NR 507 FINAL EXAM STUDY GUIDE 1

NR 507 FINAL EXAM STUDY GUIDE 1 Reproductive: The Menstrual (Ovarian) Cycle: Purpose: Pregnancy and menstrual bleeding (the menses). Starts with Menarche (first menstruation) ends with menopause (cessation of menstrual flow for 1 year). Cycles are anovulatory at first and may vary in length from 10 to 60 days then regular patterns of menstruation and ovulation occur lasting from 21 to 45 days. CYCLE: Commonly accepted cycle average is 28 (27 to 30) days, with rhythmic intervals of 21 to 35 days (Normal). Phases of the Menstrual Cycle: (two phases) 1- the follicular/proliferative phase (postmenstrual) followed by 2- the luteal/secretory phase (premenstrual). Menstruation (menses),the functional layer of the endometrium disintegrates and is discharged through the vagina. Follicular/proliferative phase: GnRH and a balance between activin and inhibin from the granulosa cells contribute to the rise of FSH levels, which stimulates several follicles. The pulsatile secretion of FSH from the anterior pituitary gland rescues a dominant ovarian follicle from apoptosis by days 5 to 7 of the cycle. Together estrogen and FSH increase FSH receptors in the granulosa cells of the primary follicleà making them more sensitive to FSH. FSH and estrogen combine to induce production of LH receptors on the granulosa cells, promoting LH stimulation to combine with FSH stimulation causing a more rapid secretion of follicular estrogen. As estrogen levels increase, FSH levels drop because of an increase in inhibin-B secreted by the granulosa cells in the dominant follicle. This drop in FSH level decreases the growth of less-developed follicles. Estrogen causes cells of the endometrium to proliferate and stimulates production of LH. A surge in both FSH and LH levels is required for final follicular growth and ovulation. An increase in stromal tissue in the late follicular phase is associated with a rise in androgen levels. Androgen production enhances the process of follicle atresia. Luteal/secretory phase (premenstrual): Ovulation is the release of an ovum from a mature follicle and marks the beginning of the luteal/secretory phase of the menstrual cycle. Ovarian follicle begins its transformation a corpus luteum (hence luteal phase) (see Fig. 24.8, A) Pulsatile secretion of LH from the anterior pituitary stimulates the corpus luteum to secrete progesterone, which in turn initiates the secretory phase of endometrial development. Glands from the endometrium start to secrete a thin glycogen-containing fluid (the secretory phase). If conception occurs, the nutrient-laden endometrium is ready for implantation. Human chorionic gonadotropin (HCG) is secreted 3 days after fertilization by the blastocytes and maintains the corpus luteum once implantation occurs at about day 6 or 7. HCG can be detected in maternal blood and urine 8 to 10 days after ovulation. If conception and implantation do not occur, the corpus luteum degenerates and STOPS production of progesterone and estrogen. Without progesterone or estrogen to maintain it, the endometrium becomes ischemic (“blood-starved”) and disintegrates, hence the name ischemic/menstrual phase. Menstruation then occurs, marking the beginning of another cycle. Ovulation Occurs: Ovulatory cycles- minimum length of 24 to 26.5 days: Primary ovarian follicle requires 10 to 12.5 days to develop, and the luteal phase appears relatively fixed at 14 days (±3 days). Menstrual blood flow usually lasts 3 to 7 days, but it may last as long as 8 days or stop after 1 to 2 days and still be considered within normal limits. Bleeding is consistently scant to heavy and varies from 30 to 80 mL, with most blood loss occurring during the first 3 days of menses. Menstrual discharge consists of blood, mucus, and desquamated endometrial tissue and does not clot under normal circumstances. It is usually dark and produces a characteristic musty odor on oxidation. Environmental factors such as severe emotional stress, illness, malnutrition, obesity, and seasonal variation may affect the length of the menstrual cycle. Uterine prolapse: is descent of the cervix or entire uterus into the vaginal canal (Fig. 25.11). In severe cases the uterus falls completely through the vagina and protrudes from the introitus. Symptoms of other pelvic floor disorders also may be present. Polycystic ovary syndrome (PCOS): is the most common cause of anovulation and ovulatory dysfunction in women. PCOS is defined as having at least two of the following three features: -irregular ovulation, -elevated levels of androgens (e.g., testosterone), and -the appearance of polycystic ovaries on ultrasound. Polycystic ovaries do not have to be present to diagnose PCOS, and conversely their presence alone does not establish the diagnosis. (2 out of 3 need to be present). PCOS is associated with metabolic dysfunction, including dyslipidemia, insulin resistance, and obesity. Cause of PCOS is unknown, a genetic basis is suspected. Symptoms are related to anovulation, hyperandrogenism, and insulin resistance and include dysfunctional bleeding or amenorrhea, hirsutism, acne, acanthosis nigricans, and infertility. Goals of treatment include reversing signs and symptoms of androgen excess, instituting cyclic menstruation, restoring fertility, and ameliorating any associated metabolic or endocrine, or both, disturbances. First-line treatment of PCOS includes combined oral contraceptives (COCs) for management of symptoms (e.g., hirsutism, acne) and to establish regular menses. For those women with PCOS who are overweight or obese, lifestyle modifications, including regular exercise and weight loss, also are considered first-line treatments. Women with insulin resistance, or those women who do not respond to contraceptive therapy, may benefit from the insulin sensitizer metformin. If COCs are not used and pregnancy is not desired, progesterone therapy is recommended to oppose estrogen's effects on the endometrium and as a means to initiate monthly withdrawal bleeding (at the expense of continued hirsutism). Clomiphene citrate, an antiestrogen, can be used to facilitate ovulation and can be combined with metformin for improved outcomes. Management of PCOS is a nearly lifelong process because the effects of the syndrome persist past childbearing years. testicular cancer and conditions that increase risk; symptoms that require evaluation for breast cancer; signs of premenstrual dysphoric disorder; Testicular cancer- testicular cancer is highly treatable and mostly often develops in young and middle aged men. 90% of testicular cancers are germ cell tumors arising from the male gametes. Germ cell tumors constitute 90% of testicular cancers and are classified in to seminomas and nonseminomas. Seminomas are the most common and the least aggressive, and make up 30% to 35% of testicular cancers. Nonseminomas make up 60% and include embryonal carcinomas (20%-25%), teratomas (5%-10%), and choriocarcinomas (1%) which are the most aggressive but rare form of testicular cancer. pg 844. Conditions that increase risk of testicular cancer- the cause of testicular cancer is unknown, but a genetic predisposition is suggested since there is higher incidence among brothers’ identical twins and other close male relatives. Risk factors include history of cryptorchidism, abnormal testicular development, human immunodeficiency virus (HIV) and AIDS, klinefelter syndrome and history of testicular cancer. Pg 845 Symptoms that require evaluation for breast cancer- More than two-thirds of breast cancer cases occur in women older than 55 years. The median age for breast cancer diagnosis was 61 years of age. Some women younger than age 45 may have a higher risk for getting breast cancer compared with other women their age if they have the following risks factors: (1) close relatives (parents, siblings, or children) who were diagnosed with breast or ovarian cancer when they were younger than 45, especially if more than one relative was diagnosed or a male relative had breast cancer; (2) alterations in certain breast genes (BRCA1 and BRCA2), or having close relatives with these alterations; (3) Ashkenazi Jewish heritage; (4) treatment with radiation therapy to the breast or chest during childhood or early adulthood; (5) have been diagnosed with breast cancer or other breast health problems, such as lobular carcinoma in situ (LCIS), DCIS, atypical ductal hyperplasia, or typical lobular hyperplasia; and (6) high breast density. A high-risk breast cancer condition is postpartum breast cancer with immune suppression and delayed involution. Pg 792-793 Signs and symptoms of breast cancer may include: • Change in the size, shape or appearance of a breast • Changes to the skin over the breast, such as dimpling • A newly inverted nipple • Peeling, scaling, crusting or flaking of the pigmented area of skin surrounding the nipple (areola) or breast skin • Redness or pitting of the skin over your breast, like the skin of an orange Clinical manifestation Pathophysiology Chest pain Metastasis to lung Dilated blood vessels Obstruction of venous return by fast growing tumor Dimpling of skin Can occur with invasion of dermal lymphatic because of retraction of cooper ligament Edema of arm Local inflammation of lymphatic obstruction Hemorrhage Erosion of blood vessels Local pain Local obstruction by tumor Nipple/areolar eczema Paget disease Nipple discharge in a no lactating woman Spontaneous and intermittent d/c caused by tumor obstruction Nipple retraction Shortening of mammary ducts Pitting of the skin Obstruction of sub lymphatic, resulting in fluid accumulation Reddened skin, local tenderness, warmth Inflammation Skin retraction Involvement of suspensory ligaments Ulceration Tumor necrosis