte  Fertilisation How is polyspermy avoided? Oocyte membrane block (fast block) ○ Once sperm binds to the oocyte sperm binding receptors, the rest are then shed = no more sperm can enter Zona/cortical reaction (slow block) ○ Increased Ca+ released by the ER in the oocyte triggers exocytosis of cortical granules that hardens zona pellucida and destroys its sperm-binding receptors Completion of meiosis II and fertilisation Oocyte completes meiosis II → forming the ovum and second polar body Sperm and ovum nuclei swell, forming pronuclei DNA is duplicated in both pronuclei, they approach each other and a mitotic spindle forms between them The membranes of the pronuclei rupture, chromosomes are released and they intermix Fertilisation involves several important steps. Which of the following is correct A. The primary/fast block involves cortical granules lying beneath the egg fusing with the membrane to harden the zona pellucida B. During capacitation, sperm membranes become less permeable to Ca2+, causing an increase in motility of sperm C. Fertilisation occurs in the ovary D. The acrosomal reaction occurs after sperm bind to the zona pellucida E. Multiple sperm bind to the sperm binding receptors Fertilisation involves several important steps. Which of the following is correct A. The secondary/slow block involves cortical granules lying beneath the egg fusing with the membrane to harden the zona pellucida B. During capacitation, sperm membranes become more permeable to Ca2+, causing an increase in motility of sperm C. Fertilisation occurs in the ampulla of the fallopian tube D. The acrosomal reaction occurs after sperm bind to the zona pellucida E. Only one sperm binds to the sperm binding receptors, the rest are shed  FEMALE IMPLANTATION ANATOMY Implantation Where is the oocyte usually fertilised? A) Infundibulum B) Ampulla C) Isthmus D) Vagina Implantation Where is the oocyte usually fertilised? A) Infundibulum B) Ampulla C) Isthmus D) Vagina What hormone do pregnancy tests test for? A) LSH B) hCG C) Estrogen D) Progesterone What hormone do pregnancy tests test for? A) LSH B) hCG C) Estrogen D) Progesterone What happens if implantation occurs outside the uterus? What happens if implantation occurs outside the uterus? Ectopic pregnancy  FEMALE PLACENTA ANATOMY Which of the following can diffuse through the placenta? a) Amino acids b) IgGs c) Cholesterol d) Nicotine Which of the following can diffuse through the placenta? a) Amino acids b) IgGs c) Cholesterol d) Nicotine Placenta Uterine arteries → placenta → umbilical artery (in umbilical cord) Two-way exchange ○ Nutrients in, waste out Layers (inside → outside) ○ Fetus ○ Amniotic fluid ○ Amnion ○ Chorion ○ Placenta Chorionic villi belong to baby Sinuses belong to mum Placental Transport  FEMALE MATERNAL ANATOMY ADAPTATIONS Which of these maternal adaptations is incorrect? a) Increased body weight b) Lumbar lordosis c) Decreased blood flow d) Insulin resistance Which of these maternal adaptations is incorrect? a) Increased body Cardiovascular: ○ Increase in ECF weight ○ Cardiac output increases 30-40% to accommodate blood flow through b) Lumbar lordosis placenta c) Decreased ○ Decrease in TPR secondary to progesterone blood flow Respiratory ○ Increase O2 consumption & CO2 production & ventilation → d) Insulin resistance compensated respiratory alkalosis Endocrine ○ Increased body weight ○ Insulin resistance MSK ○ Posture - pelvis tilts and back arches = lumbar lordosis + change to centre of mass ○ Gait - ‘waddling’ Renal ○ Increased blood flow → increase GFR  FEMALE STAGES OF ANATOMY LABOUR During which stage of labour does the cervix fully dilate? a) Stage 1 b) Stage 2 c) Stage 3 During which stage of labour does the cervix fully dilate? a) Stage 1- bonus points for which phase??? b) Stage 2 c) Stage 3 Stage 1 is split into three phases: Latent phase Longest phase Cervix thins and dilates in preparation for birth Can have regular or irregular contractions, and sometimes they may not be noticeable Active phase Cervix dilates to approx. 8cm Contractions strength and become more regular This is usually the phase in which people will come to hospital/a birthing centre Transition phase Stage 2: “Giving birth” Contractions are strong, but more spaced out, need to actively push to facilitate the birthing process Stage 3: Post baby being born Delivery of the placenta and the surrounding membranes Weaker contractions if present Umbilical cord clamped and cut  FEMALE LACTATION ANATOMY Lactation Initially prolactin is inhibited by the negative feedback of oestrogen and progesterone however following birth their levels fall dramatically which allows lactation to occur 1. Lactogenesis I → begins mid-pregnancy until 2 days after birth ○ Glands well differentiated and will secrete small quantities of casein and lactose ○ Colostrum rich in protein but poor in lactose and fat made few days before birth the synthesis of colostrum continues for two days after the birth of the baby ○ High progesterone levels before birth will severely restrict milk production 2. Lactogenesis II → marked by secretion of copious amounts of milk ○ Decrease in the levels of progesterone allows production of milk by prolactin ○ Marked by programmed transformation of mammary epithelium Changes in permeability between epithelial cells Secretion of immunoglobulins, lactoferrin and complex carbs Increased rate of secretion of all milk components Match the hormone to its effect A) Prolactin B) Oxytocin 1) Stimulates let-down reflex which allows baby to obtain the milk 2) Stimulates milk production Match the hormone to its effect Prolactin → stimulates milk production by acting on alveolar epithelial cells Oxytocin → stimulates let-down reflex which allows baby to obtain the milk Most women do not fall pregnant while breastfeeding because GnRH secretion is inhibited by: A: Oestrogen B: LH C: FSH D: Oxytocin E: Prolactin Most women do not fall pregnant while breastfeeding because GnRH secretion is inhibited by: A: Oestrogen B: LH C: FSH D: Oxytocin E: Prolactin Prolactin decreases GnRH, therefore, decreases LH and FSH  FEMALE MENOPAUSE ANATOMY D Menopause Progressive decline in follicle # + oocyte quality Menopause = The last menstrual period in a woman with an intact uterus’ Perimenopause = Time from start of cycle irregularity until 12 months after final menstrual period (about 3 years) Hormone changes Ovaries slowly stop producing estrogen Triggers ↑FSH and LH ○ Decreased negative feedback Also decrease in progesterone Menopausal Symptoms Mood/fatigue/mental health Dryness Period-type symptoms ○ Bloating ○ Sore breasts ○ Joint pain Sweats & flushes  FEMALE MICROBIOLOGY ANATOMY Bacterial Pathogen Symptoms Diagnosis Management Chlamydia - Symptoms observed 7-14 days after infection Cell culture - ELISA, Mx: doxycycline or - Chlamydia - Causes watery or urine PCR azithromycin trachomatis mucopurulent discharge and dysuria (pregnant) - Can causes pelvic inflammatory disease, chronic disease and infertility in females - Vertical transmission is possible during vaginal delivery of the baby Gonorrhoea Symptoms observed 2-7 days - vaginal or urethral Microscopy + Ceftriaxone IM with - Neisseria discharge, dysuria culture of azithromycin gonorrhoea Males often asymptomatic discharge, PCR Females: ++ complications Syphilis Incubation period 9-90 days Microscopy + High dose penicillin - Treponema 4 stages of infection serology pallidum 1) Primary = chancres - lesions (cervix, labia, urethra, penis) 2) Secondary = rash,- highly infectious 3) Latent 4) Tertiary = decades later, CVS + neurosyphilis + 5% of patients with N. gonorrhoeae are co- infected with ________? A) Syphilis B) HIV C) Estrogen D) C. trachomatis 5% of patients with N. gonorrhoeae are co- infected with ________? A) Syphilis B) HIV C) Estrogen D) C. trachomatis Which of the following is true ? A. Gardasil is the preventative vaccine for HSV B. Trichomoniasis is usually diagnosed by detection of the parasite in first past urine in women C. Neisseria gonorrhoea is caused by gram-negative bacteria D. Type-2 HSV is mainly spread through saliva Which of the following is true ? A. Gardasil is the preventative vaccine for HSV B. Trichomoniasis is usually diagnosed by detection of the parasite in first past urine in women C. Neisseria gonorrhoea is caused by gram-negative bacteria D. Type-2 HSV is mainly spread through saliva  Viral Virus Transmission Symptoms Investigations Prevention & Extra Mx HPV Skin to skin Warts Pap smear Gardasil Vaccine Linked to - 6, 11, 16 & 18 cancer: cervical, anal, vulvar, penile HIV Blood, vertical, Seroconversion ELISA Mx: HAART (NRTI, AIDs defining sexual sx NNRTI protease illness: AIDS inhibitor) toxoplasma, kaposi sarcoma Genital Type 1 HSV-1: Type 1 HSV-1: Gernital swab → Mx: acyclovir Herpes (HSV) saliva oral cold sores PCR (anti-viral Type 2 HSV-2: Type 2 HSV-2 genital Lesions heal over sexual blisters/ulcers 3-4 weeks but 75% recurrent asymptomatic infections are Sx: painful common) vesicles Micro Pathogen Transmission Symptoms Investigations Prevention & Extra Mx Trichomoniasi Vaginal, oral or Symptoms PCR on urine or Metronidazole s anal sexual mostly high vaginalsw - T. vaginalis intercourse asymptomatic ab - Flagellated 50% women - protozoan cervicitis, frothy vaginal discharge Some men - dysuria and penile discharge Candida Blood, vertical, Overgrowth → Microscopy + Topical or oral Risk factors: albicans sexual vaginal culture of antifungal hormone - Fungus candida discharge, PCR changes (norma (thrush) (menstruation), l oral, Irritation, diabetes, gut and inflammation, reduced cell vaginal cheesy mediated  FEMALE CLINICAL ANATOMY SKILLS Definitions TERM DEFINITION Menstruation Periods - uterus shedding its lining, vaginal bleeding Menarche Age of first period Menopause 12 months since last period Amenorrhoea Primary - never had period by 16 yo (usually structural cause) Secondary - had period and now stopped for 6 months (pregnancy main cause) **amenorrhoea = a (none) + menorrhoea (period) Oligomenorrhea Light or infrequent period **oligomenorrhea = oligo (few) + menorrhoea (period) Dysmenorrhoea Period pain **dysmenorrhoea = dys (pain) + menorrhoea (period) Menorrhagia Heavy periods Intermenstrual bleeding Bleeding between periods **intermenstrual = inter (between) + menstrual (period) Definitions TERM DEFINITION Gravidity (G) Total number of confirmed pregnancies Parity (P) Number of births after 20 weeks gestation Nulliparous A woman who has never given birth (including still born children) **nulliparous = nulli (none) + parous (births) Multiparous A woman who has had more than one child **multiparous = multi (many) + parous (births) Primigravida A woman who is pregnant for the first time **primigravida = primi (first) + gravida (pregnancy)  Systems review- female Menstrual Gynaecological history · Age of menarche & menopause · Pap smear & breast exam up to date · Last menstrual period · HPV vaccination status · Length of cycle · Surgeries or procedures o Regular or irregular? · Known gynaecological medical conditions · Flow character · Pain with periods (dysmenorrhoea) Obstetric history · Intermenstrual bleeding · Gravida, para · Gestations, miscarriages, terminations · Intermenstrual pain · Type of delivery · Abnormal bleeding · Complications of pregnancy or delivery o Menorrhagia (heavy or prolonged), o Oligomenorrhea (infrequent) Others o Amenorrhoea (absence of monthly periods) · Pelvic pain · Discharge · Urinary symptoms · Premenstrual symptoms · Galactorrhoea · Signs of menopause · Hyperandrogenism signs o Hot flushes, night sweats, vaginal dryness, · Signs of menopause breast pain, period changes Systems review- male Discharge Erectile dysfunction ○ Getting or maintaining Ejaculation problems ○ Premature, delayed Urinary symptoms o Storage – frequency, urgency, nocturia o Obstructive – hesitancy, poor and or/intermittent stream, feeling of incomplete bladder emptying, dribbling Testicular lump/pain/swelling ○ Appearance – size, lesions, shape Screening – prostate, STD Sexual history Partners – numbers and genders Practices – type of sex Protection from STIS Previous history of STI Prevention of pregnancy Contraception Contraception Contraception Contraception