Reproductive Module - Phase I

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Faculty of Medical Sciences University of Sri Jayewardenepura

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Introduction

The reproductive system is a unique system in three aspects.

1. The reproductive system is specialized to perpetuate the species and transfer genetic material from generation to generation whereas the functions of the other systems are to sustain the individual.

2. The structure and the functions of the reproductive organs differ significantly in males and females.

3. The reproductive system is not functional at birth but matures only at a certain period in life in contrast to the other systems which are functional at birth or shortly thereafter.

The sexual reproduction requires the production of two types of gametes, the species has a male and female forms, each with its own unique reproductive system. The functions of the female reproductive system are more complex than the functions of the male reproductive system. The functions of male reproductive system are to produce the male gametes, spermatozoa and to transfer them to the female through the process of coitus (sexual intercourse).

The female produces her own gametes called ova and her reproductive organs are specialized to receive male gametes provide a site for fertilization, development of the embryo and fetus and delivery of a baby.

The reproductive system of the female also provides means of nourishing the baby through the secretion of the mammary glands in the breast. This is a very exciting module where you would learn not only about your own sex but about the opposite sex which will be important to you in future.

In order to facilitate you learn the reproductive system case scenarios are given based on problems you are likely to encounter as a medical student.

During this module a wide variety of teaching/learning methods will be used i.e. lectures, small group discussions, tutorials, audiovisual presentations, practicals,

14/09/2017 Version 3.0 cadaver dissections, prosected specimens, models, IT laboratory based activities, language, communication skills and laboratory based activities.

Good luck and all the best for you and hope you would enjoy this module!

Module committee Dr. W.A.N.Y. Silva (Chairperson, Department of Physiology) Dr. Varuni Tennakoon (Convener , Department of Anatomy) Prof. S. G. Yasawardene (Department of Anatomy) Prof. D. M. S. Fernando (Department of Physiology) Prof. S. Suresh (Department of Biochemistry) Dr. Sajith Edirisinghe (Department of Anatomy) Dr. K. A. Athukorala (Department of Physiology) Dr. P.P.R. Perera (Department of Biochemistry)

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General Objectives

At the end of the respiratory module, the student should be able to: 1. describe the normal structure, function and regulation of the female and male reproductive systems, the process of fertilization, pregnancy, partus, puerperium and lactation by learning and applying the basic sciences.

2. apply the above knowledge to a few common clinical situations (subfertility, labour) to explain how the anatomy physiology and biochemistry are altered in the given situations.

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Main content areas

Main content area Lectures Practical/Dissections Tutorials/SGD (Hours) No. of (3hrs) No. of (2hrs) sessions sessions 06,01 - - 1. Sexual differentiation and development of the female and male reproductive systems (Anatomy, Physiology)

- 01 - 2.External genitalia (Anatomy)

02 - 01 3.Puberty (Physiology)

01 01(1hr session) 01 4.Breast (Anatomy)

5.Pelvis and Perineum (Anatomy) 03 03 01 03,00 01,02 6.Female reproductive system (Anatomy, Physiology) 01,03

03,02 04,01 01,01 7. Male reproductive system (Anatomy, Physiology)

05 01 01 8. Fertilization, pregnancy, partus, pueperium and lactation (Physiology)

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Real life situations

1. Sexual differentiation and parturition

2. Puberty

3. Sub fertility

4. Menopause

5. Prostate Cancer

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Reproductive Module - Phase I

A-Essential to know B- Good to know C- Nice to know

1. Sexual differentiation and development of the female and male reproductive systems

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the process of sexual differentiation  Define genetic male and genetic Lecture 1hr Physiology female (A)

 Sex chromosomal abnormalities (A)

 The process and the regulation of development of internal genitalia (A)

 Cells that secrete testosterone, MIS,

and explain how they regulate the

development of internal genitalia (A)

 Development of internal genitalia(A)

 Abnormalities of sexual

differentiation. (A)

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1. Sexual differentiation and development of the female and male reproductive systems (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the development of female and male  Embryology- external and internal Lecture 2hrs Anatomy reproductive systems. genitalia (A)

 Explain the embryological basis for Lecture 2hrs Anatomy the following common congenital anomalies (A) - Hypospadias, epispadias, bicornuate uterus, atresia of the genital organs

 Describe the development of placenta  Implantation(A) Lecture 2hrs Anatomy

 Decidua(A)

 Formation of chorionic villi(A)

 Placental membranes(A)

 Anomalies of placenta(A)

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2. External genitalia

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe female and male external genitalia and  Penis – root(crura and bulb), Dissection/ 3hrs Anatomy outline the blood supply and the lymph drainage body(corpus cavernosum and Demonstrations spongiosum), glans, prepuce (A)

 Scrotum (A)

 Vulva- labia majora and minora,vestibule of vagina, openings of urethra vagina & vestibular glands, clitoris (A)

 Nerve supply- illioinguinal nerve, pudendal nerve, posterior femoral cutaneous nerve (A)

 Arterial supply (A)

 Venous drainage (A)

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3. Puberty

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the physiology of puberty  Define puberty and adolescence (A) Lecture 1hr Physiology

 Male and female secondary sexual characteristics (A)

 Describe the other physiological changes that occur during puberty Lecture 1 hr Physiology (A)

 Define thelarche, adrenarche, pubarche and menarche (A) SGD 2hrs Physiology

 Factors that affect menarche (A)

 Explain the mechanisms that control the onset of puberty (A)

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4. Breast

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the macroscopic and microscopic  Situation, extent, deep relations, Lecture 1hr Anatomy structure of the breast structure of the breast, blood supply and the lymphatic drainage (A) Dissection/ 1 hr Anatomy Demonstrations

Tutorial 2 hrs Anatomy

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5. Pelvis and perineum

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the structures which form the pelvic walls  Anterior pelvic wall,(A) Lecture 1hr Anatomy the floor and the general arrangement of pelvic  Posterior pelvic wall,(A) viscera.  Lateral pelvic wall (A)

 Describe the general arrangement of the perineum.  Urogenital diaphragm - superficial Lecture 1 hr Anatomy perineal pouch, superficial perineal muscles, root of penis and bulb of Dissection/ urethra, bulb of vestibular glands, Demonstrations 3hrs Anatomy deep perineal pouch, apex of ischio rectal fossa (A) Tutorial 2 hrs Anatomy

 Describe the blood supply to the pelvis and  Branches of the internal iliac artery, perineum structures supplied and describe the Lecture 1 hr Anatomy course of each branch. (A) - Posterior division- iliolumbar Dissection/ 3 hrs Anatomy artery, lateral sacral arteries and Demonstrations superior gluteal artery - Anterior division- obturator artery, internal pudendal artery, visceral branches- superior vesical, inferior vesical, uterine, vaginal and middle rectal artery.

 Venous plexuses in the pelvis and their communications. (A)

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5. Pelvis and perineum (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the main nerve plexus in the pelvis,  Lumbar plexus - obturator nerve, Dissection/ 3hrs Anatomy course and the structures supplied lumbosacral trunk (A) Demonstrations

 Sacral plexus - nerve to the obturator internus and quadrates femoris, nerve to the piriformis, perforating branches of S2 and S3, posterior femoral cutaneous, superior and inferior gluteal nerves, sciatic nerve and the pudendal nerves(A)

 The origin course, distribution and functions of the autonomic nerves to the pelvis - sympathetic trunk, superior hypogastric plexus/presacral nerve, inferior hypogastric plexus(A)

 Pelvic splanchnic nerves para- sympathetic fibres from S2,3,4(A)

 Recall the knowledge on the anal triangle  Boundaries, anus, external anal sphincter, ischiorectal fossa, Recall Anatomy pudendal canal(with nerve and vessels) (A)

 Recall the knowledge on attachments of the  Obturatorinternus, piriformis, following muscles levatorani, coccygeus (A) Recall Anatomy

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6. Female Reproductive system

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the structure, relations, function and  Introduction to the female Lecture 1hr Anatomy regulation of female reproductive system reproductive system (A)

 Describe the uterus with its relations to the  Parts - fundus, body, isthmus and surrounding structures cervix (A) Tutorial 1 hr Anatomy  Cavity of the uterus - triangular, internal and external os(A) AVP 1 hr Anatomy  Peritoneal relations (A) Dissection ½ hr Anatomy  Broad ligament - anteverted and anteflexed, uterine tube lies in its Demonstrations ½ hr Anatomy free border.(A) - Parts- infundibulopelvic or suspensory ligament, mesosalphinx and mesovarium - Contents- ligament of the ovary, round ligament, vestigeal structures

 Uterovesical reflection (A)  Anteversion, anteflexion (A)

 Supports -transverse cervical ligament, uterosacral ligaments, round ligament of the uterus, broad ligament, anteversion and anteflexion.(A)  Basis for uterine prolapsed (A) 15

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6. Female Reproductive system (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the blood supply and the lymphatic  Arteries - course and branches of the Dissection/ ½ hr Anatomy drainage of the uterus. Uterine artery (A) Demonstrations

 Veins - uterine vein forms a wide Prosected ½ hr Anatomy plexus across the pelvic wall and Specimens communicates with the rectal and vesical plexus (A)

 Lymph - Upper part of the body and the fundus - paraaortic nodes, external illiac nodes, superficial inguinal nodes (A) - Lower part of the uterus external iliac nodes (A)

 Cervix - external, internal iliac and sacral nodes (A)

 Clinical significance - lymphatic spread in cervical and endometrial carcinoma (A)

 Describe the structure of the uterine tube.  Different parts of the uterine tube Dissection 1 hr Anatomy (A) (interstitial part, ampulla, isthmus and the infundibulum) and Demonstrations 1 hr Anatomy their microscopic differences (B).

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6. Female Reproductive system (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the relations, blood supply and the  Mesovarium, pelvic wall(internal Dissection 3 hrs Anatomy lymphatic drainage of the ovary. and external iliac vessels, ureter, obturator nerve) and fimbria of the uterine tube (A)

 Ovarian artery and its course (A)  Ovarian vein forming plexus (A)

 Lymphatic drainage to the paraaortic nodes (A)

 Describe the structure, blood supply and the  Fornices- anterior, posterior and lymphatic drainage of the vagina. lateral (A)

 Related structures (A) - Pouch of Douglas - Base of the bladder - Ureters

 Supports of vagina, mechanisms and Dissection 1 hr Anatomy effects of cystocoele, urethrocoele,

rectocoele, enterocoele(A) Demonstrations 1 hr Anatomy

 Arterial supply (A)  Venous drainage (A)

 Structures palpated in a vaginal examination (A) 17

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6. Female Reproductive system (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the histology of the female reproductive  Histology of the ovary, uterine tube, Dissection 3 hrs Anatomy system uterus, cervix and vagina (A)

 Describe the functions and the regulation of the  Changes that occur in the Lecture 2 hrs Physiology female reproductive system endometrium , cervical mucus, vagina, during menstrual cycle (A)

 Menstruation (A) SGD 2 hrs Physiology

 The length of a menstrual cycle, and the phases (A)

 Cervical smear test (A)

 The changes in the ovary during a normal menstrual cycle and its regulation by hypothalamic and pituitary hormones (A)

 Functions of the ovary (A)

 Hormones that are produced in the ovary (A)

 Synthesis, regulation and transport of oestrogen and progesterone (A)

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6. Female Reproductive system (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the functions and the regulation of the  Changes that occur in the female reproductive system(continuation) endometrium, cervical mucus, vagina, breasts and basal body temperature during menstrual cycle and the physiological basis of these changes (A)

 The pattern of secretion of GnRH, LH, FSH, oestrogen and progesterone in a normal menstrual cycle with no conception (A).

 Menopause and climacteric (A). Lecture 1 hr Physiology

 Changes in reproductive hormones, reproductive organs and other systems in the body during and after menopause (A).

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7. Male Reproductive system

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the structure, functions of the male Lecture 1hr Anatomy reproductive system and its regulation AVP 1 hr Anatomy Tutorial 2 hrs Anatomy  Describe the course of the ductus deferens from its  Course and the contents of the commencement to the formation of the ejaculatory Spermatic cord (A) Dissections 2 hrs Anatomy duct.  Name the anatomical relations of the seminal  Anterior - base of the bladder (B) Dissections 15 min Anatomy vesicles.  Posterior - rectovesical fascia (B)  Superior - rectovesical pouch (B) Demonstrations 15 min Anatomy  Medial - ampulla of the ductus deference (B)

 Describe the structure and relations of the prostate  Capsule - true and false capsules (A) Dissections 1 hr& 15 Anatomy min gland.  Different lobes of the prostate (A) Demonstrations  Central and peripheral arrangement 1 hr& 15 Anatomy of glands in the lobes and its clinical min significance. central zone- BPH,

peripheral zone - carcinoma (A)

 Relations – base - neck of the bladder, apex- membranous urethra, anterior- retropubic space and puboprostatic ligaments, inferolateral - levatorani, posterior - rectovesical fascia(A)

 Basis of different surgical approaches - transurethral, transvesicle and retropubic(A) 20

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7. Male Reproductive system (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the blood supply of the prostate gland,  Venous plexus - between the true Dissections ½ hr Anatomy arrangement of the venous plexus, the lymphatic and the false capsules, then it drains drainage and its clinical significance in prostatic to the vesicoprostatic plexus and Demonstrations ½ hr Anatomy carcinoma. flows back-wards in to the internal iliac vein (A)  Lymphatic drainage - internal iliac nodes (A)  Spread of prostatic carcinoma (A)

 Describe the microscopic structure of the ductus  Functions of ductus deferens, Lecture ½ hr Anatomy deferens, seminal vesicle and the prostate. seminal vesicle and the prostate (A)  Functional adaptations (A) Practical 1½ hrs Anatomy

 Describe the structure of the testis including its  Tunica vaginalis, tunica albuginea, coverings. tunica vasculosa, septula testis, Dissections 1 hr Anatomy seminiferous tubules, mediastinum testis, rete testis (A) Demonstrations ½ hr Anatomy

 Coverings of the testis - skin, dartos

muscle, superficial perineal fascia,

external spermatic fascia,

cremasteric fascia, internal spermatic fascia,tunicavaginalis, albuginea and vasculosa(A)  Different types of hydrocoeles and the layers cut during a hydrocoelectomy (A)

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7. Male Reproductive system (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe briefly on the blood supply, lymphatic  Testicular arteries - origin from the Dissections 1 hr Anatomy drainage and nerve supply to the testis. aorta (A)  Mechanism and effects of the torsion Demonstrations ½ hr Anatomy of the testis.(A)

 Testicular veins - right to the IVC and left to the renal vein (A)  Varicoele and its clinical significance when it occurs on the left side.(A)

 Nerve supply (A)

 Lymph drainage of the testis and scrotum - clinical relevance in different surgical approaches (A)

 Surgical approaches - transinguinal

and transscrotal(A)

 Describe the microscopic structure of the testis.  Histology of the testis (A) Lecture ½ hr Anatomy

Practical 1½ hrs Anatomy

 Describe the descent of the testis  Embryology – gubernaculum (A) Lecture 1 hr Anatomy  Mechanism and clinical significance of undescended testis and the ectopic testis (A) 22

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7. Male Reproductive system (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the functions and the regulation of the  Cross section of the testis indicating Lecture 2hrs Physiology male reproductive system. the functionally important cells (A)

 The functions of the testis (A) SGD 2 hrs Anatomy

 Spermiogenesis and spermatogenesis (A)

 The changes that occur during passage of sperm through the epididymis (A)

 A labeled diagram of the components of a mature human spermatozoon and the functions of each component (A).

 The blood testis barrier and its functional importance (A).

 The functions of the sertoli and the leydig cells (A)

 The composition of seminal fluid and the characteristics of the normal semen (A)

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7. Male Reproductive system (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the functions and the regulation of the  The neuroendocrine regulation of male reproductive system (continuation) male reproductive function (A)

 The androgens produced in a male (A)

 The synthesis transport and metabolism of testosterone and dihydrotestosterone(A)

 The actions of above hormones (A)

 Seminal Fluid Analysis (SFA)  Constituents of the semen (A) Practical/ 3hrs Physiology demonstration  Principles of collection and analysis of semen(A)

 Interpretation of SFA(A)

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8. Fertilization, pregnancy, partus, puerperium and lactation

Intermediate Objectives Broad Content Areas Activity Duration Department

 Describe the process of fertilization, pregnancy,  Fertile period, capacitation and Lecture 3 hours Physiology/ partus, puerperium and lactation. acrosome reaction of the sperm, Anatomy fertilization process of the human  Fertilization sperm and ovum, formation of SGD 2 hours Physiology blastocyst, syncytiotrophoblast and cytotrophoblast, process of implantation(A)

 Pregnancy  Formation of the corpus luteum and its role in maintaining a pregnancy (A)

 The hormones that are important in maintaining a pregnancy up to term (A)

 The site of production, structure, function and the pattern of secretion of hCG, hPL, oestrogen and progesterone during a normal pregnancy (A)

 The physiological changes that occur in the body during pregnancy including breasts (A)

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8. Fertilization, pregnancy, partus, puerperium and lactation (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Pregnancy(continuation)  The signs and symptoms of pregnancy (A)

 The physiological basis of the pregnancy test (A)

 The functions of the placenta (A)

 The exchange of substances across the placenta (A)

 The composition of amniotic fluid and its functions (A)

 The foetal circulation (A)

 Labour and the factors responsible

for the onset of labour(A)

Lecture 1hr Physiology  Partus  The hormonal regulation of labour

and factors responsible for partus Slideshow/ 1 hr Physiology and its relation to the structure (A) Video

 Puerperium  Puerperium and the physiological changes that occur during puerperium(A)

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8. Fertilization, pregnancy, partus, puerperium and lactation (continuation)

Intermediate Objectives Broad Content Areas Activity Duration Department

 Lactation  The neuroendocrine regulation of Lecture 1 hr Physiology milk production and milk ejection(A)

 Physiological basis of lactational amenorrhoea(A)

 Pregnancy testing and hormonal assay Practical 3hrs Physiology (combined with SFA)

 Human sexuality Lecture 3 hrs PPD

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Real Life Situation-1

Subfertility

Topic: Subfertility

Scenario:

Your sister is married to a company executive for the last three years. Your mother appears anxious and she advises you to have a chat with your sister regarding commencing her family. You begin to think …………..

Questions in the students mind Objectives What are the possibilities?  Describe the structure of the female reproductive system.  Describe the structure of the male reproductive system.  Explain the changes in the uterine endometrium, ovary and cervical mucus during a normal menstrual cycle.  Describe the hormonal regulation of the menstrual cycle.  List the functions of the testis  Describe spermatogenesis and spermiogenesis

 Describe the hormonal regulation of the of the male reproductive system

 Explain the various methods of Are they using a contraceptive? contraception

How is a baby formed?  Describe the process of fertilization What advice can I give my sister?  Define the fertile period of a woman.

How can I reassure my mother?

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Real Life Situation-2

Puberty

Topic: Puberty

Scenario:

You receive a letter from your school principal inviting you for a discussion with the year 9 students on puberty and related issues. You begin to think on how to prepare for this session.

Questions in the students mind Objectives What is puberty?  Define puberty and adolescence

What changes occur in the male and  Describe the male and female female around puberty? secondary sexual characteristics  Describe the other physiological Why do they occur? changes that occur during puberty

What are the commonly encountered  List the common psychological and problems during this period? physical problems that occur during puberty What are the abnormalities?  Precocious puberty  Delayed puberty

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Real Life Situation 3

Parturition and Sexual differentiation

Topic: Parturition and Sexual differentiation

Scenario:

You overheard a conversation between two senior colleagues who have been in the labour room. They were discussing about labour, the incision that was made in the perineum by the nurse and the delivery of a baby. The patient had bled from the incision and one of their colleagues had to suture it after giving a local anesthetic. Their discussion continued on ambiguous genitalia as the sex of the new born could not be determined based on the external genitalia.

Questions in the students mind Objectives Where is the uterus in the pelvis?  Describe the structures which form the pelvic walls and the floor What are the surrounding structures?  Describe the general arrangement of pelvic viscera. What is labour?  Define labour  Explain the regulation of labour and factors How is it brought about? responsible for partus. Why is the incision made in the  Describe the general arrangement of the perineum? perineum.  List the structures cut during an episiotomy. What is it called?

What perineal structures would probably be cut during this procedure?

How is it sutured?

What are the blood vessels in this area?  Describe the blood supply of the pelvis and perineum

What are the nerves innervating this  Describe the main nerve plexuses in the pelvis area?  Describe the course of main nerves in the perineum and list the structures supplied by How can we block these nerves? them.

How is normal genitalia formed?  Describe the process of sexual differentiation  Describe the development of female internal What are ambiguous genitalia? and external genitalia.  Describe the development of male internal and external genitalia How does it defer?

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Real Life Situation 4

Menopause

Topic: Menopause

Scenario:

You accompanied your mother to see one of her friends in the hospital. She is 57 years old and was hospitalized following a fall and a fracture of the neck of the femur. The doctor has told her that menopause leads to osteoporosis and therefore has a higher risk of fracture. The doctor has also mentioned that she can have other problems like heart diseases, prolapse of the uterus….etc

Your mothers’ friend mentioned that she was advised to get some tests done once she recovers from the fracture. You remember them as lipid profile, E.C.G., Mammogram and a gynaecological examination including a cervical smear. Your mother has also reached menopause 5 years back so you become anxious and decide to read about it

Questions in the students mind Objectives What is menopause?  Define menopause and climacteric

What are the changes that occur in the  Describe the changes in reproductive body? hormones, reproductive organs, and other systems in the body during and after menopause. Why are women more prone to osteoporosis and fractures?

What is the relevance of the investigations that the doctor advised to get done?

What is prolapse of the uterus?  Describe the uterus with its relations to the surrounding structures  Describe the supports of the uterus What is a mammogram?  Describe the macroscopic and microscopic structure of the breast. Why is it done?

What is the normal structure of the breast?

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Real Life Situation 5

Prostate Cancer

Topic: Prostate Cancer

Scenario:

A 70 year old man who had Prostate cancer and a prostatectomy 2 years ago complained of pain in his back. Radiograph revealed a secondary deposit in his lumbar vertebrae.

Questions in the students mind Objectives Where is the prostate gland?  Describe the structure and the relations of the prostate gland. What are the important relations?

What is the structure of the prostate gland?  Describe the blood supply of the prostate gland, arrangement of the How can the cancer cells reach his back? venous plexus and the lymphatic drainage

 Describe the histology of the prostate What are the types of cells that can give gland rise to cancer?

 Explain the functions of the prostate Can a person live without the prostate gland gland?

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