G ATP Session for FMG Students

Introduction

• Welcome to the G ATP session for FMG students.
• NEET PG students can also benefit from this session.
• Check internet connection if buffering issues occur.

Gynecology (Gy) Section

• PDFs: Blank PDFs available on the TRI S and CTG Telegram groups.
  • Annotated PDFs will be uploaded after the session.
• Important Topics: Men's hormonal cycle and menstrual cycle are crucial for FMG exams.

Menstrual Cycle and Hormones

• Oogenesis: Begins in intrauterine life; spermatogenesis begins at puberty.
• Fertilizable Span of Ova: 12-24 hours (preferably 24 hours).
• Mature Follicle Size: 18-20 mm, also known as Graafian follicles.
• Follicle Development: Begins as primary oocyte surrounded by follicular cells, which differentiate into granulosa and theca cells.
• Maximum Follicles: At 20 weeks (5th month) of intrauterine life: 6-7 million.
  • Birth: 1-2 million follicles.
  • Puberty: 4-5 lakh follicles.
  • Menopause: No more follicles.
• Ovulation: Transformation of primary oocyte into secondary oocyte and follicle into corpus luteum due to LH surge, triggered by estrogen.

Important Timings

• LH Surge to Ovulation: 32-36 hours (best), 24-36 hours (secondary).
• LH Peak to Ovulation: 10-12 hours.
• Estrogen Peak to LH Peak: 14-24 hours.
• Day of Ovulation Calculation: 14 days prior to the next menstruation.
  • E.g., 40-day cycle -> ovulation on day 26.
• Signs of Ovulation: LH surge, corpus luteum formation, hormone levels.
• Corpus Luteum: Maintained by LH in non-pregnant females and HCG in pregnant females.
  • Maximum size/activity on Day 22 of the cycle.

Tests for Ovulation

• Indirect Evidence: Regular Cycles, Mid-cycle Pain, Dysmenorrhea.
• Direct Tests: Basal body temperature, cervical mucus study, vaginal epithelial study, endometrial biopsy, serum progesterone levels.
• Ovulation Prediction Tests: Urinary LH surge, follicular monitoring.

Anovulation and Treatment

• Most Easily Treatable Infertility: Anovulation.
• Drugs: Clomiphene Citrate (first-line), Letrozole (for PCOS-related anovulation).

Premature Menopause

• Primary Ovarian Insufficiency (POI): Menopause before age 40.
• Tests for Ovarian Reserve: Day 2 or 3 levels of inhibin, FSH, antral follicle count, anti-mullerian hormone (AMH).
  • AMH is the best test; normal range is 1-3.
• Management: IVF with donor eggs.

Dysmenorrhea

• Primary Dysmenorrhea: Due to PGF2 alpha, seen in young girls from menarche, treated with NSAIDs, OCPs.
• Secondary Dysmenorrhea: Associated with pelvic pathology, often endometriosis, treated by addressing the underlying cause.

Puberty

• Normal Age of Puberty: Girls – 10.5 years, Boys – 11.5 years.
• Precocious Puberty: Puberty before age 8 in girls, before age 10 in boys.
  • Most common cause is idiopathic; some cases due to brain tumors.
  • Drug of choice: Continuous GnRH.
  • McCune-Albright Syndrome: Precocious puberty, café-au-lait spots, polyostotic fibrous dysplasias.
• Delayed Puberty: No puberty by age 13 in girls or by age 14 in boys.
  • Most common cause: Constitutional delay.
  • Drug of choice: Pulsatile GnRH.
• Puberty Sequence in Girls: Growth spurt, thelarche (breast budding), pubarche (pubic hair), peak height velocity, menarche.
• Puberty Sequence in Boys: First sign is testicular enlargement.

Primary Amenorrhea

• Definitions: No menarche by age 15 with secondary sexual characteristics, or by age 13 without them.
• Approach: Based on uterus presence.
  • Uterus Present: Cyclical pain (cryptomenorrhea), uterus palpable or tensed (imperforate hymen), transverse vaginal septum.
  • Absent Breast, Normal FSH/LH: Androgen insensitivity syndrome (breast well-developed, uterus absent, 46XY) or Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome (normal LH/FSH, normal pubic hair/breast, uterus absent, 46XX).
  • Delayed Puberty: Normal height (Kallmann syndrome – anosmia, GnRH deficiency), Tall stature (Swyer syndrome – 46XY, streak gonads).
  • Turner Syndrome: 45X0, streak ovaries, webbed neck, low posterior hairline.
  • Sweyer Syndrome: 46XY, bilateral inguinal hernia, normal stature.

Secondary Amenorrhea

• Most Common Cause: Pregnancy.
• Other Causes: Premature menopause (primary ovarian failure), PCOS, prolactinoma, Sheehan's syndrome, Asherman's syndrome.
  • Pregnancy: Positive UP test, high estrogen/progesterone, low LH/FSH.
  • Premature Menopause: High FSH/LH, low estrogen/progesterone, negative UP test.
  • PCOS: High LH, normal FSH, low progesterone, signs of hyperandrogenism (hirsutism, acne).
  • Prolactinoma: Low FSH/LH, high prolactin, MRI shows pituitary tumor, symptoms include galactorrhea, headaches, visual problems.
  • Sheehan’s Syndrome: Postpartum pituitary necrosis, low FSH/LH, inability to lactate, MRI shows empty sella turcica.
  • Asherman’s Syndrome: Intrauterine adhesions, normal FSH/LH/estrogen, history of curettage, negative estrogen-progesterone challenge test.

Ambiguous Genitalia

• Female Ambiguous Genitalia: Congenital adrenal hyperplasia (most common: 21-alpha hydroxylase deficiency).
• Male Ambiguous Genitalia: Partial androgen insensitivity syndrome.

Miscellaneous

• More Homologous Structures: Different organs develop from the same embryological origin (e.g., genital tubercle forms penis in males, clitoris in females).
• Bartholin Cyst Management: Asymptomatic (<3cm) - conservative, symptomatic - incision and drainage, recurrent - marsupialization.
• Most Common Method for Sex Determination: Karyotyping.
• Bar Bodies: Number of X chromosomes minus 1 (e.g., 46XX female - 1 bar body).

Conclusion

• Before moving on to the next session, ensure thorough understanding of these concepts.