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SMED 175 Podium: Okay, yeah, yeah. I know no one has capacity. Alright. Can you all hear me? I think it’s on, is it on? Okay? It is alright cool. Alright, we’ll get started. It wouldn’t be a session on repro if we didn’t do some Kahoot. So we’re gonna do that.
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SMED 175 Podium: I also added to our snack pile of things from Trader Joe’s because I can’t help myself.
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SMED 175 Podium: Alright
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SMED 175 Podium: here, this. There’s this huge test coming up. I’ve taken it before, but it’s been a few years so we’re gonna talk about how to prepare from a repo standpoint. I’m Dawn clap if you don’t know who I am. I don’t have anything to disclose. You can pause and stop and interrupt me at any time.
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SMED 175 Podium: You are being tested on this, but not by me. So what we cover we cover, I guess right. So if we don’t get to all the slides, it’s fine. I have a bunch of extra things. We have extra time that we can also do but if there’s like certain topics that you really really want to cover
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SMED 175 Podium: I’m I’m up for it. So that’s a-okay every year after step one, when the second years come back for 5, 13, and I was like what was on the test from April. Here’s what I heard last year, and I have heard a lot of yours, the hypothalamus, pituitary ovarian pathways.
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SMED 175 Podium: menopause the menstrual cycle contraception.
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SMED 175 Podium: And then people were like there were so many. And then back to menstrual cycle, usually a ton of menstrual cycle questions also. Some.
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SMED 175 Podium: Those were the main things that people felt like were really tough. Last year
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SMED 175 Podium: ovarian masses also came up. So we’re going to cover some of that stuff today. But if there’s other things that you want to make sure we cover, let me know.
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SMED 175 Podium: I’m also going to just share, even though I took step one a bit ago, honestly, hasn’t changed all that much other than they changed it to pass fail, and they increased the pass rate. So other than that I can just share what kind of studying techniques I used and what are supported by adult learning literature on how adults learn and take tests and succeed the best. So in case you want to use it great in case you’re like I already have my strategy. You can totally tune me out and just munch on some snacks.
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SMED 175 Podium: Alright, just to start us off. What kind of dog are you when you think about Step one? Which of these best pictures describes
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SMED 175 Podium: your feelings.
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SMED 175 Podium: Yeah, the dogs are kind of little. Oh, okay, here we are. Oh, okay. Dog 4, yeah, and 2 and 5. Okay? And a little bit of dog one. That’s all right.
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SMED 175 Podium: That’s just good to know.
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SMED 175 Podium: All right. I took step one like I said, 18 years ago I did pass. Here are things that I did that works for me, and don’t do them if they don’t work for you.
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SMED 175 Podium: I started studying and dedicated. I study from about 7 Am. Till 5 Pm. Or so. But then around 5 Pm. I would go exercise for an hour. I did eat a nice dinner. Then I would go to a different spot, and I would get my you world out, and I would do an hour of mixed questions.
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SMED 175 Podium: And they were not at all related to what I had studied that day.
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SMED 175 Podium: I read through all the answers and explanations. After I did my 1 h session.
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SMED 175 Podium: I found all the topics. I got wrong in my 1st aid paper book, and I found all of them and wrote notes to myself if I needed to remember something or make up a mnemonic or highlight something. And that’s what I did.
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SMED 175 Podium: And then during the day I would focus on different topics, like pharmacology, or physiology, or anatomy, making sure that I covered everything within the 1st like 4 ish weeks.
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SMED 175 Podium: and then the last one or 2 weeks. I just started doing 1 h blocks of questions all day long, and I increased my endurance to be able to do that.
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SMED 175 Podium: because this is still, I think, right? 7 1 h blocks of random questions.
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SMED 175 Podium: I don’t know about you. Some of you are runners in this room. If you asked me to run a half, Marathon. Right now. I would poop out at 1.2 miles, and I would give up. I would not be able to do 13. I have run a half Marathon before, but I had prepared for it, and I had run a lot of long distances before I did that.
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SMED 175 Podium: So if the day you take your exam is the 1st time you sat down and done 7 h of random questions. It’s going to hurt. It’s going to be hard to breathe just like if I actually tried to run 13 miles a day. The more that you can do that, and I would recommend this works for me. Don’t do it if it doesn’t work for you. I woke up at the same time that I had to wake up to be there at the test
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SMED 175 Podium: I started at the same time. This test started. I tried to end at the same time. This test ended so that by the time I got to test day. My body had been doing that for a while.
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SMED 175 Podium: The night before. I still looked at 1st aid to look at all the things I got wrong. At the end of the day. And then the night before, I stopped studying, and I just went to a movie. And this really dates me because I think this is the movie I saw the night before my exam. Which is how old I am, and I did not study or look at any flashcards. The morning of the exam. I just went into it just like I did every day for the last week or 2, where I would just sit down and do 7 blocks of questions.
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SMED 175 Podium: Yeah, the last week it was just 7 h like I did, basically a press practice exam every day
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SMED 175 Podium: like, and then in the evening, and then I would exercise, eat dinner, and then the evening I go over all my missed questions again, for say, yeah.
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SMED 175 Podium: great question. That’s what I did
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SMED 175 Podium: use it. If it works, you may already have an even better strategy.
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SMED 175 Podium: My classmates, a lot of my classmates would like study pharmacology all day and then do blocks of pharmacology questions in the evening. I didn’t do that, because learning that’s not the format of the test and actually testing
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SMED 175 Podium: where you don’t know what you’re going to see next actually helps to strengthen the memories and the pathways in your brain, and those concepts are called spacing and interleaving. So not doing pharmacology, pharmacology, questions, but doing pharmacology. And then all the questions actually helps your brain retain things quite a bit more.
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SMED 175 Podium: I focused on the questions I got wrong, and I was okay to get really terrible scores for several weeks. Obviously I did not do well on my Q. Banks, because our brain assigns a lot more emotion and a lot more pathways to wrong answers. Probably some of you can still think of a wrong answer you got on an Mka from 1st year. Can anyone think of one wrong question you got in the answer, or from second year. Even right? So the more you do that you’re actually going to remember things more. Or that’s my theory.
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SMED 175 Podium: That’s how I did it. Don’t do it if it doesn’t work for you. Yes, I’m very old. I’m outdated. I took this test a while ago. There are blogs from Wsu. We have coaches. We have peer tutors and lots of other people who are closer to you in this, who also have input. So use what they do. Okay? So 24 year old woman wants to prevent pregnancy. She’s tracking a basal body temperature. What causes it to increase?
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SMED 175 Podium: Oh.
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SMED 175 Podium: all right, yeah, the progesterone is causing it to increase. So this sounds like, maybe a fertility question. But it’s a menstrual cycle question, right? There are a lot of menstrual cycle questions that are going to look like other types of questions.
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SMED 175 Podium: Yeah, so wow, is this clearing off some cobwebs from June of 2024, right? So what happens after ovulation. This hormone in the green is spikes way high. That’s progesterone that increases that affects the hypothalamus and increases the basal body temperature for folks with that increase. And that’s why people tracking their cycles will notice that their basal body temperature increases in the second half of the cycle.
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SMED 175 Podium: Other really good things to know about the menstrual cycle is the sharp decline both of estrogen here and progesterone. Here, immediately prior to the start of the menstrual cycle, where it starts here where both of those levels are very low.
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SMED 175 Podium: And then another thing that you might be asked about is the Lh surge that happens here right immediately before ovulation within hours before ovulation. You might also be asked about the proliferative phase and the secretive phase, and where those take place within the menstrual cycle, and correspond that to what’s happening in the ovary with the follicular and the luteal phases.
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SMED 175 Podium: So just as a reminder, the follicular phase is happening here, and the luteal phase is happening here.
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SMED 175 Podium: So that’s how those things relate.
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SMED 175 Podium: Set. Okay?
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SMED 175 Podium: but all the other answer. Choices are actually real things that do occur right. The follicular cells are making estrogen. That’s why we see the estrogen changing during the menstrual cycle. There is this luteal luteinizing hormone surge prior to ovulation. Fsh does increase during the cycle. Other things that you might be asked about Progesterone.
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SMED 175 Podium: Not only does it change the body temperature, but it’s made by the corpus luteum. They might want to ask you about that, and the purpose of it is actually to support implantation through its action on the endometrium.
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SMED 175 Podium: Here’s some other things that you might be asked about the menstrual cycle. Remember the follicular phase, that 1st part of the menstrual cycle from the start of day 0 1 bleeding until ovulation that fluctuates in length for every individual who has a menstrual cycle, whereas the luteal phase from ovulation to menstruation is always a fixed 14 days.
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SMED 175 Podium: Right? So if someone ovulates on day 7, they’ll have a 21 day cycle. If someone ovulates on day 20, they will have a 34 day cycle. Both of those are still within the range of normal. So the myth of the 28 day cycle and ovulation on Day 14, we all know that’s not true and not real right.
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SMED 175 Podium: Usmle may try to mislead you and see how much you believe in the myth of the 28 day cycle. Yes.
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SMED 175 Podium: Question about what she had to say also.
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SMED 175 Podium: oh, my God! Who made up that question.
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SMED 175 Podium: Okay. The question was, which part of the menstrual cycle. Would someone feel happier in, are you? For it
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SMED 175 Podium: would feel dysthymic?
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SMED 175 Podium: The answer is literally okay. It’s like she’s coming in for bloating. Is that the one. Yeah, she was bloated. It was like, just cramps. What face is causing that? But she has, like a normal new kind of mood.
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SMED 175 Podium: Oh, okay, okay, I have so many questions about who wrote that question. If it’s about mood and cycle, the symptoms? Okay, the like. The bloated kind of symptoms. Okay, yeah, I do not know how I feel about any question about mood and menstrual cycle. That’s like a very nuanced discussion for another time that very few people actually agree on. Yes.
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SMED 175 Podium: but bloating is. So yeah, that’s probably a little bit easier to associate. Very interesting. Okay, just as a reminder.
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SMED 175 Podium: estrogen enhances the endometrium. That’s what it’s doing. Progesterone
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SMED 175 Podium: overall protects the endometrium by making it puny, even though it is actually in the second half of the menstrual cycle, also supporting the endometrium there as well.
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SMED 175 Podium: So it gets a little bit confusing. But the way that we primarily use Progesterone in prescription is to make the lining small and keep it that way, and estrogen is going to make it grow
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SMED 175 Podium: all right. Another question, about a 23 year old woman with a positive pregnancy test.
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SMED 175 Podium: What is that hormone that show that made the test positive. Also view.
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SMED 175 Podium: Let’s see how we did.
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SMED 175 Podium: Okay, yes, it maintains the corpus luteum. That’s what Hcg does.
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SMED 175 Podium: Right? It seems like a pregnancy question. And it is. It is a pregnancy physiology question. So it’s asking us to recall how pregnancy works. So the way pregnancy works is implantation happens in the endometrium. About 5 to 6 days after fertilization. Fertilization happens in the Fallopian tubes
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SMED 175 Podium: Beta Hcg. Is secreted by the syncytiotrophoblast, and this is what is detected on both serum and urine pregnancy tests the Hcg. Also. Its role is not to turn a pregnancy test positive. We figured that out in the last 100 years, but what it’s been doing for all of time is actually maintaining the corpus luteum, and then around 10 weeks the placenta is formed. Enough that it’ll make its own progesterone.
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SMED 175 Podium: which tells the corpus luteum. We don’t need you anymore, and that will degenerate. And so that is how pregnancy works.
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SMED 175 Podium: And this is another picture showing the same thing about what Hcg does and where it comes from, which is the syncytiotropoblast? So that would be another way to ask this question is, where did this hormone come from? And the answer would be, the syncytiotropolast like what produced it. That’s frame is pregnancy test positive.
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SMED 175 Podium: They might. Yeah.
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SMED 175 Podium: trying to think of. There’s a lot of ways to ask that question also, just as a refresher. What’s the difference between the syncytiotrophoblast and the cytotrophoblast definitely the syncytiotrophoblast is making hormones like beta hgg primarily but also progesterone and estrogen whereas the cytotrophoblast is really making a lot of the cells that will become the chorionic villi.
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SMED 175 Podium: So I think of c cellular. That’s how I think of it.
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SMED 175 Podium: All right, let’s do another question, what about menopause?
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SMED 175 Podium: What other hormones? What happens in menopause?
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SMED 175 Podium: Yeah. So medical pause increases the fsh.
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SMED 175 Podium: so this is an Hpo question, even though it seems like a menopause question. But menopause. And Pcos, there’s so many questions that are really Hpo questions. That’s what they’re really trying to get after is what’s making what and what’s happening. So why does fsh increase in menopause?
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SMED 175 Podium: Primary mechanism of action? What causes menopause is? The ovaries have very few follicles the follicles are making Estradiol. There’s very little estradiol. There’s this normal feedback loop where, when the estradiol gets low, fsh follicle stimulating hormone stimulates the follicles
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SMED 175 Podium: to wake up and make more estrogen. These follicles are never waking up ever again. And so Fsh just screams louder and louder until the end of this person’s life. Okay? And so it’ll always be high.
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SMED 175 Podium: It screams without any response, and that used to get a response. And then it ends. Here’s another graphic that I made. That shows the same thing.
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SMED 175 Podium: and actually Lh is also going up at the same time very slightly. But no one who really cares that rarely shows up as being physiologically important. But it is also slightly increasing.
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SMED 175 Podium: Here’s another graphic to think about what’s happening with hormones over time. So this black line is the fsh, right? So fsh is like
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SMED 175 Podium: it doesn’t just be. It’s not 6, and then it goes to 50. It gradually increases, and I will say, this line is kind of a misnomer in real life. It’s like fluctuating along this line, and so depending on how and when you test, you can see it fluctuating, but at a certain point it crosses the threshold, and it’s just going to stay pretty steadily high in menopause.
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SMED 175 Podium: whereas we see the Estradiol level go down right, and these 2 things are totally related, and and then we also see some of the other estrogens go down. We see testosterone go down so slightly, but because it’s not dramatically decreasing as much as the estrogens. The ratio is now tipped in the favor of testosterone and estrogen. Remember all human beings make estrogen and testosterone whether or not they were assigned male or female, in birth. Right? So that’s just a
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SMED 175 Podium: a tip for your regular practice. You don’t have to refer people assigned female at birth to me to manage their hormones because all people have hormones. Right?
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SMED 175 Podium: All right.
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SMED 175 Podium: Ovarian masses. What’s the most common in someone in reproductive age?
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SMED 175 Podium: You could.
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SMED 175 Podium: Very good. Yes. So when you all are doing your 4th year er rotation which feels light years away. But, let me tell you, is only 14 months away when you are a 4th year, and you are seeing that patient in the er who is assigned female birth and is having pain, and you get an ultrasound that shows a 2 cm right ovarian cyst
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SMED 175 Podium: that does not make you stop and say, oh, that’s what your pain was right. We know that all people who are ovulating make 2 to 3 cm ovarian cysts on one ovary once a month, and it bursts every month, and that’s called ovulation. That is a normal process, and we’re not going to blame pain for that. It can be a little painful. But if someone’s pat enough to come to the er it’s usually something else.
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SMED 175 Podium: All right. We have some chronicles of Narnia fan just doing rocking this?
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SMED 175 Podium: Another question about ovaries. What about a 65 year old person with ovaries, ascites, and elevated? Ca, 125.
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SMED 175 Podium: We look under a microscope. What are we going to see?
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SMED 175 Podium: 1, 2, 1, 4, please.
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SMED 175 Podium: Okay, we’re gonna see some Samoa bodies made of calcium.
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SMED 175 Podium: All those things are real things that are associated with other conditions, that you’re also going to be tested on. So these buzzwords are like definitely worthy of making flashcards and reviewing them. This is to me just a purely memorization or mnemonic sort of thing. Right?
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SMED 175 Podium: Alright, yeah. 1, 25, is
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SMED 175 Podium: it? I’m trying to think how much you need to know. I don’t want to fill your brain with too much. Yes, it is a marker of ovarian cancer. It can also be. It’ll be markedly elevated in any kind of peritoneal cancer
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SMED 175 Podium: which ovarian is the most common, and it’s produced in the peritoneum. So that’s what you need to know. And the ovarian cancer is pretty much a peritoneal cancer, and that’s why it spreads all over the peritoneum, because the peritoneal fluid is like sploshing around all the time right right now, all of our peritoneal fluid is washing around. And that’s what happens with ovarian cancer. And Ca, 125 is produced by that.
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SMED 175 Podium: Yeah.
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SMED 175 Podium: all right. How am I ever supposed to remember all these ovarian things? Oh, is there a question back here? Okay, all right. We’ll see if I don’t like. Hold me to it, you know. Yeah. Good question. There’s a ton of ovarian things, right? Okay, here’s how I remember it.
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SMED 175 Podium: Okay, there are functional ovarian cysts we talked about. The most common is the follicular cyst. We already talked actually also about corpus luteum today, right? That happens in pregnancy, and shortly thereafter, and then we also talked about a fecal lutean cyst
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SMED 175 Podium: and so these are all related to menstrual cycle and timing in the menstrual cycle or pregnancy. And here’s a little bit more about those.
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SMED 175 Podium: And the corpus luteum cyst happens, even if someone isn’t pregnant, because it just happens in the second half of the menstrual cycle, the corpus luteum continues, if Adhtg is present to continue it.
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SMED 175 Podium: Okay? And then beyond that.
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SMED 175 Podium: then there are 3 big buckets of ovarian Neoplasms. So the 1st big bucket is the epithelials, the malignant one of the 65 year old. In that example, with the Ascites and the Ca. 125.
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SMED 175 Podium: That is serious, epithelial, ovarian cancer. That is the most when we think of ovarian cancer, that’s where it is, and that’s the bucket it falls into all of the things. In each of these 3 buckets can either be benign or malignant.
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SMED 175 Podium: And then
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SMED 175 Podium: sex chord stromal are easy to test on, rare but easy to test on. And the reason they’re easy to test on is because granulosa cell makes estrogen, and that’ll produce symptoms. And it’s easy to test on that. And Sertole Ladig makes androgens, which also produces symptoms, making it a really easy multiple choice question, not because either of those are common, but because they’re easy questions.
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SMED 175 Podium: Germ cell that whole bucket. Also crazy. Easy to write a multiple choice question on because of the things that it makes right the Ldh.
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SMED 175 Podium: the asp. All that stuff.
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SMED 175 Podium: And then this is more of a description about what the 3 buckets are.
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SMED 175 Podium: So the 1st bucket, the surface epithelium.
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SMED 175 Podium: the serious epithelial malignancy from that example which I said is like what we think of when we think of for malignancy. These have these Somoma bodies. They might even show you a picture of these, any histology that looks like this. And it’s ovary Somoma bodies, serious, epithelial, ovarian cancer. Ca, 125. Those are the things you need to remember around that.
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SMED 175 Podium: You might be asked about mucinous or endometrioid. These are all a little bit less common. The thing to know about mucinous is, they can be really huge
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SMED 175 Podium: and large. And if someone, always the people in the news that are that are saying. I thought it was everyone. All my doctors thought it was pregnant, but it was really a 40 pound ovarian mass, that 40 pound ovarian mass is always mucinous like, just there’s no way that it’s not. If any other mass would have killed anybody by that point. But mucinous won’t. It’ll just sit and be this huge benign growth, although if it bursts it can cause crazy scar tissue.
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SMED 175 Podium: And then the second thing sex chord stroma. Here’s another another picture you might see, and these are the call external bodies here.
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SMED 175 Podium: and because this makes estrogen. If we see this on someone premenopausal, it could cause precocious puberty, puberty or postmenopausal. We’ll see postmenopausal, vaginal bleeding, maybe even endometrial hyperplasia or cancer because remember the estrogen enhances the endometrium and the more endometrium that’s there and sits around. Then it starts to do naughty things like, have DNA changes and produce precancers and cancers that don’t go away unless we use Progesterone to wash it away.
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SMED 175 Podium: Because there’s too much estrogen here. That’s why we also see a concurrent often enemy, or we have to at least evaluate for a concurrent endometrial cancer.
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SMED 175 Podium: and then certainly late produces androgens at a pretty high level. So people in that, like scenario on a multiple choice test are going to be very virilized, like clitoral hypertrophy, male pattern baldness, a beard. It’s going to be a lot more dramatic. They’re going to try to get you to weigh between that and Pcos.
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SMED 175 Podium: But if someone has an ovarian mass and it’s pretty dramatic, I would go with Sertole light egg if it’s like some acne around their jaw, and they’re having some infertility and no ovarian mass. Then you want to think, Pcos.
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SMED 175 Podium: Once again. Pcos sounds like they have masses in their ovaries, but they don’t. They do not have masses in their ovaries. They’re supposed to have follicles that are 2 to 3 cm cysts that burst every month. But they don’t. And that’s actually the problem of Pcos, also a big misnomer. Yeah, have I answered your question yet?
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SMED 175 Podium: I was just gonna ask about with the benign follicular cysts is there like hormonal changes that we need to know about? Or is it more of like a clinical diagnosis that will be described to us in a question.
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SMED 175 Podium: Yeah.
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SMED 175 Podium: my! My bet would be more on just the non-hormonal changes that you’re just going to see a benign and benign cyst. It’s you know. Someone had last had their period
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SMED 175 Podium: 15 days ago, and now they’re coming in. And you see this cyst on ultrasound. That would be my guess. Yeah.
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SMED 175 Podium: Yeah. Other questions. Yeah. I will say, fibromas are pretty benign. You won’t.
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SMED 175 Podium: yeah, with the fibromas. It’s it’s more rare. They’re benign. And the other big difference is age. So fibromas we typically see in younger ages. So we’re like usually epithelial, serous ovarian cancer is like age 50 to 60, and then you’ll have this like 34 year old, with that looks like she has that we hardly ever see young folks with that
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SMED 175 Podium: that’s at least my clinical tip off. Yeah.
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SMED 175 Podium: when it comes to like a Krukenberg tumor that spreads does that fall into one of the 3 buckets? It doesn’t. That’s a good question. So Krukenberg tumor just has a refresher is a gi tumor that metastasizes to the ovaries, and it’s going to look like the gi tumor that it came from, but it might be it could be seen on the ovaries first.st But yeah, the ovary is a metastasis point.
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SMED 175 Podium: Yeah? Great question.
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SMED 175 Podium: and then our last bucket are the germ cells. Once again, in all the buckets there’s benign and malignant things, the most common benign tumor, not mass right. The most common mass was the follicular cyst, but the most common benign
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SMED 175 Podium: tumor or neoplasm is a thing that has so many names, and I don’t know what Usmle is going to end up using, or they might use many of these different names. So just know all the names which is a benign cystic teratoma, also known as a dermoid or a dermoid cyst, or a mature cystic. Teratoma.
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SMED 175 Podium: Immature means cancer. Mature means benign when it comes to teratomas. These are the memorable masses that have hair and teeth and brain tissue within them, and sometimes intestine and all sorts of fun.
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SMED 175 Podium: Gooby things.
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SMED 175 Podium: The reason that test question. Writers love germ cells. They are really common in really young people is because of this table. This table is going to keep coming back. I think this table is really similar to a lot of the testicular malignancies. You at least have that similarity going for you, but it is really important to know which ones are going to make Afp. Which ones aren’t, which ones are going to make? Ldh. And Beta, Hcg.
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SMED 175 Podium: All right, let’s do another question.
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SMED 175 Podium: 44 year old, with a 12 week size uterus, heavy bleeding, pelvic pressure. This is what the histology looks like underneath the microscope of the uterus. What is this?
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SMED 175 Podium: Yeah, so that is a fibroid or a leiomyoma. So those were sheets of smooth muscle cells there.
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SMED 175 Podium: So this is taking us back to palm cohen palm Cohen is reminding us that abnormal uterine bleeding usually has a cause unless we can’t figure it out or we caused it. But in general the palms are the structural causes, polyp adenomyosis, myomyoma, and malignancy, and then the physiologic causes are the Cohen coagulopathy, ovulatory endometrial iatrogenic caused by us or not otherwise specified
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SMED 175 Podium: as a review.
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SMED 175 Podium: The A of the palm colon is adenomyosis. This is where endometrial tissue is inside the muscle of the uterus.
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SMED 175 Podium: and it’s not supposed to be there, so we call it ectopic.
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SMED 175 Podium: We can treat this with hormones, but usually the best cure is to not have a uterus in your body anymore.
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SMED 175 Podium: and a hysterectomy. Fibroids are not endometrial tissue, they are myometrial tissue. So more smooth muscle of the myometrium than normal, and these big whirls of cells that have a pseudocapsule, and these muscle fibers are really compressed within there
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SMED 175 Podium: and then endometriosis actually doesn’t usually change people’s menstrual bleeding at all other than the fact that it really hurts. They still have about the same amount of bleeding, and it’s still pretty regular. But what endometriosis does do? So that’s why it’s not in Palm Cohen. The physiology is that it is ectopic endometrial tissue. So it sounds like adenomyosis. But it’s outside of the uterus. So it’s in the pelvis.
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SMED 175 Podium: Okay.
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SMED 175 Podium: Last question, how many vaginas do? Kangaroos have?
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SMED 175 Podium: All right? Yes, they have 3.
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SMED 175 Podium: Alright. Let’s see how we’re doing.
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SMED 175 Podium: Did Ovie rise to the top?
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SMED 175 Podium: Oh, I did another 1. 0, what happened here? I’m sorry. Well, it looks like everyone.
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SMED 175 Podium: Very sorry.
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SMED 175 Podium: Yeah. So I have a ton of other questions, and we have about 17 min. So we can just do a ton more cahoot questions.
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SMED 175 Podium: Or we can take whatever questions you want to focus on, or things that came up on your exam yesterday that are still weird and worrisome, confusing. Yeah, could you talk about like the relationship between estrogen and like ovarian uterine cancers versus breast cancers, because I think that one was a little confusing. Yeah. So the question is, what about estrogen?
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SMED 175 Podium: And you said ovarian, uterine and breast cancer. What are the relationships there? Yeah, okay.
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SMED 175 Podium: see if I can figure out how to do that. I think I can
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SMED 175 Podium: figure that out.
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SMED 175 Podium: So, for example, there was a question yesterday with a patient that was a G. 10, p. 10. Yeah. And it was talking about like what? Out of everything in the vignette. What was her highest risk of like developing? I think it was either ovarian or breast disability? Yeah, and I think it was. I think it was trying to say like, Well, if she was, or her menopause time.
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SMED 175 Podium: hey, Natalie, isn’t there like a whiteboard or something that I can draw on that people will see, how do that? Is that in more?
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SMED 175 Podium: Okay, okay? So the question was, a patient was pregnant 10 or 11 times, yeah. And her medies was at like 1314, and menopause was at 50. You know, you think about estrogen levels. And you’re like, Okay, well, which is the risk factor. For like.
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SMED 175 Podium: I think it was. Oh, okay. So she got. And then she got endometrial cancer. And what increased her risk? Yeah, was it the multiparity age of menses, age of menopause, or just age overall.
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SMED 175 Podium: And it was weird because her age of menses was 12 and her age of menopause was normal. Yeah, I think it’s just that she’s old, right?
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SMED 175 Podium: Okay, I’m gonna pull this up just a minute.
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SMED 175 Podium: but not for breast. Yeah, because breast low estrogen means a higher increase of breast cancer. It’s just weird. Yeah. So then that’s why you get a serm. Yes, because estrogen is protective for breast cancer. But low estrogen is protective for
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SMED 175 Podium: okay? So it looks like, so someone’s saying there was a question yesterday about risk factors for endometristral cancer. So here it is. Here are the risk factors. Right?
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SMED 175 Podium: Older age is a risk factor. White race is a risk factor. Nulliparity is a risk factor. History of infertility.
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SMED 175 Podium: Type, 2 diabetes, tamoxifen use a really late age at menopause. Remember, average for white women in America is 51. Those that identify as black or African American. A couple years earlier. Early age of Menarche, average age is around 11 to 13. So it’d be before that. So the highest risk factor is unopposed. Estrogen, which it sounds like was not in this scenario.
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SMED 175 Podium: Okay, did you say agent privacy is sold
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SMED 175 Podium: like average age of Menarche is like 11 to 13 so earlier would be earlier than that. Yeah, I think she was 13, and then 50. Okay, so those seem kind of average. Then, I guess, for the purposes of this. Oh, what’s too early under the age of 40! 0, for sorry for oh, for Menarche! I would say 8 to be like an 8 to 18 to 11. Kind of age. Yeah.
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SMED 175 Podium: that would be my, just so I did not write that question. So I don’t know what they’re thinking. Okay, so the question is, why? Why is nulla parity an increased risk for endometrial cancer? Shouldn’t it decrease the risk of endometrial cancer?
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SMED 175 Podium: Yeah, okay, I’ll tell you what because what happens in pregnancy?
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SMED 175 Podium: Do we have menstrual cycles in pregnancy?
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SMED 175 Podium: No right. We have no menstrual cycles. We have a constant level of estrogen, but we’re not having estrogen fluctuations. The fluctuations are contributing to mitosis all that stuff like, you know, sloughing and shedding and all that stuff. And so no a parody people and people that have a lot of menstrual cycles. Right early age of Menarche, late age of menopause.
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SMED 175 Podium: The more menstrual cycles you have increases both your risk of breast cancer and endometrial cancer, because it’s the cycle of up and down that influences the risk.
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SMED 175 Podium: People who are pregnant don’t have those cycles as much issue, not the individual issue.
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SMED 175 Podium: You could think of it that way. Yeah, it’s it’s more that constant is better than fluctuating.
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SMED 175 Podium: We also see this with ovarian cancer, the same sort of things, right people. With this, this risk list looks very similar for ovarian cancer with ovarian cancer. We also see null parity, infertility, early age of late age of menopause. Same thing. The more cycles those ovaries are going through, the more times we’re ovulating. There’s more chances that DNA can get wrong and not be corrected right leading to cancer people who take, and then with ovary
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SMED 175 Podium: people who take
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SMED 175 Podium: estrogen and progesterone contraception that decreases ovulation. We also see a huge decrease in their risk of ovarian cancer, even if they’ve done that for only 5 years in their reproductive lifetime. Yeah. So those fluctuations also happen at the breast level, too. And so so that’s why we see these similar risk profiles for all 3 of these conditions.
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SMED 175 Podium: Yeah, does that address like, How do hormones work? And cancers?
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SMED 175 Podium: Okay, other questions. Yeah.
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SMED 175 Podium: Could you talk about the misnomer of Pcos? Yes, I could talk about this for days.
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SMED 175 Podium: I think it might even be in this presentation.
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SMED 175 Podium: Yeah.
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SMED 175 Podium: So people with Pcos do not have a menstrual cycle every 21 to 35 days
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SMED 175 Podium: do they have menstrual cycles less than 2021 days? Anyone want to raise their hand.
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SMED 175 Podium: or more than 35 days? It’s more than 35 days right. Their menstrual cycles are happening infrequently, sometimes irregularly, and the reason is because of the luteal phase we always menstruate 14 days after we ovulate people with those body parts. Right? So
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SMED 175 Podium: when people aren’t ovulating, so Pcos is an ovulation. Disorder and androgens interfere with ovulation, and people with Pcos have higher androgen levels.
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SMED 175 Podium: And for about half. And Pcos
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SMED 175 Podium: in the future, I believe, may be broken into multiple types. But right now we’re just calling everything Pcos. But about 50% of people with Pcos have obesity, and when they lose weight their Pcos resolves and goes away. And so at least for those 50% of people. We know that adipose tissue is an endocrine organ and increases estrogens and testosterones.
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SMED 175 Podium: But especially estrogens and and that’s what we see with Pcos.
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SMED 175 Podium: Like I said, there is this, only half of people have it associated with obesity, but we know that that plays a role for the majority of people in that group, and the way that we diagnose it is not necessarily even looking at the ovary, even though it has ovary and cysts in the name. We don’t see a huge 2 to 3 cm cyst. We see these teeny, tiny little baby cysts on the outside. Here.
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SMED 175 Podium: Anyone, an ovulatory person is just going to have one huge cyst
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SMED 175 Podium: of one big size, and like 8 cysts with all different sizes nearby. But these are pretty uniform. This isn’t the best picture, but these are pretty uniform all the way around, and they’re all on the outside. None of these cysts are entering that competition where every month 20 to 100 eggs get in a competition of who can make the most estrogen and get the biggest. And whoever does that gets to win and gets to be the cyst that releases its egg. The others all
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SMED 175 Podium: don’t get to enter any more competitions. They’re done for the rest of their lives. People with Pcos just have these sitting around. But we don’t actually need even need the ultrasound to see that to know that we
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SMED 175 Podium: in general just diagnose folks based on their periods are more than 35 days apart and on blood work. Their testosterone is high.
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SMED 175 Podium: So that is the misnomer of Pcos, yeah, do you ever see like multiple cysts like that at 20, plus on an ovary? And like other conditions?
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SMED 175 Podium: Yeah, I mean, there’s some really impressive Pcos overs that I’ve seen
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SMED 175 Podium: I mean anything that causes the inovulation can do that right. So if you have somebody with prolactin elevation, prolactinemia or a thyroid issue.
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SMED 175 Podium: You may also, yeah, see the same thing, because you’ll also have no ovulation. So you’ll just see ovarian follicles that are not in that competition that they’re just really small and uniform and just kind of sitting on the on the edges and not really entering into the game. Yeah.
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SMED 175 Podium: other topics. Yeah. So there was a question yesterday that was talking about if you use like a cyclin dependent kinase kind of treatment for the breast cancer, I think it was estrogen positive, but her 2 negative and progesterone negative, and it said, What
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SMED 175 Podium: There has to be something for that treatment to not work. And I think it was like
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SMED 175 Podium: this one was like, super highly specific. For like,
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SMED 175 Podium: there were like a bunch of numbers and letters in it. Yes, yeah. So it was like a cyclin dependent kinase, like inhibitor or something, is the treatment for this breast cancer. But what about the breast? Cancer would make it. So that treatment is.
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SMED 175 Podium: it’s not gonna work. I remember that.
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SMED 175 Podium: Don’t remember what the answer was like. Didn’t know. Yeah.
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SMED 175 Podium: So briefly, I can. You know we can go over breast cancer treatments. I don’t know if it’ll answer that exact question.
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SMED 175 Podium: but I’m happy to share
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SMED 175 Podium: breast masses. Yeah, let’s do some breast stuff I was in between, all right, so I’ll give you the whole lecture again. But breast masses
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SMED 175 Podium: really are on this spectrum right? I mean, it’s kind of like the 3 buckets that I think of for ovarian masses. It’s
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SMED 175 Podium: but in those 3 instead. But in those 3 buckets there’s benign and malignant of each type. Here we have, we do have some of that where we see the neoplasm could be in the duct or the lobule, and that could either be non-invasive or invasive, malignant. But in general our benign masses don’t usually become malignant. If that makes sense or don’t have very many malignant counterpoints so it’s really 3
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SMED 175 Podium: the non-invasives can become malignant. So that’s kind of a
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SMED 175 Podium: it’s hard to sort of think about what things are trying to think about the names of the masses and how to do that.
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SMED 175 Podium: So when we think about breast cancer, the non-invasive and the invasive types, we need to. For sure. Think of ductal lobular as well as for sure inflammatory. That’s like such an easy test question and Paget disease. Both of these show up quite a bit.
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SMED 175 Podium: And so I’d make sure. You know, those are there specific things within the masses like distinguishing between the subtypes like ductal and lobular. That’s important. Yeah. So ductal, we see these fill the duct of the breast. And this is the most common subtype
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SMED 175 Podium: that we see with breast cancer.
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SMED 175 Podium: and then lobular things that are really easy to ask about lobular are the loss L. And L. Right. The loss of the e-calhedron expression which they might make a note of either in the stem or could be an answer choice. And
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SMED 175 Podium: let’s see and then potentially talk about how they’re associated with Erpr or her 2. So it sounds like in this test question, they also talked about that
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SMED 175 Podium: think this is rather than is that why it’s okay
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SMED 175 Podium: that’s a good question. So the question is, since our lobular is harder to feel than ductal, just based on the Pathophysiology. I believe that’s so, but I would double check that.
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SMED 175 Podium: and our new Dean of curriculum would definitely know, because she was a breast surgeon for over for 30 or 40 years, and so
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SMED 175 Podium: inflammatory, they’re going to give you a stem about a red hot breast that hasn’t responded to antibiotics. It’s inflammatory breast cancer until proven otherwise.
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SMED 175 Podium: And then pageants. It’s gonna usually be a nipple rash
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SMED 175 Podium: and you need to think cancer with a nipple rash.
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SMED 175 Podium: And then, in terms of the subtypes, the subtypes are important because this affects treatment, and because we can treat, we can use her. We can use Tuzumab to treat her 2 positive breast cancers.
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SMED 175 Podium: and then for Erpr, positive breast cancers. We want to block estrogen and progesterone. So we would never give those people
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SMED 175 Podium: estrogen and progesterone hormone replacement right? If they had an erp or positive breast cancer in the past. We would never we would, if they still have ovaries, and they’re ovulating. We would
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SMED 175 Podium: either give them enough chemotherapy to kill their ovaries, or we would like remove their ovaries because the ovaries are making estrogen and progesterone.
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SMED 175 Podium: Can you explain the birth? One and 2 mutations? Not very well. No, I don’t. I don’t know. I don’t know what’s on Step one exactly, but that hasn’t been a very high yield thing in the past. Yeah, it’s pretty. That’s pretty minutia. Yep.
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SMED 175 Podium: just put it up there in case you want to know more about that. Yeah.
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SMED 175 Podium: Oh, yeah. Is there another question that I missed.
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SMED 175 Podium: Oh, yeah, okay.
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SMED 175 Podium: So for the, do, you have to have event for those to happen?
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SMED 175 Podium: Good question. So, yeah, like, how
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SMED 175 Podium: how do moles happen? Does there have to be fertilization.
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SMED 175 Podium: Yes, so it’s either a sperm with an empty egg or 2 sperms with an empty egg or
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SMED 175 Podium: and not empty egg. And yeah, but there are sperms and eggs involved. Whether or not they have, how much genetic material each has determines, what type of pregnancy they’ll become
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SMED 175 Podium: personal after any type of privacy. Correct? Okay?
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SMED 175 Podium: So most choriocarcinomas are most common to happen after a molar pregnancy.
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SMED 175 Podium: but can happen after a normal, healthy, genetically normal pregnancy as well, or a miscarriage of a genetically normal or a spontaneous abortion. Yeah, you’ll see their uterus looks like it’s filled with cancer.
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SMED 175 Podium: Yes.
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SMED 175 Podium: yep, alright. That’s time. If you have other questions, stop by you can talk to me, or you can email me or.
- This page was last updated on March 26, 2025.