Surgical sterilization of women and oral contraceptive use by women are the most common methods of contraception in the U.S., and are some of the most effective methods.
Contraindications to combined estrogen/progestin OCP use are thromboembolic disorders, cerebrovascular accidents, coronary artery disease, liver abnormalities, estrogen dependent cancers, pregnancy, undiagnosed vaginal bleeding and tobacco use over age 35.
Non contraceptive benefits of combined oral contraceptives include decreased endometrial cancer, uterine cancer, benign breast disease, ovarian cysts, uterine fibroids, ectopic pregnancy, menstrual irregularities, salpingitis, rheumatoid arthritis, endometriosis, atherosclerosis, and increased bone density.
Intrauterine devices are safe and effective contraceptive methods especially for monogamous females near the end of their reproductive careers.
Barrier methods and rhythm methods are highly dependent on the individuals involved.
Pregnancies in women who have undergone a surgical sterilization should be considered ectopics until proven otherwise. Likewise, a positive pregnancy in a woman with an IUD may be an ectopic pregnancy.
The number one reason for amenorrhea in a woman of reproductive age is pregnancy.
The diagnosis of early pregnancy is not always straightforward; clinicians from all disciplines must become expert in the methods of diagnosing pregnancy.
The most common disorder of early pregnancy is abortion in all its varied presentations.
The most life-threatening disorder of early pregnancy is ectopic pregnancy. High suspicion for ectopic pregnancy should always be maintained for gynecologic patients, and prompt diagnosis and therapy should be reflexive.
The genetic history is part of the obstetric history and includes the family history, reproductive outcomes, maternal and paternal ages, maternal and paternal ethnic origins, and drug exposures.
Be familiar with common genetic syndromes and teratogens.
There exist a number of prenatal diagnostic procedures, amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling, and fetoscopy, that have their indications, advantages, and disadvantages.
Be familiar with advancing molecular technology and its utility in the clinical setting. It is our responsibility as physicians to keep up with rapidly advancing diagnostic techniques. Techniques such as FISH, isolation of fetal cells in maternal circulation, and fetal stem cell transplantation are in our patients near future.
The progress of labor is measured by evaluating dilatation of the cervix and descent of the presenting part as a function of time. When an abnormality is diagnosed, the cause is identified and the appropriate treatment initiated.
The history, physical exam, and laboratory investigations will detect an etiology for male factor infertility in approximately 50% of cases.
Serum FSH levels provide an important diagnostic parameter in determining the pathological basis of azoospermia.
Karyotypic analysis is most helpful in males with azoospermia and small testes.
Obstruction of the ejaculatory ducts can be diagnosed by ultrasound.
The absence of the vas deferens can be detected by the absence of fructose in the semen sample.
The most common congenital abnormality resulting in testicular dysfunction is cryptorchidism.
The longer the testis remain outside the scrotum, the greater the degree of spermatic disruption.
The most common chromosomal abnormality resulting in deficient testicular function is Klinefelter's syndrome. The frequency of this abnormality is 1 in 500 live births. The 47,XX7 karyotype results in the destruction of all germ cells with seminiferous tubules causing small, firm testes and azoospermia. Gynecomastia and various degrees of androgen deficiency are usually noted.
The most common vascular abnormality associated with infertility is a varicocele. The higher frequency of varicocele in infertile men (21% to 41%) compared to men in the general population (4% to 23%) has been interpreted as supporting a causal relationship between varicocele and infertility. Theories to account for adverse testicular function with a varicocele include: vascular stasis, back pressure, interference with oxygenation, reflux of renal or adrenal products into the pamipiniform plexus and interference with heat exchange function of the pamipiniform plexus.
Optimal ovarian estrogen biosynthesis is contingent upon the cooperation of the two gonadotropins (LH and FSH) and the two ovarian somatic cell types (granulosa and theca). In contrast, progesterone biosynthesis is primarily LH-dependent and is carried out at the level of the granulosa-lutein cell.
The pronounced progestational capabilities of the corpus luteum reflect its highly vascular nature, a phenomenon due to the breaching of the follicular basement membrane at the time of ovulation along with neovascularization of the former follicular apparatus.
FSH reception appears to constitute an early feature of the granulosa cell. Consequently, it is the FSH receptor that provides the granulosa cell with a window to the outside world through which other signaling systems can be acquired.
Contrary to conventional wisdom, the indispensability of estrogens to intraovarian physiology is now being challenged. A strong body of evidence would suggest that primate/human follicle may not depend on estrogen for growth and maturation.
The ovary itself may, in fact, play a zeitgeber(German - "timegiver") role during the menstrual cycle. A time-keeping function subserved by the activities of the cyclic structures of the dominant ovary. The 28-day menstrual cycle is thus the result of the intrinsic life span of the cyclic ovarian dominant structure and not the result of time changes dictated by the brain or pituitary. The dominant follicle thus determines the length of the follicular phase; the corpus luteum determines the length of the luteal phase.
The pregnant patient is best served by a confident and caring physician who vigilantly searches for high-risk features and then treats the patient as is appropriate for each high-risk condition. Most patients have completely normal pregnancies, but the high-risk pregnancy mandates changes in the "normal" evaluation of the pregnant patient.
The process of antenatal care is on-going risk assessment:
a. What is the genetic risk? (maternal age, abnormal MSAFP screening, folate administration for prior NTD)
b. What is the risk for preterm birth? (BV screening, history of preterm birth)
c. What is the risk for pregnancy-induced hypertension? (history)
d. What is the risk for IUGR? (past history, small uterine size for dates)
e. What is the risk for blood group isoimmunization? (Rhogam for Rh- women NOT previously sensitized)
After the core curriculum, using this lecture as a basis, you should be able to:
a. List at least five conditions identified by medical history that results in a high-risk pregnancy.
b. List at least six conditions found during physical examination of a pregnant woman that denotes a high-risk pregnancy.
Normal mammary development depends on a critical interplay of appropriate fat deposition, vascular supply, and hormone interactions. Estrogen stimulation of ductal development and progesterone induced development of alveolar growth and the modulating activities of estrogen, progesterone, growth hormone, insulin, cortisol, thyroid and parathyroid hormone with prolactin result in a functional gland. Lactation postpartum occurs when the inhibitory activity of progesterone is reduced through its more rapid clearance compared to prolactin.
Progesterone antagonizes the alveolar cells prolactin receptor by:
Inhibiting the upregulation of the prolactin receptor
Reducing estrogen binding
Competing for binding at the glucocorticoid receptor
Galactorrhea occurs with:
Stimulation of the afferent limb of the neuroendocrine arc
Decreased dopamine release or transport or binding
Autonomous prolactin secretion
Chronic renal failure
Hyperprolactinemia may cause anovulation through:
A reduction in granulosa cell number and FSH binding
Inhibition of granulosa cell 17 estradiol production by interfering with FSH action
Inadequate luteinization and reduced progesterone
The suppressive effects of prolactin on GnRH pulsatile release.
The combination of amenorrhea and galactorrhea is associated with hyperprolactinemia in two-thirds of cases. In over one-third of women with hyperprolactinemia, a radiologic abnormality with an adenoma is found. A pituitary microadenoma (< 1 cm) or hyperplasia is the cause of hyperprolactinemia in most patients. Macroadenomas are larger than 1 cm. MRI is the optimal radiologic technique to evaluate the sella/suprasellar region. Bromocriptine is the mainstay of therapy for microadenomas and macroadenomas and hyperprolactinemia wihout evidence of an adenoma.
Puberty is the coordinated sequence of biochemical and physiologic events including adrenarche and gonadarche which result in the growth spurt of adolescence, development of secondary sex characteristics, and reproductive capacity.
The CNS activation of puberty may occur prematurely (before the age of 8 in girls or 9 in boys) or be delayed (age 14 in girls and 15 in boys), often indicating underlying medical disease.
The cessation of predictable ovarian function occurs over several years. The menopause is defined as the last spontaneous menstrual period.
Estrogen therapy may substantially decrease the risk of postmenopausal osteoporotic fractures and has been shown in epidemiologic studies to decrease the risk of coronary artery disease.
There is no clear rapid decline in gonadal function in men as there is in women, although there is a dramatic decline in adrenal androgens from their peak after puberty to middle age. Whether this is reflected in decreased function is unclear.