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E n d o c r i n e a n d
R e p r o d u c t i v e
S y s t e m s
One Stop Doc
Titles in the series include:
Cardiovascular System Jonathan Aron
Editorial Advisor Jeremy Ward
Cell and Molecular Biology Desikan Rangarajan and David Shaw
Editorial Advisor Barbara Moreland
Gastrointestinal System Miruna Canagaratnam
Editorial Advisor Richard Naftalin
Musculoskeletal System Wayne Lam, Bassel Zebian and Rishi Aggarwal
Editorial Advisor Alistair Hunter
Nervous System Elliott Smock
Editorial Advisor Clive Coen
Metabolism and Nutrition Miruna Canagaratnam and David Shaw
Editorial Advisor Barbara Moreland and Richard Naftalin
Renal and Urinary System and Electrolyte Balance Panos Stamoulos and Spyros Bakalis
Editorial Advisor Richard Naftalin and Alistair Hunter
Respiratory System Jo Dartnell and Michelle Ramsay
Editorial Advisor John Rees
ONE STOP DOC
E n d o c r i n e a n d
R e p r o d u c t i v e
S y s t e m s
Caroline Jewels BSc (Hons)
Fifth year medical student, Guys, Kings and
St Thomas Medical School, London, UK
Alexandra Tillet BSc (Hons)
Fifth year medical student, Guys, Kings and
St Thomas Medical School, London, UK
Editorial Advisor: Stuart Milligan MA DPHIL
Professor of Reproductive Biology, Department of Physiology,
Guys, Kings and St Thomas School of Biomedical Sciences, Kings College, London, UK
Series Editor: Elliott Smock BSc (Hons)
Fifth year medical student, Guys, Kings and
St Thomas Medical School, London, UK
Hodder Arnold
A MEMBER OF THE HODDER HEADLINE GROUP
First published in Great Britain in 2005 by
Hodder Education, a member of the Hodder Headline Group,
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CONTENTS
PREFACE vi
ABBREVIATIONS vii
SECTION 1 ENDOCRINE SYSTEMS AND THE HYPOTHALAMICPITUITARY AXIS 1
SECTION 2 THYROID AND PARATHYROIDS 25
SECTION 3 ADRENALS AND PANCREAS 45
SECTION 4 DEVELOPMENT AND AGEING OF THE REPRODUCTIVE TRACTS 71
SECTION 5 CONCEPTION, PREGNANCY AND LABOUR 95
INDEX 113
PREFACE
From the Series Editor, Elliott Smock
Are you ready to face your looming exams? If you have
done loads of work, then congratulations; we hope
this opportunity to practice SAQs, EMQs, MCQs
and Problem-based Questions on every part of the
core curriculumwill help you consolidate what youve
learnt and improve your exam technique. If you dont
feel ready, dont panic the One Stop Doc series has
all the answers you need to catch up and pass.
There are only a limited number of questions an exam-
iner can throw at a beleaguered student and this text
can turn that to your advantage. By getting straight
into the heart of the core questions that come up year
after year and by giving you the model answers you
need this book will arm you with the knowledge to
succeed in your exams. Broken down into logical
sections, you can learn all the important facts you need
to pass without having to wade through tons of differ-
ent textbooks when you simply dont have the time. All
questions presented here are core; those of the highest
importance have been highlighted to allow even
shaper focus if time for revision is running out. In
addition, to allow you to organize your revision effi-
ciently, questions have been grouped by topic, with
answers supported by detailed integrated explanations.
On behalf of all the One Stop Doc authors I wish
you the very best of luck in your exams and hope
these books serve you well!
From the Authors, Caroline Jewels and Alexandra
Tillett
Writing a book during our final year was quite an
undertaking, but is has been hugely rewarding.
Getting through medical school exams is no easy
task. Hopefully, this book will provide you with a
good understanding of the basic concepts of
endocrinology and reproductive physiology that you
can use tirelessly in the future, impressing tutors and
clinicians alike. If not, then at least it may provide
you with the ability to sit (and pass!) pre-clinical
exams.
Chapters have been logically divided into key topics
that you WILL be tested on. We have provided
detailed explanations in a concise and structured
format that are invaluable for last minute revision.
During clinical years, it will be ideal for brushing up
on basic concepts.
We would like to thank Elliott Smock for allowing us
this opportunity. It would not have been possible
without the exceptional help and guidance from
Professor Milligan. Thank you to everyone who has
supported us you know who you are!
We wish you the very best for your exams and your
future careers!
ABBREVIATIONS
ACE angiotensin-converting enzyme
ACTH adrenocorticotrophic hormone
ADH antidiuretic hormone/vasopressin
AMH anti-mullerian hormone
ASD atrial septal defect
ATP adenosine triphosphate
BMI body mass index
BMR basal metabolic rate
CNS central nervous system
Ca
2+
calcium
cAMP cyclic adenosine monophosphate
CBG cortisol-binding globulin
CCK cholecystokinin
cGMP cyclic guanosine monophosphate
CMV cytomegalovirus
CNS central nervous system
COCP combined oral contraceptive pill
COMT catecholmethyltransferase
CRH corticotrophin-releasing hormone
DA dopamine
DHEA dehydroepiandrosterone
DIT diiodotyrosine
DM diabetes mellitus
DNA deoxyribonucleic acid
FSH follicle-stimulating hormone
GFR glomerular filtration rate
GH growth hormone
GHIH growth hormone-inhibiting hormone
GHRH growth hormone-releasing hormone
GI gastrointestinal
GIP gastric inhibitory peptide
GnRH gonadotrophin-releasing hormone
hCG human chorionic gonadotrophin
HDL high-density lipoprotein
HIV human immunodeficiency virus
hPL human placental lactogen
HR heart rate
HRT hormone replacement therapy
ICSI intracytoplasmic sperm injection
IGFs insulin-like growth factors
IgG immunoglobulin G
IgM immunoglobulin M
IUD intrauterine device
IVF in vitro fertilization
IVC inferior vena cava
K
+
potassium
LDL low-density lipoprotein
LH luteinizing hormone
MAO A +B monoamine oxidase A + B
MIT monoiodotyrosine
mRNA messenger ribonucleic acid
MS multiple sclerosis
MSH melanocyte-stimulating hormone
OGTT oral glucose tolerance test
OTC oxytocin
PDA patent ductus arteriosus
PIF prolactin-inhibiting factor
PMS premenstrual syndrome
POP progestogen-only pill
PPi inorganic pyrophosphate
PRL prolactin
PS pulmonary stenosis
PTU propylthiouracil
PTH parathyroid hormone
Rh rhesus
SHBG sex hormone-binding globulin
SIADH syndrome of inappropriate ADH
secretion
SRY sex-determining region on the Y
chromosome
SS somatostatin
SV stroke volume
T3 triiodothyronine
T4 thyroxine
TAG triglyceride
TBG thyroxine-binding globulin
ONE STOP DOC viii
TBPA thyroxine-binding pre-albumin
TRH thyrotrophim-releasing hormone
TSH thyroid-stimulating hormone
VDR vitamin D receptor
VMA vanilmandelic acid
VSD ventricular septal defect
ENDOCRINE SYSTEMS AND THE
HYPOTHALAMICPITUITARY AXIS
SECTION
1
ENDOCRINE SYSTEMS AND THEIR
IMPORTANCE IN DISEASE 2
BASIC PRINCIPLES OF CLINICAL
ENDOCRINOLOGY 4
MICROSTRUCTURE OF THE ENDOCRINE
SYSTEM 6
GASTROINTESTINAL HORMONES 8
HYPOTHALAMUS AND PITUITARY 10
ANTERIOR PITUITARY 12
PITUITARY HORMONES 14
POSTERIOR PITUITARY 16
GROWTH 18
CIRCADIAN RHYTHMS 20
ADIPOSE TISSUE 22
ENDOCRINE SYSTEMS AND THE
HYPOTHALAMICPITUITARY AXIS
SECTION
1
1. Is it true or false that hormones
a. Are always released from glands
b. Are secreted via ducts
c. Act via specific receptors
d. Are secreted into the bloodstream
e. Are always released in response to neural stimuli
2. Regarding hormones
a. The brain is an endocrine organ
b. The gastrointestinal tract is not an endocrine organ
c. The pancreas secretes glucagon
d. The thyroid gland secretes calcitonin
e. The posterior pituitary synthesizes antidiuretic hormone and oxytocin
3. Regarding the endocrine system
a. Endocrine dysfunction always results in hormone deficiency
b. Pituitary adenoma causes hypofunction of the pituitary gland
c. Primary endocrine dysfunction can occur at the level of the thyroid
d. An inability of the cells to produce hormone results in hyposecretion
e. Graves disease is an example of hyposecretion
4. Give three characteristics of a hormone
GI, gastrointestinal; T4, thyroxine
Endocrine systems and the hypothalamicpituitary axis 3
EXPLANATION: ENDOCRINE SYSTEMS AND THEIR IMPORTANCE IN DISEASE
A hormone is a chemical substance released from a ductless gland (or group of secretory cells) directly into
the bloodstream in response to a stimulus and exerts a specific regulatory effect on its target organ(s) via
receptors (4). The main endocrine organs of the body are as follows:
Organ Hormones secreted Abbreviation
Brain Hypothalamus Somatostatin SS
Corticotrophin-releasing hormone CRH
Growth hormone-releasing hormone GHRH
Gonadotrophin-releasing hormone GnRH
Thyrotrophin-releasing hormone TRH
Dopamine DA
Pituitary (anterior) Adrenocorticotrophic hormone ACTH
Growth hormone GH
Follicle-stimulating hormone FSH
Luteinizing hormone LH
Thyroid-stimulating hormone; Prolactin TSH; PRL
Pituitary (posterior) Antidiuretic hormone and oxytocin ADH
Thyroid Thyroxine T4
Calcitonin
GI tract Gastrin
Cholecystokinin CCK
Gastrointestinal peptide
Secretin
Pancreas Insulin; Glucagon; Somatostatin; Pancreatic
polypettide
Adrenals Cortisol; Aldosterone
Ovaries and testes Testosterone; Oestradiol; Progesterone
Endocrine dysfunction can occur at different levels, for example, at the level of hormone production and secre-
tion (e.g. failure to produce a hormone), or at the level of the target organ (e.g. failure to respond to a hormone
due to lack of receptors). It can be classified into hyper- and hyposecretion. Hypersecretion can be due to a
tumour that secretes excess hormone (e.g. pituitary adenoma) or due to an inappropriate stimulation (e.g.
in Graves disease antibodies stimulate the thyroid to produce excess T4). Hyposecretion can be due to the
inability of cells to produce hormone (e.g. in hypothyroidism there is a reduction in the amount of T4
secreted) or due to hypofunction of a gland (e.g. excess somatostatin release from the hypothalamus results
in a decrease in the amount of growth hormone released by the anterior pituitary).
Answers
1. F F T T F
2. T F T T F
3. F F T T F
4. See explanation
ONE STOP DOC 4
5. In clinical endocrinology
a. Measurement of steroid levels in saliva gives a reflection of plasma hormone levels
b. Measurement of steroid levels in urine gives a reflection of secretion over the previous
several hours
c. Bioassay is the measurement of the biological responses induced by a hormone
d. Immunoassays are both sensitive and specific
e. Immunoassays detect the level of hormone antigen in the plasma
6. Draw a diagram that illustrates the integration of the nervous and hormonal control
systems in the body
7. Briefly outline the concept of feedback control
Endocrine systems and the hypothalamicpituitary axis 5
EXPLANATION: BASIC PRINCIPLES OF CLINICAL ENDOCRINOLOGY
The endocrine system is controlled by positive and negative feedback. Positive feedback acts to stimulate
release of hormones; negative feedback acts to inhibit release of hormones (7).
The integration of nervous and hormonal control systems in the body is illustrated below (6).
Hormones are present in low concentrations in the circulation and bind to receptors in target cells with high
affinity and specificity.
Hormone levels in urine and plasma samples can be estimated using:
Bioassays measurement of biological responses induced by the hormone
Immunoassays measurement of the amount of hormone present by using antibodies that are raised to
bind to specific antigenic sites on the hormone. They are sensitive and precise. Their specificity depends
on the specificity of the antibody.
NB: the measurement of steroid hormone levels in the urine represents a reflection of secretion over the pre-
vious several hours.
Answers
5. T T T T T
6. See explanation
7. See explanation
Sleep
INPUT FROM HIGHER CENTRES
Daylength
Exercise Stress
HYPOTHALAMUS
PITUITARY
HORMONES
TARGET GLAND
H
O
R
M
O
N
E

+
Positive feedback
i.e. Stimulation of
secretion
Negative feedback
I.e. inhibition of
secretion
+

+
ONE STOP DOC 6
8. With regard to steroid hormones
a. Thyroid-stimulating hormone is an example
b. They bind to a receptor in the cytoplasm or nucleus
c. They exert their effects via a second messenger mediated system
d. They affect the rate of transcription of specific genes
e. They are secreted from the smooth endoplasmic reticulum
9. Concerning peptide hormones
a. Insulin is an example
b. They bind to receptors in the cell nucleus
c. They are water soluble
d. They are secreted from the rough endoplasmic reticulum
e. They stimulate protein synthesis through activation of second messengers
10. Draw a table comparing peptide hormone secretory cells with steroid hormone
secretory cells
11. Outline the mechanism by which a hormone causes an intracellular response via a
second messenger
ADH, antidiuretic hormone; GH, growth hormone; TSH, thyroid-stimulating hormone; FSH, follicle-stimulating hormone; T4, thyroxine; cAMP,
cyclic adenosine monophosphate; cGMP, cyclic guanosine monophosphate
Endocrine systems and the hypothalamicpituitary axis 7
EXPLANATION: MICROSTRUCTURE OF THE ENDOCRINE SYSTEM
Hormones can be:
Amino acid derivatives, e.g. adrenaline
Small peptides, e.g. vasopressin (ADH)
Proteins, e.g. GH, insulin
Glycoproteins, e.g. TSH, FSH
Steroids, e.g. cortisol, oestradiol
Tyrosine derivatives, e.g. noradrenaline, T4.
The secretory cells that produce different types of hormone have distinct ultrastructural characteristics (10).
Peptide/protein hormone-secreting cells Steroid hormone-secreting cells
Large rough endoplasmic reticulum Large smooth endoplasmic reticulum
Large Golgi apparatus Many lipid vacuoles
Secretory vesicles
Steroid hormones (e.g. sex hormones, adrenal corticosteroids, vitamin D) are lipophilic (water insoluble)
and often circulate in the blood bound to proteins. When they enter cells they combine with highly specific
receptor proteins in the cytoplasm or nucleus. The hormonereceptor complex then acts within the cell
nucleus, where it binds to hormone response elements on the nuclear DNA, promoting the synthesis of spe-
cific proteins. These then mediate the effects of the hormones.
Protein and polypeptide hormones (e.g. glucagon, insulin) are water soluble and circulate largely in free
form. They do not penetrate into the cell interior but react with receptors located in the cell membrane. This
can result in direct membrane effects or intracellular effects mediated by second messenger systems (e.g.
cAMP, cGMP, protein kinase C) within the cell (11).
The actions of water-soluble and -insoluble hormones are compared in the diagrams given on page 24.
Answers
8. F T F T T
9. T F T T T
10. See explanation
11. See explanation
ONE STOP DOC 8
12. Name three gastrointestinal hormones and state their roles
13. Match the following hormones of the gastrointestinal system with the statements below
Options
A. Cholecystokinin
B. Secretin
C. Gastrin
D. Gastric inhibitory peptide
1. It is secreted by G-cells in the stomach
2. Its release is stimulated by acidic pH
3. It enhances insulin secretion
4. It stimulates contraction of the gall bladder
5. It stimulates the release of hydrochloric acid from the parietal cells
14. Regarding gastrointestinal hormones
a. All gastrointestinal hormones are secreted from the duodenum
b. The presence of fat stimulates release of both cholecystokinin and gastric inhibitory
peptide
c. A pH of 8 would stimulate release of secretin
d. Gastric inhibitory peptide is secreted from G-cells
e. The breakdown products of proteins stimulate release of gastrin
GI, gastrointestinal; CCK, cholecystokinin; GIP, gastric inhibitory peptide; HCl, hydrochloric acid; HCO
3

, bicarbonate
Endocrine systems and the hypothalamicpituitary axis 9
EXPLANATION: GASTROINTESTINAL HORMONES
The GI hormones are produced by clear cells, so-called because they appear under the microscope to have
a clear cytoplasm with a large nucleus. These are distributed diffusely throughout the gut. The GI hormones
and their roles are listed below (12).
Hormone Site of synthesis Stimulus for Action
release
Gastrin G-cells, which are located Presence of Release of HCl from parietal
in gastric pits, primarily in the peptides and cells of the stomach
antrum region of the stomach amino acids in Regulates growth of gastric
the gastric lumen mucosa
CCK Mucosal epithelial cells in Presence of fatty Contraction of the gall bladder
the first part of the acids and amino Stimulates release of pancreatic
duodenum acids in the small enzymes
intestine
GIP Mucosal epithelial cells in Presence of fat Enhances insulin secretion
the first part of the duodenum and glucose in from the pancreatic islet cells
the small intestine under conditions of
hyperglycaemia
Secretin Mucosal epithelial cells in the Acidic pH in the Stimulate HCO
3

first part of the duodenum lumen of the small secretion from the pancreas
intestine Potentiates CCK-invoked release
of pancreatic enzymes
Answers
12. See explanation
13. 1 C, 2 B, 3 D, 4 A, 5 C
14. F T F F T
ONE STOP DOC 10
15. Match the following hormones of the hypothalamicpituitary axis with the
statements below
Options
A. Growth hormone-releasing hormone
B. Somatostatin
C. Dopamine
D. Thyrotrophin-releasing hormone
E. Gonadotrophin-releasing hormone
F. Corticotrophin-releasing hormone
1. Stimulates release of follicle-stimulating hormone
2. Inhibits release of growth hormone
3. Stimulates release of growth hormone
4. Stimulates release of prolactin
5. Stimulates release of adrenocorticotrophic hormone
16. Briefly describe how a challenge test can be used to investigate the function of an
endocrine system
17. Regarding hormones
a. The hypothalamus is derived from the diencephalon
b. The anterior pituitary is derived from the primordial oral cavity
c. Rathkes pouch is derived from the endoderm
d. Pituicytes are found in the anterior pituitary
e. The adenohypophysis contains hormone-secreting cells
GH, growth hormone; TRH, thyrotrophin-releasing hormone; TSH, thyroid-stimulating hormone; PRL, prolactin; ACTH, adrenocorticotrophic
hormone; GnRH, gonadotropin-releasing hormone; CRH, corticotropin-releasing hormone; GHRH, growth hormone-releasing hormone; PIF,
prolactin-inhibiting factor; LH, luteinizing hormone
Endocrine systems and the hypothalamicpituitary axis 11
EXPLANATION: HYPOTHALAMUS AND PITUITARY
Embryologically, the hypothalamus is derived from the diencephalon. The anterior pituitary (adenohy-
pophysis) is derived from Rathkes pouch, which is an ectodermal pouch of the primordial oral cavity. The
posterior pituitary (neurohypophysis) is an extension of the nervous system.
Features of the microscopic structure of pituitary gland are:
Adenohypophysis: vascular sinusoids, hormone-secreting cells and connective tissue
Neurohypophysis: fibrous material consisting of axons and neuroglial cells (pituicytes).
Hypothalamic releasing or inhibiting factors are listed below.
Releasing or inhibiting factor Abbreviation Function
GH-releasing hormone GHRH Stimulates release of GH
Somatostatin SS Inhibits release of GH
Prolactin-inhibiting factor (dopamine) PIF Inhibits release of PRL
Thyrotrophin-releasing hormone TRH Stimulates release of TSH and PRL
Gonadotrophin-releasing hormone GnRH Stimulates release of LH and FSH
Corticotrophin-releasing hormone CRH Stimulates release of ACTH
TESTS OF FUNCTION
Challenge tests are used to investigate how a system is working and where it is going wrong, i.e. is it a
problem at the hypothalamic/pituitary or some other level. For example, provocative tests of pituitary func-
tion are based on using a known stimulus to see if the system can respond. For example, administration of
TRH normally results in increased TSH and PRL at 30 minutes, with levels declining at 60 minutes.
Suppression tests are used to see if the normal feedback mechanisms are operating or whether something
is over-riding them. For example, oral administration of glucose normally suppresses GH release, although
subsequently there is enhancement as blood sugar falls. In acromegalic patients, release of GH is not
suppressed, so the excessive secretion of GH continues (16).
Answers
15. 1 E, 2 B, 3 A, 4 D, 5 F
16. See explanation
17. T T F F T
ONE STOP DOC 12
18. Complete the table below, linking the correct site of synthesis with the correct
hormone. The first one has been done for you
Hormone Site of synthesis
GH Somatotrophs
PRL 1
TSH 2
ACTH 3
FSH 4
LH 5
19. Pituitary hormones (e.g. ACTH) can be released in a diurnal pattern. Give two examples
of other patterns of pituitary hormone release. Which hormones follow these patterns?
20. Write a short paragraph on the control of the anterior pituitary. Include the following
points: pituitary portal vessels, hypothalamus, stimulation or inhibition
GH, growth hormone; PRL, prolactin; TSH, thyroid-stimulating hormone; ACTH, adrenocorticotrophic hormone; FSH, follicle-stimulating
hormone; LH, luteinizing hormone; ADH, antidiuretic hormone
Endocrine systems and the hypothalamicpituitary axis 13
EXPLANATION: ANTERIOR PITUITARY
The anterior pituitary consists of cuboidal/polygonal epithelial secretory cells clustered around large fenes-
trated sinusoids which enable efficient transport of hormone into the blood.
The anterior pituitary hormones are listed below.
Hormone Site of synthesis
GH Somatotrophs
PRL Mammotrophs
TSH Thyrotrophs
ACTH Corticotrophs
FSH Gonadotrophs
LH Gonadotrophs
There are three main patterns of pituitary hormone release (19):
Circadian/diurnal most hormones, including ACTH, PRL, ADH (vasopressin)
Infradian/pulsatile (variations superimposed on circadian changes) e.g. ACTH, GH, LH
Longer term variations (e.g. over menstrual cycle) e.g. FSH and LH (female); many hormones show age-
related changes.
CONTROL OF ANTERIOR PITUITARY
Neuroendocrine cells of the hypothalamus whose axons project to the median eminence regulate the ante-
rior pituitary. They secrete hormones into the capillaries of the pituitary portal vessels, which in turn end
in capillaries bathing the cells of the anterior pituitary. The hypothalamic hormones either stimulate or inhibit
the release of hormones from the anterior pituitary (20).
Answers
18. 1 mammotrophs; 2 thyrotrophs; 3 corticotrophs; 4 gonadotrophs; 5 gonadotrophs
19. See explanation
20. See explanation
ONE STOP DOC 14
21. Fill in the table below the first row has been done for you
Trophic Stimulus for Target organ Action on Regulation
hormone release target organ
TSH TRH Thyroid follicle Production of Feedback inhibition by
thyroxine rising thyroxine levels
ACTH
MSH
FSH
LH
GH
PRL
22. Match the following hormones with the statements below
Options
A. Adrenocorticotophic hormone B. Prolactin
C. Thyroid-stimulating hormone D. Follicle-stimulating hormone
E. Luteinizing hormone F. Growth hormone
G. Melanocyte-stimulating hormone
1. Stimulates the bone, muscle, adipose tissue and the liver
2. Is inhibited by rising thyroxine levels
3. Stimulates spermatogenesis
4. Stimulates the mammary glands
5. Stimulates the production of cortisol
23. Draw a diagram showing the control of prolactin secretion
TSH, thyroid-stimulating hormone; TRH, thyrotrophin-releasing hormone; MSH, melanocyte-stimulating hormone; FSH, follicle-stimulating
hormone; CRH, corticotrophin-releasing hormone; LH, luteinizing hormone; GnRH, gonadotrophin-releasing hormone; GHRH, growth
hormone-releasing hormone; ACTH, adenocorticotrophic hormone; GH, growth hormone; PRL, prolactin; IGFs, insulin-like growth factors
Endocrine systems and the hypothalamicpituitary axis 15
EXPLANATION: PITUITARY HORMONES
The table below summarizes the release and action of the pituitary hormones (21).
Trophic Stimulus for Target organ Action on Regulation
hormone release target organ
TSH TRH Thyroid follicle Production of thyroxine Feedback inhibition by
rising thyroxine levels
ACTH CRH Adrenal cortex Production of cortisol Feedback inhibition by
rising cortisol levels
MSH MSH-releasing factor Melanocytes Pigmentation MSH-inhibiting factor
UV light exposure
ACTH
FSH GnRH Ovary Follicle growth, oestrogen Feedback control by
production gonadal steroids
Testis Spermatogenesis
LH GnRH Ovary Follicle growth, ovulation, Feedback control by
luteal function gonadal steroids
Testis Production of testosterone,
spermatogenesis
GH GHRH; inhibited Muscle Stimulation of cell growth Feedback control by
by somatostatin Bone and expansion IGFs
Adipose tissue Antagonizes the actions
Liver of insulin
PRL TRH; inhibited Mammary glands Stimulation of development
by dopamine of mammary glands
and milk secretion
The diagram illustrates the control of prolactin secretion (23).
Answers
21. See explanation
22. 1 F, 2 C, 3 D, 4 B, 5 A
23. See explanation
+
+
suckling
stimulus
sleep stress
HYPOTHALAMUS
DOPAMINE TRH
ANTERIOR PITUITARY
PROLACTIN
This stimulates
release of Prolactin
This inhibits
release of
Prolactin
Stimulation of development
of mammary glands
Stimulation of
milk secretion
+
ONE STOP DOC 16
24. The following are features of Syndrome of Inappropriate ADH secretion (SIADH)
a. Excess antidiuretic hormone
b. Renal failure
c. Retention of water
d. High plasma osmolality
e. Normal adrenal function
25. Diabetes insipidus
a. Is characterized by production of large volumes of dilute urine
b. Is never caused by head injury
c. Diagnosis is made by the dexamethasone suppression test
d. Is due to excess vasopressin secretion
e. Can be caused by damage to the neurohypophyseal system
26. The following inhibit release of ADH
a. Rise in temperature
b. Nausea and vomiting
c. Reduced plasma osmolality
d. Negative feedback on hypothalamic osmoreceptors
e. Pain
27. Oxytocin release is stimulated by
a. Suckling
b. Parturition
c. Stress
d. Rise in progesterone
e. Vaginal distension
ADH, antidiuretic hormone; SIADH, syndrome of inappropriate ADH secretion
Endocrine systems and the hypothalamicpituitary axis 17
EXPLANATION: POSTERIOR PITUITARY
The posterior pituitary consists of axons of modified neurons, supported by a group of glial-like cells
called pituicytes. The cell bodies of these neurons lie in the supraoptic and paraventricular nuclei of
the hypothalamus.
Two hormones are released by the posterior pituitary: ADH (vasopressin) and oxytocin.
ADH
ADH release is stimulated by an increase in osmotic pressure in the circulating blood; haemorrhage; pain
and trauma; nausea and vomiting; rise in temperature. It causes retention of water by the kidney, which
reduces plasma osmolality. It acts on the final section of the distal convoluted tubule and on the collecting
ducts to increase their permeability to water and therefore its reabsorption. It also raises blood pressure by
contracting vascular smooth muscle cells.
ADH is regulated through reduced plasma osmolality acting as a negative feedback signal on the hypothal-
amic osmoreceptors, which suppress ADH secretion.
SIADH is a condition characterized by hypersecretion of ADH. The result is retention of water, low plasma
osmolality, concentrated urine, normal renal and adrenal function. Causes can include brain trauma and
infection, pneumonia and malignant disease, and cytotoxic therapy. Treatment is to restrict fluid intake.
In diabetes insipidus large volumes of dilute urine are produced due to a reduction in or absence of ADH
secretion. It is most commonly caused by damage to the neurohypophyseal system, for example, as the result
of head injury or growth of a tumour. A water-deprivation test may be used to confirm the diagnosis: the
body is unable to concentrate the urine, so the flow of urine continues and the patient loses weight.
OXYTOCIN
Oxytocin release is stimulated by vaginal stimulation at parturition and nipple stimulation during suckling.
It acts by contracting smooth muscle cells, especially of the uterus during childbirth and myoepithelial cells of
the mammary gland during lactation.
A positive-feedback mechanism operates to regulate oxytocin release during childbirth when the fetus
stretches the cervix. Oxytocin causes muscle contraction, causing increased stretching, which stimulates
further release of oxytocin. Suckling also stimulates oxytocin secretion, but stress inhibits the release of oxy-
tocin and so reduces the flow of milk.
Answers
24. T F T F T
25. T F F F T
26. F F T T F
27. T T F F T
ONE STOP DOC 18
28. GH release is stimulated by
a. Sleep
b. Stress
c. Hypoglycaemia
d. Exercise
e. Growth hormone-releasing hormone
29. GH deficiency leads to
a. Increase in body fat
b. Hypertension
c. Hyperinsulinaemia
d. Glucose intolerance
e. Decreased muscle strength
30. The following are characteristics of acromegaly
a. Excess growth hormone
b. Joint pain
c. Increase in body fat
d. Hypertension
e. Lethargy and fatigue
31. Draw a diagram showing the control of release of GH
32. Outline the effects of GH on carbohydrates, proteins, lipids and IGFs
Disorders associated with GH deficiency or excess production include:
Hyposecretion (GH deficiency) Hypersecretion (GH excess) (Acromegaly)
In children short and fat with characteristic facies Lethargy or fatigue
Loss of growth rate Joint pain
Increase in body fat and decreased muscle strength Hyperinsulinaemia
(due to loss of metabolic functions of GH) Glucose intolerance
Hypertension
Soft tissue overgrowth
Enlargement of heart
GH, growth hormone; GHRH, GH-releasing hormone; IGFs, insulin-like growth factors; ACTH, adrenocorticotrophic hormone
Endocrine systems and the hypothalamicpituitary axis 19
EXPLANATION: GROWTH
The diagram below shows the mechanisms underlying the regulation of GH (31).
GH secretion is stimulated by both physiological and pharmacological factors:
Physiological exercise, stress, sleep and post-prandial glucose decline
Pharmacological hypoglycaemia, amino acid infusions, small peptide hormones (e.g. ACTH),
monoaminergic stimuli and non-peptide hormones.
The actions of GH on various substrates are as follows (32):
Carbohydrates GH increases blood glucose, decreases peripheral insulin sensitivity (is diabetogenic),
increases hepatic output of glucose
Proteins GH increases tissue amino acid uptake, increases amino acid incorporation into protein,
decreases urea production and nitrogen balance
Lipids GH is lipolytic, and after long administration can be ketogenic, particularly in diabetics
IGFs GH stimulates production of IGFs from the liver and other tissues. They mediate GHs growth-
related effects. A number of disorders are associated with a deficiency or excess production of GH.
See opposite for a table of disorders associated with GH deficiency or excess production.
Answers
28. T T T T T
29. T F F F T
30. T T F T T
31. See explanation
32. See explanation
+
+
+
?
Stress Exercise Sleep
HYPOTHALAMUS
ANTERIOR
PITUITARY
GROWTH
HORMONE
LIVER
IGFs
IGFs
GHRH SOMATOSTATIN

+
BONES
Bone growth
Cartilage synthesis
(chondrogenesis)
ADIPOSE
TISSUE
Lipolysis
BONE
Chondrogenesis
Carbohydrate metabolism
MUSCLE Carbohydrate metabolism
LIVER Carbohydrate metabolism
SOFT TISSUE
Growth
promotion
ONE STOP DOC 20
33. Draw a diagram illustrating the diurnal variation in GH secretion
34. Regarding circadian rhythms
a. Growth hormone secretion is solely influenced by circadian rhythms
b. The hypothalamus is involved in control of circadian rhythms
c. The supraoptic nucleus acts as a clock by providing timing cues
d. Melatonin secretion is maximal at night
e. Body temperature is affected by circadian rhythms
35. Answer true or false to the following
a. Testosterone secretion is maximal at night
b. Testosterone secretion decreases with increasing age
c. Retinal ganglion cells are involved in detecting changes in environmental light
d. Urine output is not affected by circadian rhythms
e. Growth hormone secretion is maximal at midday
Endocrine systems and the hypothalamicpituitary axis 21
EXPLANATION: CIRCADIAN RHYTHMS
A circadian rhythmdescribes the regular recurrence, in cycles of about 24 hours, of biological processes, such
as hormone secretion, sleeping, feeding, etc. This rhythm seems to be regulated by a biological clock that is
set by recurring daylight and darkness. In mammals, the biological clock lies in the individual neurons of the
suprachiasmatic nucleus in the hypothalamus.
The suprachiasmatic nucleus
receives signals from the
environment and provides
timing cues. Circadian
rhythms are co-ordinated by
clock genes whose protein
products reflect different
phases of the daily cycle.
Circadian rhythms are seen in most physiological parameters (e.g. sleep/wake cycle, body temperature, urine
output). The clock in the suprachiasmatic nucleus also controls the pineal secretion of melatonin.
Melatonin secretion is maximal at night and probably helps to co-ordinate circadian rhythmicity, although
the mechanism is unclear. The exact mechanism of detecting changes in environmental light is also unclear.
Among the theories suggested, melanopsin, which is found in the retinal ganglion cells, has been proposed.
A number of systems are affected by a light/dark (sleep/wake) cycle, for example, core body temperature and
melatonin secretion from the pineal gland.
In addition to variation with a light/dark cycle, there are also age-related changes in endocrine function.
GH is secreted at increased levels at night, but this level is dramatically reduced with increasing age. In
contrast, testosterone secretion is decreased with increasing age.
Answers
33. See diagram
34. F T F T T
35. F T T F F
Paraventricular
nucleus
Supraoptic
nucleus
Suprachiasmatic
nucleus
Optic chiasma
Anterior pituitary Posterior
pituitary
Hypothalamo-
hypophyseal tract
Mamillary
body
60
40
20
0
0 1800 0600
Clock time (h)
M
e
l
a
t
o
n
i
n

(
p
g
/
m
L
)
Melatonin secretion
is maximal overnight
1200
12
8
4
0
P
l
a
s
m
a

G
H

(

g
/
L
)
GH secretion is maximal
at night and in younger
age groups
Aged 1724 yrs
Aged 7083 yrs
0800 1600 0000
Clock time (h)
0800
ONE STOP DOC 22
36. Leptin
a. Is a steroid hormone
b. Is secreted by adipose tissue
c. Receptors are found in both the ovaries and the hypothalamus
d. Promotes a signal reflecting the energy state of the body
e. Is solely involved in the control of appetite
37. Consider leptin
a. Leptin release is stimulated by a high body mass index
b. Leptin acts to inhibit insulin
c. Both catecholamines and androgens inhibit release of leptin
d. Long-term hyperinsulinaemia stimulates release of leptin
e. Leptin stimulates appetite
38. Draw a diagram showing the actions of leptin and the factors that affect its
secretion
BMI, body mass index; CNS, central nervous system
Endocrine systems and the hypothalamicpituitary axis 23
EXPLANATION: ADIPOSE TISSUE
Leptin is a protein hormone that is secreted by white adipose (fat) tissue. Leptin receptors have been found
in the hypothalamus, pancreas, ovaries, testes, uterus, kidneys, heart, lungs and skeletal tissue. Leptin provides
a signal reflecting the energy states of the body and may be involved in the control of appetite and
reproduction. It reduces food intake and increases energy expenditure. Obese people tend to have high
leptin levels.
The actions of leptin and the factors that affect its secretion are illustrated below.
Answers
36. F T T T F
37. T T T T F
38. See diagram
+
ADIPOSE TISSUE
Androgens
Fasting
Catecholamines
Inhibition
of insulin
Possible role
in fertility
HYPOTHALAMUS
(CNS)
Reduction in production
of neuropeptide Y
Suppression of food intake
Increase in energy consumption
Glucocorticoids
BMI
Long-term
hyperinsulinaemia
Excess food ingestion
LEPTIN
ONE STOP DOC 24
ATP, adenosine triphosphate; PPi, inorganic pyrophosphate; DAG, diacylglycerol; mRNA, messenger RNA; DNA, deoxyribonucleic acid
Cell membrane
Cytoplasm
EFFECTOR
RECEPTOR
ACTIVATION OF ENZYME
adenyl cyclase
phospholipase C
2nd messenger
2nd messenger
ATP cAMP + PPi
activation of protein kinases
activation of enzymes
PRODUCT
i.e. protein synthesis
PIP
2
DAG protein kinase C
opening of Ca
2+
channels
influx of Ca
2+
into cell
Ca
2+
binds to cytoplasmic
receptors
PRODUCT
i.e. protein synthesis
This process activates pre-existing protein enzymes
WATER-SOLUBLE HORMONE
e.g. adrenaline
Protein
Water-insoluble hormone
(most circulate bound to protein)
e.g. thyroid hormones
Unbound hormone crosses
cell membrane
Cell membrane
receptor
mRNA
mRNA
Translation
PRODUCT
DNA contains specific
hormone responsive elements
This process activates the synthesis of new products (proteins)
Cytoplasm
MICROSTRUCTURE OF THE ENDOCRINE SYSTEM: continued from page 7.
The actions of water-soluble and -insoluble hormones are compared in the diagrams below.
THYROID AND
PARATHYROIDS
SECTION
2
ANATOMY 26
T3 AND T4 28
THYROID HORMONES 30
THYROID DYSFUNCTION 32
SYMPTOMS OF THYROID DYSFUNCTION 34
TREATMENT OF THYROID DISEASE 36
FUNCTION OF PARATHYROID GLANDS 38
REGULATION OF CALCIUM 40
OSTEOMALACIA AND RICKETS 42
THYROID AND
PARATHYROIDS
SECTION
2
1. Outline the congenital malformations of the thyroid that may result from abnormal
development
2. Name the anatomical relations, the blood supply, and the venous and lymphatic drainage
of the thyroid gland
3. In the thyroid and parathyroid glands
a. Thyroglobulin accumulates in follicles as colloid
b. Calcitonin is secreted by thyroid follicles
c. Parafollicular cells originate in the neural crest
d. Parathyroid hormone is secreted from principal cells
e. The thyroid develops from the endodermal floor of the pharyngeal cavity
Thyroid and parathyroids 27
EXPLANATION: ANATOMY
The adult thyroid gland weighs 1020 g. It is nearly always asymmetric and it is usually larger in women than
it is in men.
Anatomical relations of thyroid and parathyroid glands are shown in the diagram (2):
Thyroid development commences at day 24 as a midline thickening and then as an outpouching of the
endodermal floor of the pharyngeal cavity, which then descends. The parathyroid glands are derived from
the epithelium of the third and fourth pharyngeal pouches.
Congenital abnormalities of the thyroid and parathyroid include (1):
Persistent thyroglossal duct
Failure of thyroid to descend to correct level,
resulting in a thyroid gland in the sublingual
or intrathoracic positions
Development of only a single thyroid lobe
Complete absence of thyroid very rare, but
serious as it can lead to the development of
cretinism.
On the microscopic level, thyroid epithelial cells are organized into follicles that secrete thyroglobulin (which
accumulates in follicles as colloid). The C-cells (parafollicular cells) secrete calcitonin and are found within
the follicular epithelium or as clusters between the follicles. They are larger and more rounded than the folli-
cle cells and originate from the neural crest in the embryo.
The parathyroid glands consist of densely packed, small chief cells (principal cells) arranged in irregular
cords around blood vessels, which secrete parathyroid hormone (parathormone).
Answers
1. See explanation
2. See explanation
3. T F T T T
Trachea
Oesophagus
Left superior thyroid artery
(off the external carotid artery)
Left superior thyroid vein
(drains into internal jugular vein)
Left middle thyroid vein
(drains into internal jugular vein)
Left inferior thyroid artery
(branch from the thyrocervical trunk)
Left inferior thyroid vein
(drains into the brachiocephalic vein)
Pyramidal lobe
Lateral lobes
Isthmus
Parathyroid gland
(there are between
4 and 6 of these
and they are situated
posterior to the gland)
* Lymphatic drainage to the pretracheal,
paratracheal and inferior deep cervical nodes*
Fenestrated capillary
Follicle
Colloid
Lymphatic
Parafollicular
cell
Cubtoidal/
columnar
epithelial
cells
ONE STOP DOC 28
4. Regarding triiodothyronine and tyroxine
a. Only triiodothyronine is cleaved from thyroglobulin
b. Triiodothyronine and thyroxine are bound to plasma proteins
c. Thyroxine contains three molecules of iodine
d. Thyroid hydroxylase is the main enzyme involved in thyroid hormone synthesis
e. Thyroxine is excreted in the bile
5. What are the key steps in the synthesis of triiodothyronine and tyroxine
6. Draw a diagram of the feedback loop regulating thyroid hormone secretion
7. Thyroid-stimulating hormone
a. Acts on the thyroid follicles
b. Stimulates iodination of thyroglobulin
c. Stimulates release of triiodothyronine only
d. Is released by the hypothalamus
e. Is regulated by thyroxine
T3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating hormone; TRH, thyrotrophin-releasing hormone; MIT, monoiodotyrosine; DIT,
diiodotyrosine; TBG, thyroxine-binding globulin; TBPA, thyroxine-binding pre-albumin
Thyroid and parathyroids 29
EXPLANATION: T3 AND T4
TSH is secreted by the anterior pituitary gland. It acts on the thyroid follicles stimulating colloid droplets,
which contain thyroglobulin, to be taken up into the thyroid cell cytoplasm. Following lysosomal fusion and
proteolysis, T3 and T4 are cleaved from thyroglobulin.
Synthesis of T3 and T4 involves active uptake of iodine from the blood by the thyroid follicular cells and
incorporation of iodine atoms into tyrosol residues of thyroglobulin (5). The addition of iodine to tyrosol
residues of thyroglobulin is catalysed by thyroid peroxidase to give MIT and DIT. The combination of
MIT + DIT gives T3 and DIT + DIT gives T4. T3 and T4 are cleaved from thyroglobulin as required.
In plasma, T3 and T4 are strongly bound to serum proteins, such as TBG, TBPA and serum albumin,
restricting their access to cells and their potential biological activity. Only 0.015 per cent of T4 and 0.33 per
cent of total serum T3 are present in the free/active form. Stores and plasma levels of protein-bound T4 are
20 times those of T3. T4 is excreted in the bile following a process of deiodination.
Answers
4. F T F F T
5. See explanation
6. See diagram
7. T T F F T

+
+
HYPOTHALAMUS
TRH
ANTERIOR PITUITARY
TSH
THYROID
T3 and T4
Growth
Metabolic
rate
Thermogenesis
Oxygen
consumption
Heart rate
+
+
+
+
+

+ Thyroglobulin
MIT
DIT
Thyroid
peroxidase
Thyroid
peroxidase
Thyroid
peroxidase
T3 T4
bound to
thyroglobulin
Cleavage
TSH
T3
T4
Release
Reverse T3 (inactive)
ONE STOP DOC 30
8. List the four main actions of thyroid hormones
9. Thyroid hormones
a. Are vital for growth and development
b. Act to increase basal metabolic rate
c. Are produced in equal quantities
d. Increase heart rate
e. Are secreted in increased amounts in cold temperatures
10. Thyroid hormones
a. Stimulate mRNA production
b. Bind to extracellular receptors
c. Act via nuclear receptors
d. Increase the number of adrenoreceptors
e. Decrease adenosine triphosphate turnover
T3, triiodothyronine; T4, thyroxine; ATP, adenosine triphosphate; BMR, basal metabolic rate; TRH, thyrotrophin-releasing hormone; CNS,
central nervous system; mRNA, messenger ribonucleic acid; TSH, thyroid-stimulating hormone
Thyroid and parathyroids 31
EXPLANATION: THYROID HORMONES
T4 has a half-life of 7 days; T3 of 1 day. T3 is the main biologically active hormone, although more T4 is
secreted. T4 is converted to T3 in peripheral tissues by deiodinase enzymes.
Thyroid hormones bind to intracellular receptors that are similar to steroid receptors (i.e. stimulate mRNA
production). They act to increase Na
+
/K
+
ATPase levels (and thus increase ATP turnover), increase O
2
con-
sumption, increase BMR and increase the number of adrenoreceptors.
The main physiological actions of the thyroid hormones are as follows (8):
1. Calorigenesis: T3 and T4 increase the rate of O
2
consumption by the heart, skeletal muscle, liver and
kidney. In adults, brain, spleen and gonad metabolism is less susceptible to the effects of T3 and T4. In
cold conditions, CNS input through the hypothalamus (TRH) increases TSH, and T3 and T4 secretion
to increase metabolic rate, thus maintaining body temperature.
2. Carbohydrate and fat metabolism is increased.
3. Growth and development regulation, especially in the fetus. T3 and T4 impact upon numerous systems,
including muscle, bone, CNS development, myelination, dendritic formation and synapse formation.
4. Cardiovascular: T4 and T3 have cardiovascular effects, increasing the heart rate and force of contraction
to achieve increased cardiac output. In hyperthyroidism, the number of beta-adrenergic receptors in the
heart is increased (beta-adrenergic receptor antagonists are sometimes used as part of treatment).
Answers
8. See explanation
9. T T F T T
10. T F T T F
ONE STOP DOC 32
11. List three causes of hypothyroidism, giving the origin of the dysfunction
12. Explain the term goitrogen and give two examples
13. Match the following thyroid disorders with the statements below
Options
A. Hashimotos thyroiditis
B. Pituitary tumour
C. Cretinism
D. Graves disease
E. Toxic nodular goitre
F. Thyroiditis
1. Is a benign neoplasm
2. Destroys thyroid tissue
3. Is an autoimmune disorder
4. Is secondary hypofunction of the thyroid
5. Is a congenital disorder
TSH, thyroid-stimulating hormone; TRH, thyrotrophin-releasing hormone; T3, triiodothyronine; T4, thyroxine
Thyroid and parathyroids 33
EXPLANATION: THYROID DYSFUNCTION
The causes of hypofunction of the thyroid (hypothyroidism) are as follows (11):
Primary, e.g. Hashimotos thyroiditis (chronic immune disease) insufficient synthesis of thyroid receptors
due to destruction of thyroid tissue in thyroiditis; cretinism (congenital lack of thyroid tissue); radio-
therapy for hyperthyroidism (which destroys thyroid cells); iodine deficiency (iodine requirement =
150 g/day)
Secondary, e.g. Pituitary tumours
Tertiary, e.g. Hypothalamic lesion.
Hyperfunction of the thyroid (hyperthyroidism) is caused by:
Graves disease (diffuse toxic goitre) the thyroid becomes enlarged and produces too much thyroid
hormone due to stimulation by antibodies (see page 35)
Toxic nodular goitre (benign neoplasm) the cells in the nodule produce excess thyroid hormone
Thyroiditis (inflammation of the thyroid).
A goitrogen suppresses thyroid hormone production, resulting in increased TSH production and enlarge-
ment of the thyroid gland (goitre) due to compensatory stimulation of thyroid follicles. Goitrogenic substances
include kelp (high doses of iodine), cabbage and cassava (glycosides), lithium and some cough mixtures (12).
Answers
11. See explanation
12. See explanation
13. 1 E, 2 A, 3 D, 4 B, 5 C
T3
T4
TRH
+
+
+
ANTERIOR PITUITARY
THYROID
TSH
HYPOTHALAMUS Hypothalamic problem
leads to low TSH
and low thyroid
hormone release
Pituitary problem
leads to low TSH
release and low
thyroid hormone
release
Autoimmune disease
TSH receptor-like antibodies
stimulate thyroid release,
leading to massive inhibition
of TSH release

ONE STOP DOC 34

14. Explain how autoantibodies may mimic a stimulating hormone, giving a clinical
example
15. Give three features associated with Graves disease
16. What is the physiological basis of the symptoms seen in thyroid disease?
17. Complete the table below with the symptoms of hypo- and hyperthyroidism. The first
row has been done for you
Clinical symptoms Hyperthyroidism Hypothyroidism
Appearance Weight loss, sweating, tremor, goitre Weight gain, coarse skin, dry hair,
hoarse voice, puffy appearance
Disposition
Cardiac function
Neuromuscular function
Others
18. In Graves disease
a. There is hypertrophy of thyroid follicular cells
b. There is decreased synthesis of thyroid hormones
c. There is a low thyroid-stimulating hormone level
d. There is a goitre
e. There is thyrotoxicosis
TSH, thyroid-stimulating hormone; T4, thyroxine; BMR, basal metabolic rate; IgG, immunoglobulin G
Thyroid and parathyroids 35
EXPLANATION: SYMPTOMS OF THYROID DYSFUNCTION
The effects of hypothyroidism in adults are the result of a lowered metabolic rate. Conversely, many of the
classic symptoms of hyperthyroidism are due to an increased basal metabolic rate and enhanced beta-
adrenergic activity (16). NB: TSH and T4 influence the BMR; the BMR does not affect them, although
temperature does.
The following table lists the symptoms of hyperthyroidism and hypothyroidism (myxoedema) (17).
Clinical symptoms Hyperthyroidism Hypothyroidism
Appearance Weight loss, sweating, tremor, Weight gain, coarse skin, dry hair,
maybe a goitre hoarse voice, puffy appearance
Disposition Agitated and nervous, easy Cold, particularly at extremities,
fatiguability, heat intolerance lethargic, depressed
Cardiac function Tachycardia and atrial fibrillation Reduced cardiac output, so slow pulse
Neuromuscular function Muscle weakness and loss of Generalized muscle weakness and
muscle mass paraesthesiae; slow relaxing tendon
reflexes
Others Diarrhoea, shortness of breath, Menstrual irregularities
infertility, amenorrhoea; rapid
growth rate and accelerated
bone maturation in children
The most common cause of hyperthyroidism is Graves disease: This is an autoimmune disease. Antibodies
(called thyroid-stimulating antibodies) of the IgG1 subclass bind to TSH receptors on the thyroid follicular
cell membrane causing stimulation of adenylate cyclase. This results in hypertrophy of the follicular cells,
increased synthesis and secretion of thyroid hormones, and goitre formation (14). This is a clear example of
how autoantibodies can mimic a stimulating hormone. There is a high circulating T4 concentration due to
the increased stimulation, and a low TSH concentration due to negative feedback on the hypothalamic
pituitary axis.
Features associated with Graves disease include the following (15):
Triad of goitre, eye signs and thyrotoxicosis (hyperthyroidism) eye signs include upper lid retraction,
stare, periorbital oedema, redness and swelling of the conjunctiva, exophthalmos, impaired eye movement,
inflammation of cornea
Pretibial myxoedema thickening of skin over the lower tibia due to deposition of glycosaminoglycans
Others vitiligo, acropachy (clubbing of fingertips), proximal myopathy, fine tremor.
Answers
14. See explanation
15. See explanation
16. See explanation
17. See explanation
18. T F T T T
ONE STOP DOC 36
19. What is the treatment for hyperthyroidism?
20. Describe the mechanisms of action of propylthiouracil?
21. In thyroid disease
a. Iodine supplementation is used to treat hyperthyroidism
b. Radioiodine is used to treat hyperthyroidism
c. Beta-blockers block the parasympathetic effects of thyroid hormones
d. Thyroxine administration can be used in treatments of both hyper- and hypothyroidism
e. Surgery is always used to treat hyperthyroidism
T4, thyroxine; PTU, propylthiouracil; T3, triiodothyronine
Thyroid and parathyroids 37
EXPLANATION: TREATMENT OF THYROID DISEASE
Hyperthyroidism is treated using antithyroid drugs, either a block-replacement regimen, using a high dose
of an antithyroid drug, such as carbimazole or propylthiouracil, together with T4 replacement, or beta-
blockers, for example, propanolol (blocks the sympathetic effects of thyroid hormones). Alternatively, it can
be treated with radioiodine (kills thyroid cells) or surgically (subtotal ablation of the gland) (19).
PTU inhibits iodine and peroxidase from interacting normally with thyroglobulin to form T4 and T3. This
action decreases thyroid hormone production. It also interferes with the conversion of T4 to T3, and, since T3
is more potent than T4, this also reduces the activity of thyroid hormones (20).
Hypothyroidism is treated through thyroid hormone replacement with oral T4 or liothyronine (Na
+
salt of
T3), or with iodine supplementation.
Answers
19. See explanation
20. See explanation
21. F T F T F
ONE STOP DOC 38
22. Explain the importance of the parathyroid glands
23. In the regulation of calcium
a. Ca
2+
absorption is increased by diets containing brown bread
b. Ca
2+
absorption is increased by diets containing milk
c. The majority of the bodys Ca
2+
is stored in the bone
d. Ca
2+
exists bound to plasma proteins as well as its free ionic form
e. The reference value for plasma Ca
2+
is 500 mM
24. Calcium is involved with
a. Hormone release
b. Muscle contraction
c. Cardiac muscle
d. Neuromuscular junction excitability
e. Bone mineral formation
25. Outline the relationship between phosphate and calcium
PTH, parathyroid hormone
Thyroid and parathyroids 39
EXPLANATION: FUNCTION OF PARATHYROID GLANDS
Parathyroid glands produce PTH (parathormone) which is important in Ca
2+
and PO
4
3
homeostasis (22).
There is a total of about 1 kg of Ca
2+
in the adult body, and about 99 per cent of it is in bone, in the form of
hydroxyapatite. An equilibrium is reached between absorption and excretion. Ca
2+
levels within the body
are closely associated with those of PO
4
3
and they work together to carry out the following functions (25):
Bone formation and maintenance
Muscle contraction including cardiac muscle
All processes that involve exocytosis, including synaptic transmission and hormone release.
Normal Ca
2+
and PO
4
3
levels are as follows:
Plasma Ca
2+
2.5 mM (2.22.6 mM)
Free ionic form of Ca
2+
1.2 mM
Ca
2+
bound to plasma proteins 1 mM
Ca
2+
complex, e.g. with citrate 0.3 mM
Plasma PO
4
3
0.81.4 mmol
Factors that affect absorption of Ca
2+
are listed in the following table.
Increase absorption Decrease absorption
Dietary lactose Fibre
Basic amino acids, e.g. high protein, milk Phytic acid, e.g. in fortification of brown bread
Vitamin D from sunlight and diet Increasing age
Children, pregnancy, lactation
Answers
22. See explanation
23. F T T T F
24. T T T T T
25. See explanation
ONE STOP DOC 40
26. Give two signs of hypercalcaemia
27. Outline the mechanism of action of parathyroid hormone on bone
28. Match the following calcium-regulating substances with the statements below
Options
A. Parathyroid hormone
B. Cholecalciferol
C. Calcitonin
1. Increases plasma PO
4
3
2. Is secreted when plasma Ca
2+
is high
3. Binds to intracellular receptors
4. Increases Ca
2+
reabsorption in the kidney
5. Binds to receptors on bone-forming cells
PTH, parathyroid hormone; cAMP, cyclic adenosine monophosphate; VDR, vitamin D receptor; mRNA, messenger ribonucleic acid; ATP,
adenosine triphosphate; DNA, deoxyribonucleic acid
Thyroid and parathyroids 41
EXPLANATION: REGULATION OF CALCIUM
The effects of PTH, calcitonin and vitamin D on Ca
2+
levels are listed in the following table.
Plasma Ca
2+
Plasma PO
4
3
PTH
Vitamin D (cholecalciferol)
Calcitonin
PTH acts on bone by binding with receptors on osteoblasts (bone-forming cells), causing an increase in cAMP
and inhibiting collagen synthesis. These cells then release soluble factors such as prostaglandins and inter-
leukin, which cause osteoclasts to release their Ca
2+
and PO
4
3
content. There is also increased osteoclast colle-
genase activity and therefore increased osteolytic activity, which results in increasing plasma Ca
2+
levels (27).
In the kidney, PTH causes increased Ca
2+
reabsorption in the distal tubule and decreased PO
4
3
reabsorp-
tion in the proximal and distal tubules, resulting in increased PO
4
3
excretion. It also activates 1 alpha-
hydroxylase, which is needed for the conversion of vitamin D into its active form.
Calcitonin is secreted from C-cells (parafollicular cells) when plasma Ca
2+
is high. It acts on osteoclasts via
cAMP and suppresses their activity. NB: Osteoclasts are involved in bone demineralization.
Vitamin D is produced in the skin from 7-dehydrocholesterol by UV radiation. The liver and other tissues
metabolize vitamin D by 25-hydroxylation to 25-OH-D, the principal circulating form of vitamin D.
25-OHD is then further metabolized to 1,25(OH)
2
D in the kidney: this is the principal hormonal form of
vitamin D, responsible for most of its biologic actions. Vitamin D has genomic and non-genomic actions:
Genomic vitamin D acts as a steroid hormone and binds to an intracellular receptor (VDR) in the intes-
tinal mucosal cell. The VDR binds DNA and promotes synthesis of mRNA and proteins, many of which
are Ca
2+
-binding proteins (calbindins). These have a great affinity for Ca
2+
at the brush border membrane
of the intestinal mucosa and they facilitate transport of Ca
2+
to the basolateral membrane, thus increasing
plasma Ca
2+
levels. They also activate the Ca
2+
ATPase pump at the basolateral side, which pumps Ca
2+
out
of the cell into the plasma.
Non-genomic vitamin D has a direct effect on cell membranes causing rapid stimulation of Ca
2+
trans-
port (transcaltachia) via the opening of voltage-gated Ca
2+
channels, and activation of a vesicular mechanism
of Ca
2+
transport involving microtubules and calbindin.
Common signs of hypo- and hypercalcaemia are listed in the table below.
Hypocalcaemia Hypercalcaemia (26)
Hyperexcitable nervous system Nervous response sluggish
Tetany Ectopic calcification (kidneys, synovial membrane)
Plasma Ca
2+
<1.5 mM=lethal Plasma Ca
2+
>3.75 mM=lethal
Answers
26. See explanation
27. See explanation
28. 1 B, 2 C, 3 B, 4 A, 5 A
ONE STOP DOC 42
29. Lack of calcium absorption from the gut can result in osteomalacia or rickets list the
characteristics of these
30. Groups at risk of osteomalacia include
a. Breast-fed babies
b. Elderly people
c. Women of Asian origin
d. Lactating mothers
e. Housebound people
31. Match the following calcium-related disorders with the statements below
Options
A. Vitamin D-resistant rickets
B. Osteomalacia
C. Rickets
1. A cause is phenytoin therapy
2. A cause is lack of Ca
2+
absorption in the gut in adults
3. Is characterized by bone pain
4. Is characterized by decreased mineral:matrix ratio in children
5. Results from defective 25-hydroxylation
Thyroid and parathyroids 43
EXPLANATION: OSTEOMALACIA AND RICKETS
Osteomalacia occurs in adults and rickets in children as a result of a lack of Ca
2+
absorption from the gut.
In both, there is a decrease in the mineral:matrix ratio of bone.
Groups at risk of osteomalacia and rickets include:
Breast-fed babies
Children and women of Asian origin, especially those on vegetarian diets low in Ca
2+
and high in phytate
Elderly and housebound people.
Osteomalacia is characterized by bone pain, increased incidence of bone fractures and thin bones on X-ray,
and other features of hypocalcaemia.
There are two types of rickets (29):
1. Rickets due to vitamin D deficiency the characteristics of which are knock-knees or bow-legs caused
by bending of long bones, postural abnormalities and other features of hypocalcaemia
2. Vitamin D-resistant rickets this may be due to defective 25-hydroxylation because of liver disease or
defective enzyme production; or defective 1-hydroxylation because of renal disease or defective enzyme
production. Other causes include barbiturate and phenytoin therapy (for epilepsy), chronic renal failure
and a mutation on the X-chromosome that causes an X-linked disorder.
Answers
29. See explanation
30. T T T F T
31. 1 A, 2 B, 3 B, 4 C, 5 A
This page intentionally left blank
ADRENALS AND PANCREAS
SECTION
3
ADRENAL GLANDS 46
ADRENAL CORTEX 48
STEROIDOGENESIS 50
GLUCOCORTICOIDS 52
MINERALOCORTICOIDS 54
ADRENAL MEDULLA 56
PANCREAS 58
GLUCOSE HOMEOSTASIS 60
DIABETES MELLITUS 62
DIAGNOSIS AND MANAGEMENT OF
DIABETES MELLITUS 64
PHARMACOLOGICAL MANAGEMENT OF
DIABETES MELLITUS 66
COMPLICATIONS OF DIABETES MELLITUS 68
ADRENALS AND PANCREAS
SECTION
3
1. Give the anatomical relations of the adrenal gland
2. Match the following parts of the adrenal glands with the statements below
Options
A. Cortex
B. Medulla
1. It is the innermost part of the adrenal gland
2. It is derived from the neural crest
3. It consists of three zones
4. Its cells secrete adrenaline
5. Its cells secrete steroids
3. Draw a diagram of the microstructure of the adrenal gland
Adrenals and pancreas 47
EXPLANATION: ADRENAL GLANDS
The cells of the adrenal cortex are organized into three zones: zona glomerulosa, zona fasciculata and zona retic-
ularis. These secrete steroids. The medulla consists of large cells arranged in clumps or cords that receive a stim-
ulatory cholinergic input. On stimulation, they secrete catecholamines (adrenaline and noradrenaline). The
cells of the medulla stain when treated with chromate salts due to the reaction with catacholamines and are often
referred to as chromaffin cells.
The anatomical relations of the adrenal glands are shown in the table below (1).
Left Right
Anterior Splenic vessels +pancreas Vena cava +right lobe of liver
Posterior Left crus of diaphragm Right crus of diaphragm
Inferior Upper pole of left kidney Upper pole of right kidney
Superior Stomach
Blood supply: Derived from a circle of arteries arising from the superior, middle and inferior arteries
capsular vessels, cortical vessels and medullary arterioles
Nerve supply: Splanchnic nerves
Venous and lymphatic drainage: The central vein of the right adrenal drains into the inferior vena cava, while
on the left, it drains into the left renal vein.
DEVELOPMENT OF THE ADRENAL GLANDS
The cortex is derived from the epithelium (mesothelium) lining the embryonic coelomic cavity. The medulla
is derived from the neural crest and is a modified sympathetic ganglion.
Answers
1. See explanation
2. 1 B, 2 B, 3 A, 4 B, 5 A
3. See diagram
Cortex
Medulla
Capsule
Zona
reticularis
Zona
fasciculata
Zona
glomerulosa
Inferior phrenic artery
Adrenal artery
Left adrenal gland
Adrenal vein
Renal vein
Aorta Inferior vena cava
Adrenal vein
Adrenal artery
Adrenal artery
Right adrenal
gland
R L
ONE STOP DOC 48
4. Name the three zones of the adrenal cortex and give examples of their secretions
5. Match the following substances with the statements below
Options
A. Cortisol
B. Aldosterone
C. Adrenaline
D. Corticotrophin-releasing hormone
E. Adrenocorticotrophic hormone
F. Dehydroepiandrosterone
1. Is stimulated by the reninangiotensin pathway
2. Is released by the hypothalamus
3. Stimulates the adrenal cortex to produce steroids
4. Potentiates the synthesis of catecholamines
5. Is an adrenal androgen
ACTH, adrenocorticotrophic hormone; DHEA, dehydroepiandrosterone; cAMP, cyclic adenosine monophosphate; CRH, corticotrophin-
releasing hormone
Adrenals and pancreas 49
EXPLANATION: ADRENAL CORTEX
The adrenal cortex is under the control of ACTH. The zona fasciculata produces glucocorticoids (e.g. cor-
tisol); the zona glomerulosa produces mineralocorticoids (e.g. aldosterone) and the zona reticularis pro-
duces adrenal androgens (e.g. DHEA) (4). All steroids are synthesized from cholesterol.
ACTH binds to high-affinity adrenal receptors on the adrenal cortical cell, increasing intracellular concentra-
tions of cAMP. This enhances transport of cholesterol and activation of cholesterol ester hydroxylase, resulting
in increased production of steroids.
Answers
4. See explanation
5. A B, 2 D, 3 E, 4 A, 5 F
+
+
+
+
-
Hypothalamus
CRH
Anterior pituitary gland
ACTH
The synthesis of the
catecholamines is
potentiated by cortisol
Catecholamines
e.g. adrenaline
and noradrenaline
ReninAngiotensin pathway
This stimulates
release of aldosterone
High levels of cortisol act to
inhibit further release of CRH
Glucocorticoids e.g. cortisol
Mineralocorticoids
e.g. aldosterone
Adrenal androgens
e.g. DHEA
Cortex
Medulla
ONE STOP DOC 50
6. Name two enzymes involved in steroid biosynthesis from cholesterol, and state which
steps they are involved in
7. Draw the basic chemical structure of steroids
8. Put the following steps of biosynthesis of steroids into the correct order:
A. Further transformation of pregnenolone
B. Side-chain cleavage to produce pregnenolone
C. Transportation of cholesterol from storage droplets into the mitochondria
D. Hydrolysis of cholesterol esters
E. Transport of pregnenolone out of the mitochondria into smooth endoplasmic reticulum
9. Regarding hormones
a. Cortisol and oestrogen are cholesterol derivatives
b. A deficiency in adrenocorticotrophic hormone leads to feminization of newborn males
c. The C-ring structure of steroids has no bearing on the physiological action of steroids
d. Steroid hormones are synthesized and secreted as required
e. Pregnenolone is synthesized in the mitochondria
EXPLANATION: STEROIDOGENESIS
All steroids are derived from cholesterol and share a characteristic
chemical structure that accounts for the physiological action of
steroids. Cholesterol is made up of three hexagonal carbon rings
(A, B, C) and a pentagonal carbon ring (D) to which a side chain
(carbons 2027) is attached. Two angular methyl groups are also
found at position 18 and 19.
Changes to the side chain give rise to different compounds. These
individual compounds are characterized by the presence or absence
of specific functional groups (mainly hydroxy, keto(oxo) and alde-
hyde functions for the naturally occurring steroids) at certain posi-
tions of the carbon skeleton.
Steroid hormones are not stored but are synthesized and secreted as required.
Deficiencies of the enzymes involved in steroidogenesis can occur with
resulting hormone imbalance:
21-Hydroxylase deficiency (this accounts for 95 per cent of all cases)
Congenital virilizing adrenal hyperplasia
Congenital 17 alpha-hydroxylase deficiency
Congenital lipoid adrenal hyperplasia
Corticosterone methyl oxidase
(type II) deficiency.
Adrenals and pancreas 51
Answers
6. See diagram
7. See diagram
8. 1 D, 2 C, 3 B, 4 E, 5 A
9. T F F T T
CH
3
C
2027
A B
C D
CH
3
OESTRADIOL
TESTOSTERONE
Androstenedione
DEHYDROEPIANDROSTERONE ALDOSTERONE
CORTISOL
PROGESTERONE PREGNENOLONE
CHOLESTEROL
OESTRONE
*
occurs in mitochondria
*
*
*
Corticosterone
Androstenedione
17-hydroxyprogesterone
11-hydroxyandrost-
enedione
Aldolase
17-hydroxypregnenolone
20, 22-dihydrocholesterol
21-hydroxylase
17,20 lyase
17 alpha-
hydroxylase
11-deoxy-
corticosterone
11 beta-hydroxylase
11-deoxycortisol
17 alpha-hydroxylase
ONE STOP DOC 52
10. In glucocortoid disease
a. A diabetes test should be performed in a patient presenting with symptoms of
Cushings syndrome
b. Cushings syndrome is caused by cortisol deficiency
c. Cortisol deficiency can lead to hyperkalaemia
d. Centripetal obesity and striae are characteristics of Cushings syndrome
e. There is increased pigmentation of skin in Addisons disease
11. Give three causes of hypersecretion of glucocorticoids
12. Give five symptoms of Cushings syndrome
13. Cortisol
a. Is a glucocorticoid
b. Controls the effects of adrenaline
c. Adapts the bodys response to stress
d. Is secreted maximally at night
e. Circulates bound to cortisol-binding globulin
14. Addisons disease
a. Results from increased plasma levels of cortisol
b. Is characterized by increased adrenocorticotrophic hormone release
c. Causes hypertension
d. Causes hypokalaemia
e. Can occur as a result of the treatment of inflammatory disorders
ACTH, adrenocorticotrophic hormone; CBG, cortisol-binding globulin
Adrenals and pancreas 53
EXPLANATION: GLUCOCORTICOIDS
Cortisol is the major glucocorticoid. It circulates bound to CBG and has three main physiological actions:
1. It maintains the responsiveness of target cells to adrenaline and noradrenaline
2. It maintains metabolic balance
3. It adapts the bodys response to stress by preventing it fromover-responding (e.g. suppresses inflammation).
There is a circadian (diurnal) rhythm to plasma cortisol levels, although it is probably secreted all the time
in varying amounts. Levels are higher in the morning and lower at night.
Hypersecretion of glucocorticoids can be
caused by pituitary adenoma, adrenal
adenoma or carcinoma, and ectopic ACTH
syndrome (11). NB: High plasma levels
can also be caused by excess administerd
glucocorticoids. It results in increased lipol-
ysis and fat redeposition, increased protein
breakdown, increased liver glucose produc-
tion and aldosterone-like effects.
Cortisol excess results in Cushings syndrome, characterized by (12):
Round moon face Muscle wasting/weakness Diabetes Truncal obesity Hypertension
Striae Infections Buffalo hump Bruising Osteoporosis.
Hyposecretion of glucocorticoids can result from exogenous steroids causing feedback inhibition, for
example, prednisolone given to suppress inflammatory or allergic disorders; and surgical removal of ACTH-
producing tumours. It causes reduced lipolysis, reduced protein breakdown, a tendency to salt and water
depletion, and a tendency to hypercalcaemia.
Cortisol deficiency results in secondary Addisons, the symptoms of which include:
Increased pigmentation of skin and mucosa caused by increased ACTH release
Lethargy
Hyperkalaemia
Postural hypotension.
NB: Addisons disease can be due to either a primary cause, where there is lack of both cortisol and aldos-
terone (as seen in chronic insufficiency of the adrenal cortex, e.g. caused by autoimmune disease and TB infec-
tion) or a secondary cause where there is lack of cortisol only (e.g. in pituitary ACTH deficiency).
Answers
10. T F T T T
11. See explanation
12. See explanation
13. T T T F T
14. F T F F T
400
200
0
0600 1800
Time of day
P
l
a
s
m
a

c
o
r
t
i
s
o
l
Levels of cortisol are
higher in the morning
ONE STOP DOC 54
15. Draw a diagram outlining the reninangiotensinaldosterone pathway
16. Outline the features of Conns syndrome
17. In mineralocorticoid disorders
a. Conns syndrome occurs when there is hypersecretion of aldosterone
b. A decrease in plasma K
+
stimulates release of aldosterone
c. Aldosterone acts to promote Na
+
reabsorption
d. Changes in blood Na
+
activate the reninangiotensinaldosterone pathway
e. Changes in blood osmolality stimulate antidiuretic hormone secretion
18. Match the following with the statements below
Options
A. Aldosterone B. Angiotensin II
C. Antidiuretic hormone D. Renin
E. Adrenocorticotrophic hormone
1. Decreases the rate of Na
+
secretion
2. Is stimulated by changes in blood Na
+
3. Is stimulated by changes in blood osmolality
4. Increases the rate of K
+
excretion
5. Is released by the anterior pituitary gland
19. Hyposecretion of aldosterone
a. Can be caused by tuberculosis
b. Causes hypotension
c. Causes high plasma K
+
levels
d. Results in hypertension
e. Is caused by adrenal adenoma
ACTH, adrenocorticotrophic hormone; ADH, antidiuretic hormone
Adrenals and pancreas 55
EXPLANATION: MINERALOCORTICOIDS
Aldosterone is a major mineralocorticoid. It circulates bound to plasma albumin. It acts directly on the
kidney to:
decrease the rate of Na
+
excretion (with accompanying retention of water)
increase the rate of K
+
excretion.
Stimuli for aldosterone secretion include angiotensin II, increased plasma K
+
concentration and ACTH. It
is controlled by the pathways shown below.
Hypersecretion of aldosterone (Conns syndrome) is caused by adrenal adenoma, where tumour cells
secrete excess aldosterone, and adrenal hyperplasia. It results in hypokalaemia, hypokalaemia alkalosis and
hypertension (16).
Hyposecretion of aldosterone (primary Addisons syndrome) is caused by autoimmune disease, tuberculosis,
and malignancy. Its symptoms include hyperkalaemia, mild metabolic acidosis and hypotension.
Answers
15. See diagram
16. See explanation
17. T F T T T
18. 1 A, 2 D, 3 C, 4 A, 5 E
19. T T T F F
ReninAngiotensin
pathway
ACTH
Increased plasma
K
+
concentration
ALDOSTERONE
Plasma Angiotensin II
Renin secretion
Changes in
blood Na
+
Changes in effective circulatory volume
ADH
Changes in
cardiac output
and blood pressure
Changes in
venous blood return
to the heart
Changes in blood osmolality
Changes in amount of
water reabsorption/excretion
ONE STOP DOC 56
20. Outline the pathway for the synthesis of adrenaline and noradrenaline
21. Regarding hormones of the adrenal medulla
a. Noradrenaline is a tyrosine derivative
b. Both noradrenaline and adrenaline are degraded to vanilmandelic acid
c. Adrenaline mediates the stress response fight or flight
d. Noradrenaline only affects the systolic blood pressure
e. Adrenaline causes pupillary constriction
22. Concerning hormones
a. Phaeochromocytoma results in hypertension
b. Adrenomedullary hyposecretion has severe clinical consequences
c. Adrenal atrophy results in adrenomedullary hypersecretion
d. Hypertension is seen in adrenomedullary hypersecretion
e. Pallor, headaches and sweating are associated with excess adrenaline release
MAO, monoamine oxidase; COMT, catechomethyltransferase; VMA, vanilmandelic acid
Adrenals and pancreas 57
EXPLANATION: ADRENAL MEDULLA
The synthesis and degradation of the catecholamines are shown below (20).
Adrenaline release is stimulated by stress (e.g. exercise, pain, fear, hypotension, hypoglycaemia, hypoxia).
The effects of adrenaline include increased systolic blood pressure, but reduced diastolic blood pressure, tachy-
cardia, reduced gut motility, bronchodilatation, piloerection and dilatation of pupils. It also promotes
hepatic glycogenolysis, leading to hyperglycaemia and lactic-acidaemia. Adrenaline is regulated via the
hypothalamicpituitaryadrenal axis and degradation is via MAO A and B and COMT to VMA.
Noradrenaline release is also stimulated by stress (e.g. exercise, pain, fear, hypotension, hypoglycaemia,
hypoxia). It has the effect of raising both systolic and diastolic blood pressure, so increasing mean blood pres-
sure. It also causes bradycardia, piloerection, dilatation of pupils, and mobilization of free fatty acids. Regulation
is via the hypothalamicpituitaryadrenal axis and degradation is via MAOA and B and COMT to VMA.
Adrenomedullary hypersecretion is caused by phaeochromocytoma (catecholamine-secreting tumour),
resulting in hypertension, neuroblastomas and ganglioneuromas. It results in hypertension, pallor, headaches,
sweating and glucose intolerance.
Adrenomedullary hyposecretion is caused by adrenal atrophy. There are no clinical consequences due to
compensation for catecholamine deficiency by the nervous system.
Answers
20. See explanation
21. T T T F F
22. T F F T T
TYROSINE
DOPA
DOPAMINE
NORADRENALINE
PNMT
ADRENALINE
COMT
MAO
DOMA
MAO
COMT
METANORADRENALINE METADRENALINE
COMT
MAO
MAO
VMA
Tyrosine hydroxylase
Dopa decarboxylase
Dopamine beta-hydroxylase
ONE STOP DOC 58
23. Name the anatomical relations of the pancreas
24. Match the following cell types of the endocrine pancreas to their secretions
Options
A. Alpha cells
B. Beta cells
C. Delta cells
D. F or PP cells
1. Secrete insulin
2. Secrete somatostatin
3. Secrete glucagon
4. Secrete pancreatic polypeptide
25. Regarding the pancreas
a. The pancreas is derived from the midgut
b. The acinar cells release bicarbonate via the pancreatic duct
c. The pancreas is a retroperitoneal organ
d. The islets of Langerhans are exocrine cells
e. The B cells secrete insulin
HCO
3

, bicarbonate
Adrenals and pancreas 59
EXPLANATION: PANCREAS
The pancreas is a retroperitoneal organ. It consists of a head with an uncinate process, a neck, a body and a
tail. Embryologically, it arises from dorsal and ventral endodermal outgrowths from the foregut, which then
form a branching duct system.
The anatomical relations of the pancreas are as follows (23):
Head: Lies within curve of the duodenum, in front of the vena cava
Tail: Reaches hilus of spleen.
Blood is supplied to the pancreas by branches of the splenic artery, and superior and inferior pancreatico-
duodenal arteries. Nerve supply is from the splanchnic nerves and the vagi via the coeliac plexus, and lym-
phatic drainage is to the coeliac group of pre-aortic nodes via the suprapancreatic nodes.
The exocrine cells (acinar cells) of the pancreas release digestive enzymes and HCO
3

into the duodenum via

the pancreatic duct. The endocrine cells (islets of Langerhans) are small, rounded clusters of cells embedded
within the exocrine pancreas. The cells are smaller and more lightly stained than the exocrine cells, and are
arranged in irregular cords around the capillaries. Four main cells types can be distinguished using immuno-
cytochemistry (24):
A or alpha cells which secrete glucagon
B or beta cells which secrete insulin
D or delta cells which secrete somatostatin
F or PP cells which secrete pancreatic polypeptide.
Answers
23. See diagram and explanation
24. 1 B, 2 C, 3 A, 4 D
25. F T T F T
Coeliac branch Stomach
Splenic artery
Spleen
Tail of pancreas
L Kidney
Neck
Body
Duodenojejunal
flexure
Aorta
Inferior vena cava
Pancreatic duct
R Kidney
Head
2nd part of
duodenum
Uncinate process
ONE STOP DOC 60
26. Increased secretion of the following occurs in the fasting state:
a. Adrenaline
b. Glucagon
c. Insulin
d. Glucocorticoids
e. Noradrenaline
27. Briefly outline the effect on blood glucose level of the release of insulin and glucagon
28. Give an example of a cause of hyperglycaemia and the resulting clinical characteristics
29. The following can be seen in hypoglycaemia
a. Tachycardia
b. Vomiting
c. Hyperventilation
d. Boils on the skin
e. Impaired consciousness
GH, growth hormone; DM, diabetes mellitus
Adrenals and pancreas 61
EXPLANATION: GLUCOSE HOMEOSTASIS
Glucose is the principal energy source for tissues of the body, and uptake by many peripheral tissues
requires a minimal, though continuous, secretion of insulin. When blood glucose levels are high, insulin is
released. When blood glucose levels are low, glucagon is released (27). Because of the dual and opposite
actions of insulin and glucagon, hypoglycaemia does not develop in the fasting state or during exercise. In
addition, adrenaline, cortisol and GH are involved in the regulation of plasma glucose levels.
Hyperglycaemia is caused by diabetes mellitus as a result of impaired insulin secretion and/or insulin resist-
ance by the tissues, or, very rarely, by glucagonoma (28). It has the following effects:
Glycosuria Tiredness and weakness
Salt and water depletion Tachycardia, hypotension and hyperventilation
Weight loss due to protein degradation Infections (pruritus vulvae and boils)
to supply glucose Impaired consciousness and visual acuity
Vomiting Convulsions and coma (if severe).
Hypoglycaemia occurs as a complication of the treatment of DM (insulin overdose plus insufficient carbo-
hydrate intake), during fasting in a patient with a non-diabetic disorder and can occur as postprandial hypo-
glycaemia after a meal. It causes adrenergic symptoms (e.g. sweating, tachycardia and tremor) due to
increased catacholamine release, and neuroglycopenic symptoms (e.g. blurred vision, slurring of speech,
unsteadiness of gait and impaired consciousness) due to deficiency of glucose supply to the brain.
Answers
26. T T F T F
27. See explanation
28. See explanation
29. T F F F T
FED FASTING
Insulin Glucagon
Adrenaline
Glucocorticoids
MUSCLE
BLOOD GLUCOSE
MUSCLE
protein amino acids
Glycogen Glucose
LIVER
Glycogen Glucose
Triglycerides
LIVER
ADIPOSE
ADIPOSE
Glucose
Triglycerides Fatty acids triglycerides
Glucose
Fatty acids
amino acids
glycogen
fatty acids
ONE STOP DOC 62
30. Type 2 diabetes mellitus
a. Usually presents with ketoacidosis
b. Has a late onset
c. Can be due to insulin resistance in the tissues
d. Has no genetic basis
e. Cannot be controlled by diet only
31. With regard to type 1 diabetes mellitus
a. It has a juvenile onset
b. Islet cell antibodies are only present in 20 per cent of cases
c. Insulin therapy is required
d. It is caused by a total/near total insulin deficiency
e. There is a positive family history in 60 per cent of cases
32. The following are not seen in type 2 diabetes mellitus
a. Hyperventilation
b. Polydipsia
c. Polyuria
d. Weight loss
e. Islet cell antibodies
33. Give five features associated with type 1 diabetes mellitus
34. Give an example where overproduction of another hormone can give rise to the clinical
syndrome of diabetes mellitus
DM, diabetes mellitus; GH, growth hormone
Adrenals and pancreas 63
EXPLANATION: DIABETES MELLITUS
Type 1 DM usually has a juvenile onset and is caused by total or near-total insulin deficiency. This results
from the destruction of beta cells in the pancreas. Islet cell antibodies are present in 85 per cent of cases. The
cause of the autoimmune disease is usually idiopathic but can be secondary to viral infections of the pancreas
and toxins. There is also a strong genetic component (e.g. 50 per cent concordance in identical twins and a
positive family history in 10 per cent of patients). Patients require insulin therapy.
Type 2 DM has a late onset and is often associated with obesity. It is caused by impaired insulin secretion
from the pancreas, and/or insulin resistance in the tissues (there is a post-receptor defect so it is the signalling
pathway inside the cell that is affected). There is almost a 100 per cent concordance in identical twins and a
positive family history in 30 per cent of patients. Patients are advised to lose weight and watch their diet.
Those not controlled by diet need to take oral hypoglycaemia agents to increase the secretion of insulin or
potentiate its actions. In the advanced stages of disease, insulin may be required.
The following table compares the features of type 1 and type 2 DM.
Features exclusive to type 1 (33) Features common to type 1 and 2 Features exclusive to type 2
Ketones on breath Tiredness, impaired consciousness,
impaired visual acuity
Hyperventilation Polydipsia, vomiting
Weight loss prior to presentation Tachycardia, hypotension Minimal weight loss
Ketonuria (ketones in the urine) Muscle weakness and wasting No or trace of ketonuria
+/ ketoacidosis Polyuria and prone to kidney Not associated with
infections ketoacidosis, although ketosis
can occur
Islet cell antibodies present Prone to skin infections, e.g. Islet cell antibodies not
pruritus vulvae and boils present
Overproduction of some hormones can give rise to the clinical syndrome of DM as their actions oppose
insulin, for example, in acromegalic patients where the elevated GH acts against insulin (34).
Answers
30. F T T F F
31. T F T T F
32. T F F T T
33. See explanation
34. See explanation
ONE STOP DOC 64
35. Give three lifestyle changes that can be made in the management of type 2 diabetes
mellitus
36. State four aims of therapy in diabetes mellitus
37. Match the following diagnoses with the fasting plasma glucose levels below
Options
A. Normal
B. Diabetes mellitus
C. Impaired fasting glycaemia/impaired glucose tolerance
1. 9 mmol/L fasting venous plasma glucose
2. 14 mmol/L OGTT venous plasma glucose
3. 4 mmol/L fasting venous plasma glucose
4. 6.5 mmol/L fasting venous plasma glucose
5. 4.5 mmol/L OGTT venous plasma glucose
DM, diabetes mellitus; OGTT, oral glucose tolerance test
Adrenals and pancreas 65
EXPLANATION: DIAGNOSIS AND MANAGEMENT OF DIABETES MELLITUS
The diagnosis of DM requires a fasting venous plasma glucose level over 7.0 mmol/L in the presence of
symptoms of DM (such as polyuria and polydipsia). The normal level is <6.1 mmol/L. A level of 6.07.0
implies there is either impaired fasting glycaemia or impaired glucose tolerance.
If the fasting venous plasma glucose is >7 mmol/L but there are no symptoms, an OGTT must be performed.
A level of >11.1 mmol/L is diagnostic (OGTT is an oral glucose tolerance test where a glucose load is given
and blood glucose level is measured after 2 hours).
A full examination of the patient must always be performed to exclude signs of complications.
Management of DM aims to (36):
Minimize hypoglycaemia
Relieve symptoms and prevent long-term complications
Provide education and support, and improve quality of life, for example, introduce to a specialist nurse,
dietician and chiropodist.
Lifestyle changes have an important role in the management of type 2 DM. They include the adoption of a
diet that is high in carbohydrate and low in fat and refined sugars, stopping smoking, and taking adequate
exercise. Home glucose monitoring is recommended (35).
Answers
35. See explanation
36. See explanation
37. 1 B, 2 B, 3 A, 4 C, 5 A
ONE STOP DOC 66
38. Match the following with the statements below
Options
A. Alpha-glucosidase inhibitors B. Biguanides
C. Sulphonylureas D. Thiazolidinediones
1. Increase glucose uptake
2. Increase insulin release
3. Prevent the post-prandial increase in glucose
4. Decrease insulin resistance
5. Metformin is an example
39. Write short notes on the use of insulin to treat type 1 diabetes mellitus
40. Concerning insulin therapy
a. Insulin can be given orally
b. Infection reduces insulin requirements
c. Insulin reduces glucose uptake
d. All patients receive identical insulin regimens
e. Type 1 diabetes mellitus patients always require insulin therapy
DM, diabetes mellitus; ATP, adenosine triphosphate; GI, gastrointestinal
Adrenals and pancreas 67
EXPLANATION: PHARMACOLOGICAL MANAGEMENT OF DIABETES MELLITUS
Patients with type 1 DM always require administration of insulin. In type 2 DM, sometimes diet restriction
is enough, other patients require oral hypoglycaemics, and some require insulin therapy.
Oral hypoglycaemics that may be prescribed include:
Sulphonylureas (e.g. gliclazide and glibenclamide) increase insulin release from beta cells by inhibiting
the ATP-sensitive K
+
channel in the beta cell membrane
Biguanides (e.g. metformin) act peripherally to increase glucose uptake and reduce hepatic glucose
output. Their mechanism of action is not understood but they do not increase insulin release
Alpha-glucosidase inhibitors (e.g. acarbose) inhibit alpha-glucosidase and therefore the digestion of
starch, so blood glucose does not shoot up after a meal (post-prandial)
Thiazolidinediones (e.g. rosiglitazone) a new class of oral hypoglycaemics that decrease insulin resistance.
They are used in conjunction with insulin therapy.
Insulin administration inhibits glucose production and reduces glucose uptake. There are three main types of
insulin preparation:
Short-acting
Intermediate-acting
Long-acting.
Usually a mixed preparation is used (for example, Mixtard 30 which is 30% short-acting and 70%
intermediate-acting insulin).
The dose of insulin is adjusted on an individual basis by gradually increasing the dose. Insulin requirements
may be increased by infection, stress, accidental or surgical trauma, puberty and pregnancy. Insulin is
inactivated by GI enzymes, so must be given by injection usually subcutaneous (39).
Answers
38. 1 B, 2 C, 3 A, 4 D, 5 B
39. See explanation
40. F F T F T
ONE STOP DOC 68
41. Give three factors that should be controlled in order to reduce the complications of
diabetes mellitus
42. Diabetic patients have
a. Raised high-density lipoprotein cholesterol
b. Raised triglycerides
c. An increased risk of cardiovascular disease
d. An increased risk of limb ischaemia
e. A decreased risk of cataracts
43. Describe the chronic complications of diabetes mellitus
ACE, angiotensin-converting enzyme; DM, diabetes mellitus; LDL, low-density lipoprotein; TAG, triglyceride
Adrenals and pancreas 69
EXPLANATION: COMPLICATIONS OF DIABETES MELLITUS
To obtain good control over the complications of diabetes the following must be achieved (41):
Control of blood glucose
Control of hyperlipidaemia (lipid-regulating drugs can be given)
Control of blood pressure (130/80 tight blood pressure control reduces macro- and microvascular disease
and mortality use an ACE inhibitor drug).
Acute complications include hypoglycaemia (as a result of incorrect management) and ketoacidosis (charac-
terized by dehydration, air hunger, smell of ketones, vomiting and abdominal pain).
Chronic complications of DM can be either macrovascular or microvascular (43).
MACROVASCULAR This is atherosclerotic disease affecting medium and large blood vessels. It covers:
Cardiovascular disease There is a two- to four-fold increase in cardiovascular disease in diabetic patients,
independent of other risk factors. Diabetic patients have raised LDL-cholesterol and raised TAGs
Renovascular disease (impaired renal function) this involves increased excretion of albumin and is asso-
ciated with cardiovascular disease (hypertension, myocardial infarction, coronary heart disease), the inci-
dence of which is about 15-fold greater in patients with diabetic nephropathy
Cerebrovascular disease stroke
Peripheral vascular disease resulting in limb ischaemia due to reduced blood supply
Neuropathy loss of sensation increases risk of accidental trauma.
MICROVASCULAR
Retinopathy this is a microvascular disease that leads to capillary occlusion, interrupting the blood supply
to the retina
Cataracts.
Answers
41. See explanation
42. F T T T F
43. See explanation
This page intentionally left blank
DEVELOPMENT AND AGEING OF
THE REPRODUCTIVE TRACTS
SECTION
4
SEXUAL DIFFERENTIATION 72
PUBERTY 74
ABNORMALITIES OF SEXUAL
DIFFERENTIATION AND PUBERTY 76
OOGENESIS 78
HYPOTHALAMIC CONTROL OF GONADAL
FUNCTION IN THE FEMALE 80
OVARIAN FUNCTION 82
SPERMATOGENESIS 84
HYPOTHALAMIC CONTROL OF GONADAL
FUNCTION IN THE MALE 86
PHYSIOLOGICAL EFFECTS OF OESTROGENS
AND ANDROGENS 88
SEXUAL BEHAVIOUR AND RESPONSE 90
FERTILITY CHANGES WITH AGE AND THE
MENOPAUSE 92
DEVELOPMENT AND AGEING OF
THE REPRODUCTIVE TRACTS
SECTION
4
1. Concerning sexual determination and early sexual differentiation
a. Male sex is determined by the sex-determining region on the X chromosome
b. The default pathway of sexual differentiation is male
c. Androgens determine testis formation
d. Sertoli cells secrete anti-mullerian hormone
e. Testosterone is involved in the development of the male genital ductal system
2. Concerning the internal genital tracts
a. Both male and female embryos initially contain similar primordial duct systems
b. Until week 8 of gestation, male and female reproductive tracts develop along an
identical course
c. The paramesonephric ducts give rise to the epididymis and vasa deferentia
d. The mesonephric ducts develop into the fallopian tubes, uterus and superior part of the
vagina
e. Abnormal fusion of the mullerian ducts may result in a bifurcate uterus
3. Match the following male and female anatomical structures with the indifferent
genitalia below
Options
A. Genital tubercle
B. Urogenital slit
C. Urethral fold
D. Labioscrotal swelling
1. Scrotum
2. Clitoris
3. Labium minus
4. Urethral meatus
5. Glans penis
6. Labium majus
AMH, anti-mullerian hormone; SRY, sex-determining region on the Y chromosome
Development and ageing of the reproductive tracts 73
EXPLANATION: SEXUAL DIFFERENTIATION
Genes on the Y chromosome are directly responsible for determining gender. It is the sex-determining region
on the Y chromosome (SRY ) gene that induces testis formation and it is the absence of this region in a
female embryo that results in the development of the female reproductive tract, along a default pathway.
This is why XY individuals are normally male and XX individuals are normally female.
The time course of embryological development is explained on page 94.
Answers
1. F F F T T
2. T F F F T See text on page 94
3. 1 D, 2 A, 3 C, 4 B, 5 A, 6 D See diagram on page 94
XY XX
SRY gene expression
on Y chromosome
GONADAL RIDGE
LEYDIG CELLS
TESTOSTERONE DIHYDROTESTOSTERONE
MALE GENITAL
TRACT DEVELOPMENT
MALE EXTERNAL
GENITALIA
DEVELOPMENT
AMH = Anti-Mullerian Hormone
(Secreted by Sertoli Cells)
SERTOLI
CELLS
Mullerian
duct
regression
AMH
Gonadal ridge
No SRY gene expression
Ovary development
No testosterone No AMH
Mullerian duct
development
Wolffian duct
regression
Female
external
genitalia
ONE STOP DOC 74
4. Concerning the initiation of puberty
a. The gonads are responsible for the initial rise in circulating androgens
b. Growth hormone and thyroid-stimulating hormone contribute to the adolescent growth
spurt
c. Maturation of hypothalamic control mechanisms occurs
d. Adrenal androgens provoke pubic and axillary hair growth in the early stages of puberty
e. Growth hormone stimulates sex steroid secretion by the gonads
5. With regard to pubertal changes in the female
a. Thelarche occurs approximately 2 years after menarche
b. Adrenarche is the earliest developmental event
c. Menarche signals the start of ovulatory menstrual cycles
d. Breast growth and development does not occur until menarche
e. Includes the keratinization of the vaginal mucosa
6. Pubertal changes in the male
a. Adrenarche stimulates the development of pubic hair
b. Testicular maturation occurs prior to adrenarche
c. Seminiferous tubules grow and develop
d. Spermatogenesis begins
e. Testicular androgens are secreted from the Leydig cells
GH, growth hormone; TSH, thyroid-stimulating hormone; ACTH, adrenocorticotrophic hormone; GnRH, gonadotrophin-releasing hormone
Development and ageing of the reproductive tracts 75
EXPLANATION: PUBERTY
In both males and females, hypothalamic maturation during late childhood results in raised levels of GH, TSH
and ACTH. ACTH stimulates the adrenal cortex to produce sufficient amounts of adrenal androgens
required for initiating pubic and axillary hair growth adrenarche. Girls with ACTH deficiency may go
through the gonadotrophic events of puberty normally but develop no pubic hair. Boys have sufficient testic-
ular testosterone to make up for the loss of adrenal androgen secretion. Increased GnRH, initially secreted
more at night, stimulates LH and FSH secretion which in turn stimulates gonadal growth. The sub-
sequent rise in gonadal sex steroids prompts the development of secondary sexual characteristics. GH,
TSH and sex steroids are responsible for the adolescent growth spurt.
The initiation of puberty is not fully understood but it is at least partly dependent on energy status, with
body weight, fat mass, nutritional status and exercise all playing a role.
Female Male
Adrenarche: Growth spurt begins, lasts approx. Adrenarche: Growth spurt begins, lasts approx.
23 years. Pubic and axillary hair growth 23 years. Pubic and axillary hair growth
Thelarche: Breast development, nipple enlargement, Testicular maturation: Involves initiation of
pigmentation and fat deposition androgen production by Leydig cells, seminiferous
tubule growth and initiation of spermatogenesis
Menarche: Menstruation begins. Approx. 90 per cent of
menstrual cycles are anovulatory in the first year of
menarche and the frequency of ovulatory cycles
gradually increases with age
Secondary sexual characteristics: Secondary sexual characteristics:
Pubic and axillary hair Pubic and axillary hair
Breast growth and development Testicular and penile enlargement
Enlargement of labia minora, majora +uterus Increased hair on trunk, pubis, axillae, face
Keratinization of vaginal mucosa Increased laryngeal size, deepening of voice
Increased fat deposition in thighs, hips Increased bone and muscle mass
Answers
4. F T T T F
5. F T F F T
6. T F T T T
ONE STOP DOC 76
7. With regard to the condition of secondary hermaphroditism
a. It results from a failure of a hormone response in the genitalia
b. Testicular feminization syndrome is due to an increased sensitivity of fetal genitalia to
oestrogen
c. The genotype is XXY
d. Female external genitalia and intra-abdominal testes are present in testicular feminization
syndrome
e. Insensitivity to androgens results in little pubic or axillary hair growth
8. Outline the main causes of delayed puberty in the male and female
AMH, anti-Mullerian hormone; GnRH, gonadotrophin-releasing hormone; LH, luteinizing hormone; FSH, follicle-stimulating hormone; CNS,
central nervous system
Development and ageing of the reproductive tracts 77
EXPLANATION: ABNORMALITIES OF SEXUAL DIFFERENTIATION AND PUBERTY
Failure in endocrine communication between the gonads (ovaries and testes), and internal and external
genitalia can result in a mismatch between gonadal and genital sex causing the condition of secondary
(or pseudo) hermaphroditism. An example of this is testicular feminization syndrome (also called andro-
gen-insensitivity syndrome). The genotype is XY (male). Testes develop normally due to the presence of the
SRY gene and produce testosterone and AMH. However, these individuals are genetically insensitive to
androgens because they have a lack of functional androgen receptors and there is a regression of the Wolffian
ducts. The mullerian ducts have already regressed due to the presence of AMH. The external genitalia cannot
respond to circulating androgens. Thus, this genetically male individual has intra-abdominal testes but appears
female with labia, clitoris and vagina. There is little or no pubic and axillary hair and the individual is infer-
tile.
Delayed puberty may be defined as the absence of secondary sexual characteristics by the age of 13 years in
the female and 16 years in the male. There are three main causes of pubertal delay (8):
Constitutional delay (includes growth delay) may only be diagnosed in an individual in the absence of
pathology and thus may be considered normal for that individual. A positive family history of delayed
puberty is usually present
Hypogonadotrophic hypogonadism occurs due to deficiencies in pulsatile GnRH, LH or FSH. GnRH
deficiencies may occur as a result of genetic and developmental defects of the hypothalamus or destructive
lesions of the hypothalamus or pituitary stalk. Intense exercise may also delay puberty due to inhibition of
GnRH secretion. CNS tumours are the main cause of LH and FSH deficiencies
Hypergonadotrophic hypogonadism occurs most commonly due to primary gonadal failure, resulting
in decreased or failed gonadal steroid secretion. The lack of testicular or ovarian steroids causes increased
FSH and LH secretion due to the lack of negative feedback. Examples of primary gonadal failure include
Klinefelters syndrome, Turners syndrome, mosaicism and congenital adrenal hyperplasia.
Answers
7. T F F T T
8. See explanation
ONE STOP DOC 78
9. Outline the structure of an ovary
10. Concerning gametogenesis
a. All potential gametes in the female are produced before birth
b. The loss of many oocytes occurs during childhood
c. Women enter puberty with approximately two million oogonia remaining
d. Primary oocytes continue to develop throughout childhood
e. Post puberty, there is regular recruitment of follicles into the pool of growing follicles
11. A Graafian follicle
a. Is the final stage of the development of the primary follicle
b. Is under the influence of luteinizing hormone
c. Ruptures on day 12 of the menstrual cycle
d. Normally contains only one oocyte at any one time
e. Develops into the corpus luteum only once the ovum has been fertilized
12. Arrange the following stages of oogenesis to match with the correct statement
Options
A. Produces the division of the oocyte and the first polar body
B. Produces a haploid gamete and the second polar body
C. Increases the number of potential eggs
D. Occurs during follicular growth
1. The LH surge 2. Fertilization
3. Miltoses of oogonia 4. Growth of the oocyte
LH, luteinizing hormone
Development and ageing of the reproductive tracts 79
EXPLANATION: OOGENESIS
Gametogenesis differs dramatically between males and females. In the female, mitosis of oogonia terminates
well before birth. Women are therefore born with all the oocytes they will ever have (approx. two million).
Primary oocytes arrest in their development and many degenerate until puberty is reached (approx. only
400 000 oocytes may remain by the time puberty is reached). Oocytes are contained in primordial follicles.
Regular recruitment of these follicles into a pool of growing follicles occurs after puberty. The sequence of steps
involved in the development of an ovum (oogenesis) is shown below.
Definitions:
Haploid: each set of chromosomes
is called a haploid set
Diploid: 23 pairs of homologous
chromosomes, i.e. 46 chromo-
somes.
The diagram below shows the structure of an ovary (9).
The Graafian follicle contains one oocyte per follicle. On about day 14 of the menstrual cycle, in response
to the LH surge, the epithelium and granulosa cell surface of the ovary rupture. The oocyte is released into
the peritoneal cavity and is collected by the cilia on the fimbria of the fallopian tubes. The ruptured follicle
forms the corpus luteum, which in the non-pregnant female regresses after approximately 10 days. In the
pregnant female, the corpus luteum continues to secrete progesterone until the placenta takes over this role.
Answers
9. See explanation
10. T T F F T
11. T T F T F
12. 1 A, 2 B, 3 C, 4 D
Oogonium
Mitosis
Maturation
1st meiotic
division
2nd meiotic
division
In utero
Birth
Puberty
Ovulation
Fertilization
Fertilization
Primary
oocytes
Secondary
oocyte
Mature
ovum
1st polar body
2nd polar body
Thecal cells
Oocyte
Antrum
Graafian
follicle
Released ovum
Granulose cells
Corpus luteum
Atretic follicle
Corpus albicans
Germinal epithelium
Stroma
Primordial follicle
Primary follicle
Antral follicle
ONE STOP DOC 80
13. Draw a diagram to illustrate the communication between the hypothalamus and the
ovary
14. Regarding gonadotrophin-releasing hormone
a. The hypothalamus releases gonadotrophin-releasing hormone in pulses
b. Higher neural centres regulate the hypothalamus
c. Gonadotropes are found in the posterior pituitary
d. Gonadotrophin-releasing hormone stimulates luteinizing hormone and follicle-stimulating
hormone secretion
e. Gonadotrophin-releasing hormone secretion increases at puberty
15. Regarding feedback mechanisms
a. Gonadotropin secretion increases when oestrogen levels are low
b. Plasma luteinizing hormone and follicle-stimulating hormone levels decrease after the
menopause
c. Oestrogen may exert a positive feedback effect on luteinizing hormone secretion
d. Progesterone exerts negative feedback on the anterior pituitary during the luteal phase
e. High plasma oestrogen levels may cause ovulation at any point in the menstrual cycle
GnRH, gonadotrophin-releasing hormone; LH, luteinizing hormone; FSH, follicle-stimulating hormone
Development and ageing of the reproductive tracts 81
EXPLANATION: HYPOTHALAMIC CONTROL OF GONADAL FUNCTION IN THE FEMALE
The cells of the hypothalamus receive signals from higher centres in the brain, generate neural signals of their
own and have a neuroendocrine function. GnRH is released as a series of pulses into the portal vessels; binds
to receptors on the gonadotropes in the anterior pituitary and drives LH secretion (and to a lesser extent
FSH) in a similar pulsatile fashion. Therefore a change in GnRH pulse frequency affects the secretion of LH
and FSH.
Negative and positive feedback mechanisms are important to understand.
1. Oestradiol exerts both a positive and a negative feedback effect on the anterior pituitary.
1. If oestradiol levels are low, negative feedback is low, and FSH and LH secretion rises, thus stimulat-
ing the production of oestrogen from the ovary. As oestrogen levels rise, the effect of negative feedback
upon the anterior pituitary reduces FSH and LH secretion. The increase in plasma FSH and LH fol-
lowing ovariectomy or the menopause demonstrates this best, and an infusion of oestrogen results in the
rapid decline of FSH and LH levels.
1. However, under some circumstances, oestradiol can exert a positive feedback effect. For example, if
oestrogen concentrations remain high for 48 hours or so (as seen at the end of the follicular phase of the
menstrual cycle), FSH and LH secretion is enhanced, not suppressed. Thus, the LH surge occurs.
2. Progesterone exerts a negative feedback effect on the anterior pituitary. During the luteal phase of the
menstrual cycle, progesterone enhances the negative feedback effects of oestrogen, LH and FSH levels are
kept low and the growth of new follicles is limited. As steroid hormone levels fall at the end of the luteal
phase, negative feedback is reduced and LH and FSH levels rise, stimulating a new wave of follicular
growth.
Answers
13. See diagram
14. T T F T T
15. T F T T F
+
-
+
-
-
-
-
-
+
Hypothalamus
GnRH
Anterior pituitary
FSH
LH
Oestradiol Inhibin
Progesterone and oestradiol
Corpus
luteum
Follicle cells
Positive
feedback
Negative
feedback
Both positive
and negative
feedback
Ovary
ONE STOP DOC 82
16. In relation to a normal fertile menstrual cycle, which of the following statements are
correct
Options
a. Basal body temperature rises shortly before ovulation
b. The LH surge triggers ovulation
c. Both the follicle and the corpus luteum secrete oestradiol
d. Progesterone levels fall after the onset of menstruation
e. Cervical mucus secretion peaks around mid-cycle
17. Regarding the endometrium during the menstrual cycle
a. The endometrium has two distinct layers
b. The stratum basale contains spiral arteries that are influenced by changing hormone levels
c. Menstruation occurs with the constriction and necrosis of the spiral arteries
d. Rising progesterone levels are responsible for the glandular proliferation of the
endometrium
e. The stratum basale is shed during menstruation
18. Other changes during the menstrual cycle
a. The Graafian follicle develops during the luteal phase
b. Cervical mucus increases during the follicular phase of the cycle
c. Spinnbarkeit of mucus is present during the follicular phase
d. Basal body temperature is affected by the phase of the menstrual cycle
e. Body temperature rises during menstruation
19. Menstruation
a. Occurs at the end of the follicular phase
b. Occurs if fertilization does not take place
c. Occurs in response to falling gonadotrophin levels
d. Prompts new follicular development within the ovary
e. Usually occurs about every 28 days
FSH, follicle-stimulating hormone; LH, luteinizing hormone
Development and ageing of the reproductive tracts 83
EXPLANATION: OVARIAN FUNCTION
Hormonal and other changes during the menstrual cycle are shown below.
MENSTRUATION
The endometrium has two distinct layers: the stratum basale and functionale. It is the stratum functionale
that is shed at menstruation, due to the constriction and necrosis of the supplying spiral arteries. The chang-
ing hormone levels bring about these changes in the arteries.
If fertilization does not occur during the luteal phase of the menstrual cycle, the corpus luteumcannot sustain
progesterone production and disintegrates into the corpus albicans. The fall in progesterone increases the
availability of prostaglandins (potent stimulators of myometrial contractility) and menstruation begins. The
fall in steroid levels reduces the negative feedback on LH and FSH secretion, and the levels of these hormones
rise, stimulating a new wave of follicular growth.
Answers
16. F T T F T
17. T F T T F
18. F T T T F
19. F T F F T
Ovulation
14 28 days of cycle
C
37
36.6
300
200
100
p
g
/
m
L
n
g
/
m
L
A
r
b
i
t
r
a
r
y

u
n
i
t
s
0
8
4
0
20
10
0
0
m
Plasma
LH
Basal body
temperature
Plasma
oestradiol
Plasma
Progesterone
Volume of cervical
mucus
Uterine
endometrium
ONE STOP DOC 84
20. Outline the structure of a testis
21. Seminiferous tubules
a. Are the site of spermatogenesis
b. Contain androgen-secreting cells
c. Contain Sertoli cells that produce a blood/testis barrier
d. Store spermatids until they become motile
e. Are surrounded by blood vessels and Leydig cells
22. Concerning the sequence of spermatogenesis
a. It commences at birth
b. It produces haploid spermatozoa by meiosis from diploid spermatogonia
c. Spermatogonia undergo meiosis prior to mitosis
d. The process takes approximately 64 days in the post-pubertal male
e. Spermatids undergo extensive cell modelling as part of spermiogenesis
23. The mature spermatozoon
a. Does not become motile until it has passed through the epididymis
b. Releases sex steroids
c. Is capable of fertilization immediately after ejaculation has occurred
d. Are stored, ready for ejaculation, in the seminal vesicles
e. Contain an acrosomal cap, a mitochondrial midpiece and a tail
Development and ageing of the reproductive tracts 85
EXPLANATION: SPERMATOGENESIS
The testes have two distinct functions: spermatogenesis and androgen production. Spermatogenesis occurs
within the seminiferous tubules and androgen production occurs in Leydig cells that lie in the interstitium.
The seminiferous tubules contain the cells responsible for spermatogenesis, Sertoli cells and spermatogonia.
The Sertoli cells perform a variety of functions. They act as a nurse cell, providing metabolic and structural
support for the developing spermatozoa and they form a blood/testis barrier that protects spermatogenic cells
from an adverse immune response. In addition, this barrier excludes many substances present in the circula-
tion from the seminiferous tubule fluid.
Spermatogenesis begins at puberty, in contrast to oogenesis in the female, which happens before birth. It
involves three phases and takes approximately 64 days:
1. Mitotic proliferation to produce a large germ cell population. Diploid spermatogonia lie on the basement
membrane of the seminiferous tubules and undergo mitotic division in order to maintain the germ cell
population. Primary spermatocytes are the product of the final mitotic division
2. Meiotic division to produce genetic diversity. Primary spermatocytes undergo two meiotic divisions to
halve their number of chromosomes. Haploid spermatids are the result of the second division. The
spermatids undergo extensive cytoplasmic remodeling during the process of spermiogenesis. They develop
an acrosome, and a tail with a midpiece containing mitochondria
3. Maturation. Spermatozoa are not fully mature as they leave the testis. Further cell membrane and
cytoplasmic changes occur as they pass through the epididymis. However, it is not until they reach the
female tract that they are fully capable of fertilizing an egg.
Answers
20. See diagram
21. T F T F T
22. F T F T T
23. T F F F T
Vas
deferens
Testicular
artery
Testis
Sperm
production
Testosterone
production
Epididymis
Sperm
maturation
and storage
Sperm
Lumen
Sertoli
cell
Spermatid
Tight junctions
between Sertoli
cells
Spermatogonium
Myoid
cells
Leydig cells
ONE STOP DOC 86
24. Concerning testicular steroids
a. Androgen production occurs in Sertoli cells
b. Once synthesized, they diffuse into the circulation
c. Sertoli cells produce inhibin
d. Sex-hormone binding globulin and albumin bind testosterone in the plasma
e. Follicle-stimulating hormone secretion stimulates testosterone production in the testis
25. Draw a diagram to illustrate the hormonal control of testicular function
26. Concerning feedback control
a. Inhibin acts to suppress luteinizing hormone secretion
b. Follicle-stimulating hormone acts on the Leydig cells
c. Enhanced testosterone secretion may feedback on the anterior pituitary to decrease
luteinizing hormone secretion
d. Many of the peripheral actions of testosterone are due to its conversion to
dihydrotestosterone
e. Dihydrotestosterone can be metabolized to oestradiol
GnRH, gonadotrophin-releasing hormone; FSH, follicle-stimulating hormone; LH, luteinizing hormone; SHBG, sex-hormone-binding globulin
Development and ageing of the reproductive tracts 87
EXPLANATION: HYPOTHALAMIC CONTROL OF GONADAL FUNCTION IN THE MALE
The hormonal control of testicular function is described in the following diagram.
In the testes, androgen production occurs in the Leydig cells, under the influence of LH. Androgens either
enter the circulation or diffuse into the Sertoli cells. Androgens feedback onto the hypothalamicpituitary axis
to inhibit LH secretion. Sertoli cells produce the hormone inhibin, which acts on the anterior pituitary to sup-
press FSH secretion.
In the circulation, 60 per cent of testosterone is transported via SHBG and 38 per cent by albumin. The
remaining 2 per cent is free to diffuse into cells and exert an effect. Many of the peripheral responses to
testosterone are due to its conversion to 5-alpha-dihydrotestosterone. Testosterone can also be metabolized to
oestradiol in peripheral tissues.
Answers
24. F T T T F
25. See diagram
26. F F T T F
-
-
-
FSH LH
Dihydrotesterone
Peripheral effects
Hypothalamus
Gonadotroph
GnRH
Anterior pituitary
Negative
feedback
Interstitial
Leydig cells
Inhibin
Seminiferous
tubule
Sertoli cell
Testosterone
ONE STOP DOC 88
27. Concerning the physiological effects of progesterone
a. It is involved in breast tissue proliferation
b. It causes a decrease in the viscosity of cervical mucus during the menstrual cycle
c. It is solely responsible for pubic and axillary hair growth
d. It influences the central nervous system regulation of thermogenesis
e. It is directly responsible for ovulation
28. During pregnancy
a. Ovulation ceases
b. Oestrogen stimulates myometrial hypertrophy
c. Progesterone causes an increase in the contractility of the myometrium towards term
d. Fluid retention and an increase in uterine blood flow are due to oestrogens
e. Progesterone inhibits prepartum lactation
29. During puberty
a. Fat deposition is under the control of progesterone
b. The initiation of cyclical changes to the endometrium are influenced by oestrogen
c. Oestrogen is responsible for the closure of bone epiphyses in the female
d. Rising androgen levels stimulate facial hair growth
e. Progesterone causes a rise in basal body temperature in the luteal phase
30. Outline the physiological effects of testicular androgens in the adult male
Development and ageing of the reproductive tracts 89
EXPLANATION: PHYSIOLOGICAL EFFECTS OF OESTROGENS AND ANDROGENS
The tables below list the effects of progesterone and oestrogen in the female, and testosterone in the male
(30).
Effects of oestrogen Effects of progesterone
Puberty Stimulation of uterine, vaginal Proliferation of breast tissue
and breast tissue Cyclical changes to endometrium
Proliferation of breast tissue Regulates thermogenesis
Fat deposition
Closure of epiphyses
Menstrual cycle Endometrial proliferation Increases body temperature
Clear mucus secretion Increases secretions of endometrium
Maturation of vaginal epithelium Thick cervical mucus production, increases pH
Pregnancy Growth of breast duct system Maintains decidual lining of uterus
Myometrial hypertrophy Decreases myometrial contractions and relaxes
Fluid retention uterine smooth muscle
Increases in uterine blood flow Limits prepartum lactation
Increases growth of breast alveoli
NB: Testosterone is responsible for pubic and axillary hair growth in females.
Effects of testosterone
In the fetus Sexual differentiation
Puberty Pubic and axillary hair growth
Penile, scrotal and muscle growth
Deepening of voice
Spermatogenesis
Closure of long bone epiphyses (after conversion to oestradiol)
Adulthood Hair loss
Anabolic effects
Maintenance of external genitalia, spermatogenesis and libido
Answers
27. T F F T F
28. T T F T T
29. F T T T T
30. See explanation
ONE STOP DOC 90
31. Sexual behaviour in humans
a. Is solely genetically determined
b. Is influenced by the sex steroids
c. Begins to differentiate between girls and boys at puberty
d. May be influenced by social stereotyping
e. If male genitalia are present, male sexual behaviour is predetermined
32. Concerning the female and male sexual responses
a. The male has to wait for a period of time before penile erection can occur again
b. The female orgasm may last for a longer period of time than in the male
c. The female has a refractory period post-ejaculation
d. Penile erection results from the vasodilatation of penile smooth muscle
e. Vaginal lubrication aids coitus
33. With regard to sexual dysfunction
a. Alcohol is the commonest cause of impotence in the male
b. It can result from a loss of libido
c. It may be caused by diabetes mellitus
d. Hormone replacement therapy may improve sexual dysfunction if caused by
postmenopausal vaginismus
e. It may be a result of pelvic infections in females
DM, diabetes mellitus; MS, multiple sclerosis
Development and ageing of the reproductive tracts 91
EXPLANATION: SEXUAL BEHAVIOUR AND RESPONSE
Human sexual behaviour is not completely understood. It is influenced by many different factors including
gender, gonads, endogenous sex steroids and social stereotyping, none of which exclusively determines sexual
behaviour. The rise in endogenous hormones at puberty acts on both the brain and the genitalia, influencing
subsequent sexual behaviour. Male and female sexual responses are compared in the table below.
Phase Male Female
Excitement Vasodilatation of penile smooth muscle =erection Clitoral engorgement
Vaginal lubrication
Plateau Further vasocongestion Further vasocongestion
Sperm emission into urethra NB: May take longer to reach than in male
Orgasm Urethral contraction =ejaculation Rhythmic contractions of uterus
NB: May last longer than male orgasm
Resolution First phase: absolute refractory period. This refers to the No absolute refractory period
initial period of time after ejaculation when the penis does
not respond to further stimulation
Second phase: relative refractory period. This refers to the
secondary stage post-ejaculation when the penis may
become excitable again with sufficient stimulation
Causes of sexual dysfunction are listed in the table below.
Sexual dysfunction Possible causes Sexual dysfunction Possible
causes
Male Female
Loss of libido Systemic illness Loss of libido Systemic illness
Stress Medication
Fatigue Alcohol
Depression Sexual arousal disorders
Erectile dysfunction Alcohol Dyspareunia Infection
Drugs Vaginismus Psychosomatic
Endocrine disorders, e.g. DM Infection
Vascular disease, e.g. atherosclerosis Anorgasmia
Neuropathy, e.g. MS
Answers
31. F T T T F
32. T T F T T
33. T T T T T
ONE STOP DOC 92
34. Ageing and fertility
a. Ageing is synonymous with the term senescence
b. Fertility is highest in women in their thirties
c. The ability to conceive decreases after the age of 35 years
d. A post-menopausal female is infertile
e. Testosterone levels decrease as men increase in age
35. Concerning the menopause
a. It is defined as the last menstrual cycle
b. Oestrogen levels decrease
c. It is often preceded by irregular cycles
d. Circulating levels of gonadotrophins decrease
e. Hot flushes and night sweats are common
36. How may menopausal symptoms be managed? Outline the benefits and risks
37. Post-menopausal bleeding
a. Is considered to be of malignant origin until proven otherwise
b. Is classified as bleeding occurring more than one year after the last menstrual cycle
c. Should always be investigated
d. Is a late sign of malignant disease
e. May be benign
HRT, hormone replacement therapy
Development and ageing of the reproductive tracts 93
EXPLANATION: FERTILITY CHANGES WITH AGE AND THE MENOPAUSE
Ageing begins at conception and is a description of what happens with the passage of time. Senescence
describes deterioration related to dysfunction and disease and typically begins in middle age.
In general, women are most fertile in their twenties, declining thereafter. The capacity to conceive declines
rapidly after the age of 35 years. The menopause marks the end of female reproductive capacity, resulting from
the exhaustion of functional ovarian follicles and the last menstrual cycle. Oestrogen levels fall (remaining
low levels of oestrogen are produced via peripheral conversion of adrenal steroids) and gonadotrophin secre-
tion increases. Common immediate side effects of the menopause are hot flushes, night sweats, insomnia and
depression. These may be relieved with the use of HRT.
Men do not experience a similar dramatic decrease in fertility, and spermatozoa are normally produced
throughout life. However, there is a gradual decrease in testosterone production as men increase in age. Loss
of libido, erectile dysfunction and failure occur with higher frequency after the age of 40 years.
The benefits and risks of HRT are summarized in the table below (36).
Benefits Risks
Gives good and immediate symptom relief Increases risk of thromboembolism (risk highest in
first year of treatment)
Reduces risk of osteoporosis and related fractures Increases breast cancer risk (increases with each
year of use)
Reduces risk of colon cancer Increases risk of vascular disease (e.g. heart attacks,
strokes)
May reduce incidence of Alzheimers disease Oestrogen-only preparations increase the risk of
endometrial cancer
NB: In osteoporosis there is reduced bone mass, resulting in fragile bones and an increased risk of
fractures.
Post-menopausal bleeding is defined as bleeding from the genital tract occurring six months or more after
the menopause. It is a serious symptom that is considered to be an early sign of malignant disease until proven
otherwise. Thus it always warrants investigation. However, it may have a benign cause. Causes of post-
menopausal bleeding include neoplasia of the reproductive tract, vaginitis, polyps or foreign bodies.
Answers
34. F F T T T
35. T T T F T
36. See explanation
37. T F T F T
ONE STOP DOC 94
SEXUAL DIFFERENTIATION: continued from page 73.
TIME COURSE OF EMBRYOLOGICAL DEVELOPMENT
Week 3: Somatic sex cord formation (later differentiating into follicular granulosa cells in the female and
Sertoli cells in the male)
Week 4: Mesonephric (Wolffian) ducts develop (later developing into the vasa deferentia and epididymis in
the male, whilst in the female, they regress)
Week 6: Paramesonephric (mullerian) ducts develop (in the female, these later develop into the fallopian
tubes, uterus and superior vagina; whilst in the male, they regress. Abnormal fusion of the mullerian ducts
may result in a bifurcate uterus)
Week 7: Indifferent external genitalia develop
Week 9: Paramesonephric duct fusion begins
Week 12: Differentiation of external genitalia begins.
Genital
tubercle
Urethral fold
Labioscrotal
swelling
Urogenital
slit
Undifferent genitalia
Anal pit
Tail
Clitoris
Urethral meatus
Labium minus
Labium majus
Vaginal
orifice
Anus
Female genitalia
Urethral
meatus
Anus
Glans penis
Scrotum
Raphe
Male genitalia
CONCEPTION, PREGNANCY
AND LABOUR
SECTION
5
FERTILIZATION 96
CONTRACEPTION 98
PLACENTAL STRUCTURE AND
DEVELOPMENT 100
PLACENTAL FUNCTION 102
MATERNAL PHYSIOLOGY 104
FETAL AND PERINATAL PHYSIOLOGY 106
LABOUR 108
THE BREAST AND LACTATION 110
CONCEPTION, PREGNANCY
AND LABOUR
SECTION
5
1. Concerning capacitation of spermatozoa
a. Tail movements increase and promote sperm motility
b. It releases enzymes to dissolve the zona pellucida
c. Loss of glycoprotein molecules occurs
d. It occurs in the female genital tract
e. It follows the acrosome reaction
2. The acrosome reaction
a. Occurs after fertilization
b. Occurs within the male reproductive tract
c. Involves break down of the spermatozoan acrosome
d. Enables penetration of the zona pellucida of the oocyte
e. Is essential in order for fertilization to occur
3. Concerning fertilization
a. It involves the fusion of male and female gametes
b. The diploid state of the embryo is necessary for normal development
c. Polyspermy may be prevented by a rise in intracellular Ca
2+
in the oocyte
d. ZP3 is initially responsible for binding the spermatozoon to the oocyte
e. It is most likely to occur in the fallopian tubes
4. Concerning subfertility in the male and female
a. Sperm defects contribute to more than 20 per cent of subfertility causes in the
population
b. Failure to conceive within three months of unprotected intercourse is clinically defined
as subfertility
c. Subfertility may be caused by endometriosis
d. In vitro fertilization always results in a viable pregnancy
e. Intracytoplasmic sperm injection is indicated in women who have decreased numbers of
viable oocytes
IVF, in vitro fertilization; ICSI, intracytoplasmic sperm injection
Conception, pregnancy and labour 97
EXPLANATION: FERTILIZATION
Fertilization involves the fusion of two haploid gametes (e.g. a sperm and an ovum) to form one diploid zygote
(a fertilized ovum). Freshly ejaculated spermatozoa must undergo two processes before they are able to fertilize
an ovum.
1. CAPACITATION This typically occurs within the female reproductive tract and involves two important
events: (a) increased tail movements to increase motility and (b) stripping of glycoproteins from the sper-
matozoon membrane, which alters surface membrane properties. An increase in Ca
2+
sensitivity of the sper-
matozoon is also seen.
2. THE ACROSOME REACTION This renders the spermatozoa capable of penetrating the zona pellucida of the
ovum. ZP3 on the surface membrane of the ovum binds to ZP3 receptors on the spermatozoa. This induces
the spermatozoon to swell, revealing inner membranes and uncovering the ZP2 receptors. ZP2 is responsible
for the binding of the sperm and oocyte to allow penetration. This reaction must occur within close proxim-
ity to an oocyte because acrosome-reacted sperm do not survive for long.
The most common site for fertilization is within the fallopian tubes. A rise in intracellular Ca
2+
in the oocyte:
(a) prevents polyspermy, (b) depolarizes the egg cell membrane, (c) induces the cortical reaction and (d)
induces the resumption of meiosis and expulsion of the second polar body.
Subfertility may be defined clinically as a failure to conceive within one year of unprotected intercourse. Both
partners may contribute to this. Causes are compared in the following chart.
There are currently two main assisted conception techniques:
IVF: This involves mixing sperm with one or more ovum, allowing fertilization and early embryo develop-
ment to occur outside of the body (in vitro). The developing embryo is then placed in the female tract,
allowing implantation to occur naturally. This procedure is referred to as one IVF cycle. Despite imple-
menting fertilization, IVF frequently does not result in a viable pregnancy.
ICSI: This involves injecting one spermatozoon into the ooplasm of the ovum in vitro before continuing
with an IVF cycle. It is used in cases of severe male subfertility.
Answers
1. T F T T F
2. F F T T T
3. T T T T T
4. T F T F F
50
40
30
20
10
0
A Endometriosis
B Tubal factor
C Ovulatory problems
D Sperm defects
E Unexplained
= Between
i.e. A = 515%
frequency
A B C D E
P
E
R

C
E
N
T

F
R
E
Q
U
E
N
C
Y
ONE STOP DOC 98
5. Concerning non-hormonal methods of contraception
a. They may all be classified as barrier methods of contraception
b. The natural method is most effective in women with irregular menstrual cycles
c. The intrauterine device may remain in the uterus for up to 10 years
d. The male condom must be placed on the flaccid penis prior to intercourse
e. The diaphragm does not protect against infection transmission
6. Briefly outline mechanisms of producing permanent contraception in both the female
and male
7. Concerning contraception in the female
a. The combined oral contraceptive pill may prevent implantation of the fertilized ovum
b. Depot injections result in high progestogen levels similar to those that occur in
pregnancy
c. The intrauterine device may interrupt the implantation of a fertilized ovum
d. The progestogen-only pill blocks the luteinizing hormone surge mid-cycle, thus
suppressing ovulation
e. The combined oral contraceptive pill increases the risk of thromboembolic disease
8. Write short notes on the natural method of contraception
9. Rank the following methods of contraception in order of their failure rates, starting
with the method with the highest failure rate
A. Sterilization B. Combined oral contraceptive pill
C. Male condom D. Natural method
E. Implant
COCP, combined oral contraceptive pill; POP, progestogen-only pill; PMS, premenstrual syndrome; IUD, intrauterine device
Conception, pregnancy and labour 99
EXPLANATION: CONTRACEPTION
The available non-hormonal methods of contraception are described in the following table.
Condom Diaphragm IUD Natural (8) Sterilization (6)
Description Latex sheath Rubber cap Small plastic or Sexual intercourse Permanent
used with copper device avoided during surgical
spermicide fertile period of contraception
menstrual cycle
Administration Placed over Fitted prior to Inserted into Measurement of Bilateral
erect penis intercourse to the uterus via basal body vasectomy in
or inside cover cervix cervix temperature, male, fallopian
vagina prior cervical mucus tube ligation in
to intercourse changes and female
ovulation timing
Mode of action Barrier Barrier Interrupts sperm Prevents sperm Sperm-free
migration and encountering ejaculate,
implantation of ovum prevents oocyte
ovum encountering
sperm
Failure rate 23 per cent 35 per cent 0.31 per cent 535 per cent 00.5 per cent
per cent female
per hundred 0.02 per cent
woman years male
Advantages Helps prevent Female is May remain in No side effects Permanent.
infection in control. uterus up to Useful for those
transmission Reusable 5 years. May who have
be used as finished their
emergency families
contraception
Disadvantages Requires Not protective May cause Requires regular Permanent, risk
motivation against sexually heavy periods, menstrual cycles of failure
transmitted does not
diseases protect against
infection
transmission
Answers
5. F F F F T
6. See explanation
7. T T T F T
8. See explanation
9. 1 D, 2 C, 3 B, 4 E, 5 A
The available hormonal methods are described in the table on page 112.
ONE STOP DOC 100
10. Concerning implantation
a. The embryo remains in the fallopian tube until the late morula/early blastocyst stage
b. A morula is formed from the rapidly dividing zygote
c. The syncytiotrophoblast develops into the trophoblast
d. Implantation occurs approximately 15 days post fertilization
e. Initially the trophoblast invades the endometrium
11. Concerning hormone levels in the early stages of pregnancy
a. The fertilized ovum may implant in the uterus without progesterone support
b. The corpus luteum is sustained by the release of progesterone from the developing
trophoblast
c. Human chorionic gonadotrophin is produced by the trophoblast
d. The corpus luteum regresses from approximately week 7 of gestation
e. Human chorionic gonadotrophin is produced following implantation
12. Concerning the placenta
a. The syncytioblast acts as the interface between maternal and fetal blood
b. The decidua basalis lies between the myometrium and the syncytiotrophoblast
c. The umbilical cord is comprised of two umbilical veins and one umbilical artery
d. The intervillous space contains fetal blood
e. The placenta develops from the trophoblast
13. Match the following placental structures with the statements
Options
A. Carries oxygenated blood to the fetus
B. Carries deoxygenated blood to the maternal circulation
C. Lies in the decidua basalis
D. Carries maternal blood
E. Synthesizes placental hormones
1. Trophoblast 2. Umbilical vein
3. Umbilical artery 4. Intervillous space
5. Endometrial vein
hCG, human chorionic gonadotrophin
Conception, pregnancy and labour 101
EXPLANATION: PLACENTAL STRUCTURE AND DEVELOPMENT
Embryo development and implantation are illustrated in the diagram below.
Implantation occurs approximately 67 days post ovulation.
The embryo is unable to implant in the uterus without progesterone support. The corpus luteum produces
progesterone, inhibin and relaxin until week 9 of gestation, when it regresses. At this point, the developing
trophoblast (placenta) takes over the production of progesterone. hCG is produced by the trophoblast fol-
lowing implantation and secreted into the maternal bloodstream. It acts on the corpus luteum to stimulate
continued progesterone secretion.
Answers
10. T T F F T
11. F F T F T
12. T T F F T
13. 1 E, 2 A, 3 B, 4 D, 5 C
Morula Blastocyst Zygote
Fallopian
tube
Rapidly
dividing zygote
Endometrial
epithelium
Endometrial
stroma
Maternal
blood vessels
Trophoblastic
lacunae
Uterus
Trophoblast
Invading
trophoblast
Blastocoele
Syncytiotrophoblast
Yolk sac cavity
Amniotic cavity
Chorionic villus
Chorionic
plate
Umbilical vein
Carries oxygenated
blood from the placenta
to fetus
Two umbilical arteries
Carry deoxygenated
blood from fetus to
placenta
Intervillous space filled
with maternal blood
Endometrial veins
Carry deoxygenated
blood from intervillous
space to maternal
circulation
Endometrial arteries
Carry oxygenated
blood from the maternal
circulation to placenta Syncytioblast
Decidua
basalis Myometrium
The Placenta
ONE STOP DOC 102
14. Concerning respiratory gas exchange in the placenta
a. Exchange of O
2
from mother to fetus occurs down a concentration gradient
b. CO
2
tension is high and O
2
tension is low in the maternal circulation
c. At the same partial pressure of O
2
, saturation in fetal blood is significantly lower than
that in maternal blood
d. The O
2
binding ability of fetal haemoglobin is greater than that of adult haemoglobin
e. The double Bohr effect facilitates increased O
2
transfer from mother to fetus
15. Concerning placental function
a. The placenta secretes luteinizing hormone
b. Human placental lactogen is secreted by the placenta
c. Na
+
and water are able to cross the placenta by simple diffusion
d. Amino acids may cross the placenta by special transport mechanisms
e. Maternal IgG cannot cross the placenta, whereas IgM can
16. Briefly explain the physiology of the double Bohr effect, using a diagram if required
hCG, human chorionic gonadotrophin; hPL, human placental lactogen; IgM, immunoglobulin M; IgG, immunoglobulin G
Conception, pregnancy and labour 103
EXPLANATION: PLACENTAL FUNCTION
The placenta has five main functions:
1. SYNTHESIS OF HORMONES INVOLVED IN THE MAINTENANCE OF PREGNANCY The placenta secretes many
steroid and peptide hormones that act locally (within the placenta) or systemically. The main placental hor-
mones are hCG (until week 9 only), progesterone, oestrogens (mainly oestradiol and oestriol), hPL and
relaxin.
2. RESPIRATORY GAS EXCHANGE The partial pressure of O
2
in fetal blood is low and that of CO
2
is high
when compared with maternal blood. Gradients therefore exist to drive diffusion. In addition, fetal haemo-
globin has an increased binding ability for O
2
compared with adult haemoglobin due to a difference in
haemoglobin chain morphology. The double Bohr effect further facilitates O
2
transfer to the fetus. A fall in
the pH of maternal blood, due to uptake of fetal CO
2
, drives the release of maternal O
2
. The rise in fetal pH,
due to the removal of CO
2
, facilitates the uptake of O
2
. Thus, the O
2
saturation of fetal and maternal blood
is similar (see diagram) (16). Note that fetal blood has a greater O
2
concentration than maternal blood at any
given O
2
tension (see diagram).
3. NUTRIENT TRANSFER AND WASTE
PRODUCTION Simple diffusion between
fetal and maternal circulation facilitates
the transport of low molecular weight
molecules, e.g. Na
+
, water, urea, fatty acids
and lipid-soluble steroids. Special trans-
port mechanisms exist for the transfer of
complex sugars, conjugate steroids, amino
acids, vitamins, plasma proteins and cho-
lesterol.
4. HEAT TRANSFER
5. IMMUNOLOGICAL PROTECTION The
placenta prevents rejection of the fetus by
the maternal immune system. Maternal
IgM cannot cross the placenta, whereas
IgG can.
Answers
14. T F F T T
15. F T T T F
16. See explanation
20
18
16
14
12
10
8
6
4
2
0
20 60 100
O
2
TENSION (mmHg)
O
2

C
O
N
C
E
N
T
R
A
T
I
O
N

(
m
L
/
1
0
0

m
L
)
pH 7.4
pH 7.2
pH 7.4
pH 7
FETAL
MATERNAL
ONE STOP DOC 104
17. Concerning the endocrine system during pregnancy
a. Prolactin secretion is depressed due to increased secretion of oestrogen
b. Circulating progesterone levels rise until term
c. Increased placental progesterone and oestrogens prevent further follicular development
d. Human placental lactogen release declines towards term
e. Human chorionic gonadotrophin levels continue to rise throughout pregnancy
18. Concerning the cardiovascular system
a. Generalized vasoconstriction occurs during pregnancy
b. Maternal plasma volume increases
c. Blood pressure normally decreases in pregnancy
d. Heart rate and stroke volume increase
e. Ejection systolic murmurs are common due to increased maternal cardiac output
19. During pregnancy
a. The level of the diaphragm rises and the ribcage expands, causing an increase in
ventilation rate
b. Fat stores become depleted by the demands of the fetus
c. Varicose veins and ankle oedema are common
d. Gas exchange in the maternal lungs is increased
e. Thromboembolism is more common than in the non-pregnant state
20. Concerning the immune system
a. Cellular immunity increases during pregnancy
b. Pregnant women are more susceptible to viral infections
c. Rhesus isoimmunization may result from a rhesus-negative mother carrying a rhesus-
positive child
d. Rhesus anti-D disease may occur if a direct exchange occurs between maternal and
fetal blood
e. Maternal rhesus anti-D disease may cause a haemolytic anaemia in the fetus
GFR, glomerular filtration rate; T3, triiodothyronine; T4, thyroxine; TBG, thyroxine-binding globulin; HR, heart rate; SV, stroke volume; IVC, infe-
rior vena cava; IgM, immunoglobulin M; IgG, immunoglobulin G; Rh, rhesus; hPL, human placental lactogen; hCG, human chorionic
gonadotrophin
Conception, pregnancy and labour 105
EXPLANATION: MATERNAL PHYSIOLOGY
Physiological and structural changes occur in pregnancy to
support the fetus, and prepare for labour and breast-feeding.
Multiple pregnancies cause more marked physiological adap-
tations, as the demands on the mother are greater.
Rhesus isoimmunization occurs due to an incompatibility of maternal and fetal blood antigens. If an
exchange between maternal and fetal blood occurs (e.g. during invasive procedures or at delivery) then an
immune response is mounted in the form of IgMproduction. Because IgM cannot cross the placenta, the fetus
is not affected. If, during a subsequent pregnancy, repeat exposure to the same red blood cell antigen occurs,
then IgG antibodies are produced. IgG antibodies cross the placenta easily and cause red cell destruction and
a haemolytic anaemia in the fetus. This most commonly occurs in Rh-negative mothers with an Rh-posi-
tive fetus. Rh anti-D prophylaxis may be given in these cases.
Answers
17. F T T T F
18. F T T T T
19. T F T T T
20. F T T T T
P
L
A
S
M
A

H
O
R
M
O
N
E
C
O
N
C
E
N
T
R
A
T
I
O
N
0 10 20 30 40 (TERM)
WEEKS OF PREGNANCY
hCG
hPL
OESTRIOL
OESTRADIOL
PLACENTA
OESTROGENS
Prolactin
LH + FSH
PROGESTERONE LH + FSH
Respiratory system
Ventilatory rate to
gaseous exchange
No change in vital capacity
Rib cage expands + diaphragm
rises to accommodate fetus
Thyroid gland
Enlarges
Produces T3, T4, + TBG
Cardiovascular system
Blood pressure due to general vasodilatation
Cardiac output (as HR + SV)
Gastrointestinal system
Gut motility
Adsorption
Varicose veins
Common due to venous congestion
caused by uterus obstructing the IVC
Ankle oedema
Water retention may cause slight ankle oedema
Kidneys
Cortisol release from adrenal
gland
GRF
Fat stores during pregnancy
Adipose tissue
ONE STOP DOC 106
21. Concerning the first breath of life
a. It requires a large inspiratory effort by the fetus
b. Breathing movements are practised in utero prior to parturition
c. Surfactant may be produced in fetal lungs from week 20
d. Surfactant production is stimulated by fetal corticosteroids
e. It may be prompted by light, cold and noxious stimuli
22. Match the following congenital heart defects with the correct statement
Options
A. May occur in approx. 10 per cent of adults
B. Is the most common congenital heart defect
C. May take up to a year to close in normal babies
D. Is a defect in the septum between the right and left hand side of the heart
1. Ventricular septal defect
2. Atrial septal defect
3. Patent ductus arteriosus
4. Persistent foramen ovale
23. Concerning the fetal circulation
a. The ductus arteriosus diverts blood away from the liver
b. It requires blood flow from the fetal lungs to maintain high left-sided pressures in the
heart
c. The ductus venosus diverts blood away from the fetal lungs
d. The foramen ovale enables oxygenated blood to flow from the right to the left side of the
heart
e. The fetal lungs are the site of gaseous exchange in utero
24. Briefly outline how the fetal circulation changes at birth
RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; FO, foramen ovale; DA, ductus arteriosus; VSD, ventricular septal defects;
PDA, patent ductus arteriosus; ASD, atrial septal defects; PS, pulmonary stenosis
Conception, pregnancy and labour 107
EXPLANATION: FETAL AND PERINATAL PHYSIOLOGY
The fetal and adult circulations are compared in the following diagram.
The fetal circulation differs from that in the adult because the organ of gaseous exchange is the placenta and
not the lungs. The FO and DA act as shunts, enabling blood to bypass the developing fetal lung. This opti-
mizes O
2
delivery. A third shunt, the ductus venosus, diverts blood away from the liver. At birth, these shunts
are designed to close so that the lungs are perfused and gaseous exchange is maintained in the absence of
the placenta.
During labour, the delivery of O
2
and nutrients to the fetus is reduced. This prompts the fetal circulation to
pass through the lungs, causing a drop in pressure in the right side of the heart. The return of blood from the
lungs causes increased pressure in the left side of the heart, reversing the blood flow through the DA and
prompting its collapse. These pressure changes also cause the FO to close, allowing the heart to work as two
pumps in series rather than one in parallel. The DA is closed permanently in most individuals by one year of
age. The FO closes more slowly and remains patent in 10 per cent of adults (24).
Congenital heart defects occur in approx. 8 per 1000 births. The most common include VSD (25 per cent),
PDA (15 per cent), ASD (15 per cent) and PS (10 per cent).
RESPIRATORY FUNCTION CHANGES AT BIRTH
The fetus mimics breathing movements while in utero for reasons that are not fully understood. They may
carry an element of practice but also promote growth and development by distending the fetal lungs.
Primitive air sacs in the lungs are present at week 20, blood vessels at week 28 and surfactant from week 30.
Surfactant forms a surface film over the alveolus, reducing the pressure required to expand the fetal lung.
Surfactant synthesis is promoted by fetal corticosteroids that rise towards delivery.
Mechanisms that may promote the large inspiratory effort at birth include cold and light exposure, auditory
and noxious stimuli.
Answers
21. T T F T T
22. 1 B, 2 D, 3 C, 4 A
23. F F F T F
24. See explanation
RA
PLACENTA
LV
BODY
LA
DA
LUNGS
RV
Present in adult
Present in fetus
Present in fetus
+ neonate
FO
ONE STOP DOC 108
25. Regarding the onset of labour
a. It is considered to be normal if between weeks 37 and 40 of gestation
b. Post-maturity may be defined as labour occurring after 40 weeks
c. It is recognized by the presence of Braxton-Hicks contractions
d. Contractions may be augmented with oxytocin
e. Contractions increase in frequency and duration as labour progresses
26. Match one of the three stages of labour with the most appropriate statement
Options
A. The placenta is delivered
B. Ends at full cervical dilatation
C. Contractions slowly subside
D. May be initiated due to fetal hypothalamic maturation
E. Ends with the expulsion of the fetus
1. First stage of labour
2. Second stage of labour
3. Third stage of labour
27. List the hormones that are important in parturition and state their functions
Conception, pregnancy and labour 109
EXPLANATION: LABOUR
Labour is the process by which the fetus, placenta and membranes are expelled from the uterus by
co-ordinated myometrial contractions. This normally occurs between 37 and 42 weeks of gestation.
Premature labour occurs prior to 37 weeks and post-mature labour occurs after 42 weeks. The onset of labour
may be recognized by the conversion of non-painful Braxton-Hicks contractions to painful, regular con-
tractions and cervical ripening (dilatation and shortening).
The factors that trigger labour are not fully understood. A number of contributory factors may be involved:
Increased fetal adrenal activity
Maturation of fetal hypothalamus
Distension of uterus stimulating oxytocin production
Local production of prostaglandins
Alterations in oestrogen/progesterone ratio
Circadian rhythms.
Labour is divided into three distinct stages:
First stage Second stage Third stage
Onset Regular, painful contractions Full cervical dilatation Birth of the fetus
Outcome Cervical softening and dilatation, Fetal head engages with pelvis, Uterine contractions
increase in uterine contractions, uterine contractions increase, subside, delivery of
fetal head descends into pelvis, delivery of baby placenta and membranes
membranes rupture
The hormones involved in progression of labour and their functions are listed below (27).
Hormone Function
Oestrogen Stimulates production of oxytocin receptors in myometrium prior to labour
Stimulates myometrial prostaglandin synthesis
Oxytocin Stimulates and augments uterine contractions
Stimulates prostaglandin production
NB: Exogenous oxytocin can augment the first stage of labour and accelerate the third stage
Prostaglandin Stimulates Ca
2+
release to augment myometrial muscle contraction
Involved in cervical ripening
Relaxin Promotes pelvic ligament relaxation prior to parturition
Softens cervix
Answers
25. T F F T T
26. 1 B, D, 2 E, 3 C, A
27. See explanation
ONE STOP DOC 110
28. Draw a simple diagram of the female breast
29. Regarding lactation
a. Prolactin stimulates and regulates milk production
b. Prolactin levels rise at the onset of labour
c. Oestrogen potentiates the action of prolactin
d. Prolactin inhibits the production of follicle-stimulating hormone and luteinizing hormone
e. Suckling stimulates both prolactin and oxytocin secretion
30. Using a diagram, outline the mechanism of the suckling reflex
31. Concerning breast-feeding of the infant
a. Breast milk confers immunity to the infant
b. Breast milk contains lipids, proteins, vitamins and immunoglobulins
c. Colostrum is secreted for the first 45 days after delivery
d. Colostrum is low in protein and high in fat
e. Is contraindicated in mothers who are HIV positive
PRL, prolactin; IgG, immunoglobulin G; HIV, human immunodeficiency virus
Conception, pregnancy and labour 111
EXPLANATION: THE BREAST AND LACTATION
The most important hormone involved in lactation and the suckling reflex is PRL. Levels of PRL rise through-
out pregnancy and remain high until approximately 46 weeks after delivery. After this period, continued breast-
feeding is necessary to stimulate the release of prolactin from the anterior pituitary via the suckling reflex.
Suckling also induces the secretion of oxytocin from the posterior pituitary. Oxytocin acts on the mysepithelial
cells of the mammary alveoli to cause milk ejection. Progesterone and oestrogen inhibit the action of PRL,
thus lactation does not occur prior to delivery when oestrogen levels are still high.
Colostrum is secreted during late pregnancy
and for the first 45 days after delivery. It is a
thick yellow fluid that has a high protein and
low fat content. Breast milk is composed of
lipids, milk proteins, vitamins, minerals and
IgG. It is high in fat, providing a source of
energy.
Breast-feeding increases bonding between
mother and baby, reduces the incidence of
allergies in later life and leads to an improved
immune system for the baby. It is not recom-
mended for mothers who are infected with:
HIV
Cytomegalovirus
Hepatitis B and/or C due to the risk of
transmission from mother to baby.
Answers
28. See diagram
29. T F F T T
30. See diagram
31. T T T F T
Lactiferous duct
Areola
Ampulla of lactiferous
duct
Lobule
Adipose tissue
Suspensory ligaments
(Coopers)
Clavicle
Pectoralis minor muscle
Pectoralis major muscle
2nd rib
3rd rib
4th rib
5th rib
6th rib
Higher neural
centres
Hypothalamus
+
+ +
+
+
+
Posterior pituitary Anterior pituitary
PRL
Milk
production
Milk
ejection
Baby
suckling
Oxytocin Nipple stimulation
sends neural
messages via
anterolateral
columns to higher
neural centres
CONTRACEPTION: continued from page 99.
Hormonal methods of contraception are listed in the table below.
COCP POP Depot injection Implants
Description Synthetic oestrogen Synthetic Synthetic Synthetic
and progestogen progestogen progestogen progestogen
Administration Oral, taken for Oral, taken Intramuscular Subcutaneous
21 days with a continuously at injection implantation
7-day gap for the same time
withdrawal bleed every day
Mode of action Multiple sites of Inhibits sperm Suppression of Prevents
action: suppression transport in ovulation ovulation
of ovulation, cervical mucus
implantation
interference
Failure rate 0.20.3 per cent if 0.30.4 per cent 01 per cent 01 per cent
per cent protocol followed
per hundred correctly
woman years
Advantages May decrease PMS, Useful if women Do not need to Same as for
menstrual bleeding, cannot use remember to depot
pain and acne COCP take pill daily
Disadvantages Increased risk of Irregular bleeding, Same as for POP Same as for
thromboembolic breast discomfort, plus weight gain POP, may be
disease, PMS, increased and loss of bone difficult to
dyslipidaemia, risk of ectopic density remove due to
hypertension pregnancy fibrosis formation
COCP, combined oral contraceptive pill; POP, progestogen-only pill; PMS, premenstrual syndrome
ONE STOP DOC 112
INDEX
absolute refractory period 91
absorption 39, 43
acarbose 67
ACE inhibitors 69
acidosis, metabolic 55
acromegaly 11, 18, 63
acrosome reaction 96, 97
Addisons disease 52, 53
primary 55
adenylate cyclase 35
adipose tissue 223
adrenal adenoma 53, 55
adrenal androgens 49, 75
adrenal carcinoma 53
adrenal cortex 479, 75
adrenal glands 3, 4557
anatomy 467
development 47
glucocorticoids 523
mineralocorticoids 545
steriodogenesis 4951
adrenal hyperplasia 55
adrenal medulla 47, 567
adrenal receptors 49
adrenaline 53, 567, 61, 109
adrenarche 75
adrenergic symptoms 61
adrenocorticotrophic hormone (ACTH) 13, 15, 49,
55, 75
adrenomedullary hypersecretion 57
adrenomedullary hyposecretion 57
age
and endocrine function 21
and fertility 923
albumin 69, 87
aldosterone 53, 54, 55
alpha cells (pancreatic) 59
alpha-glucosidase inhibitors 67
amino acids 9, 19
anaemia, haemolytic 105
androgen-insensitivity syndrome 77
androgens
adrenal 49, 75
physiological effects 889
testicular 85, 879
angiotensin II 55
anorgasmia 91
anti-mullerian hormone (AMH) 77
antibodies 5, 35, 63
see also autoantibodies
antidiuretic hormone (ADH) 16, 17
antithyroid drugs 37
appetite 23
assisted conception techniques 97
ATP-sensitive K
+
channels 67
atrial septal defects (ASD) 107
autoantibodies 34, 35
autoimmune diseases 35, 55, 63
axillary hair growth 75
axons 13, 17
barbiturates 43
basal body temperature 83
basal metabolic rate (BMR) 31, 35
basolateral membrane 41
beat-blockers 37
beta cells (pancreatic) 59, 63, 67
beta-adrenergic activity 31, 35
biguanides 67
binding affinity 5
bioassays 5
biological clock 21
bleeding, post-menopausal 92, 93
block-replacement regimen 37
blood
fetal 105
hormones in 3
maternal 103, 105
blood pressure 17, 57, 69, 107
see also hypertension; hypotension
body temperature 83
bone 39, 40, 41
mineral:matrix ratio 43
bow-legs 43
brain 3, 61
Braxton-Hicks contractions 109
breast 11011
breast milk 111
breast-feeding 105, 111
bruising 53
C-cells (parafollicular cells) 27, 41
Ca
2+
and fertilization 97
regulation 3843
transport (transcaltachia) 41
Ca
2+
ATPase pump 41
Ca
2+
-binding proteins (calbindins) 41
calcitonin 27, 41
calorigenesis 31
carbimazole 37
carbohydrates 18, 19, 31
INDEX 114
carbon rings, hexagonal/pentagonal 51
cardiac output 31
cardiovascular disease 69
cardiovascular system 31, 104, 105
cataract 69
catecholamines 47, 57, 61
catecholmethyltransferase (COMT) 57
cell membrane 7
cervix
mucus 83
ripening 109
challenge tests 10, 11
chief cells 27
cholecystokinin (CCK) 9
cholesterol 49, 50, 51
low-density lipoprotein (LDL) 69
cholesterol ester hydroxylase 49
chromaffin cells 47
chromate salts 47
chromosomes 73, 79
circadian (diurnal) rhythms 13, 201, 53, 109
circulation, fetal 106, 107
clear cells 9
clinical endocrinology 45
clock genes 21
CO
2
103
coelmic cavity 47
collecting ducts 17
colloids 29
colostrum 111
combined oral contraceptive pill (COCP) 112
conception 957
condoms 99
congenital 17 alpha-hydroxylase deficiency 51
congenital adrenal hyperplasia 77
congenital disorders 267, 33, 51, 77, 1067
congenital heart defects 106, 107
congenital lipoid adrenal hyperplasia 51
congenital virilizing adrenal hyperplasia 51
Conns syndrome 54, 55
contraception 989
hormonal methods 112
non-hormonal methods 98, 99
corpus albicans 83
corpus luteum 79, 83, 101
corticosterone methyl oxidase deficiency 51
corticotrophin-releasing hormone 11
cortisol 52, 53, 61
cortisol-binding globulin (CBG) 53
cretinism 27, 33
Cushings syndrome 52, 53
cyclic adenosine monophosphate (cAMP) 41, 49
cytoplasm 7, 9
7-dehydrocholesterol 41
deiodinase enzymes 31
delta cells 59
deoxyribonucleic acid (DNA) 7
depot injections 112
diabetes insipidus 16, 17
diabetes mellitus 19, 53, 61, 629
complications 689
control 69
diagnosis 645
education/support for 65
features 63
and hyperglycaemia 61
lifestyle changes and 64, 65
macrovascular complications 69
management 63, 647
microvascular complications 69
pharmacological management 667
type 1 623, 667
type 2 625, 67
diabetic neuropathy 69
diaphragm 99
diencephalon 11
diet 63, 65, 67
diffusion 103
5-alpha-dihydrotestosterone 87
diiodotyrosine (DIT) 29
diploid set 79, 85, 97
direct membrane effects 7
distal convoluted tubule 17, 41
double Bohr effect 102, 103
ductless glands 3
ductus arteriosus (DA) 107
ductus venosus 107
duodenum 9
dyspareunia 91
ectopic ACTH syndrome 53
embryo 97, 101
endocrine systems 124
adipose tissue 223
circadian rhythms 201
clinical endocrinology 45
and disease 3
gastrointestinal hormones 89
growth 1819
hypothalamus 1011
microstructure of the endocrine system 67
Index 115
pituitary gland 1017
pituitary hormones 1215
in pregnancy 104, 105
endodermal floor 17
endometrium 82, 83
energy 23, 61
enzymes 31, 51, 67
epithelium 9, 27
erectile dysfunction 91, 93
excitement (sexual arousal) 91
excretion 39, 55
exocytosis 39
eye signs 35
fallopian tube 79, 97
fasting state 60, 61, 64, 65
fasting venous plasma glucose level 65
fatty acids 9
feedback 4, 5
negative 5, 17, 35, 77, 81, 83
over-ride 11
positive 5, 17, 81
in the reproductive system 77, 80, 83, 86, 87
tests of 11
fertility 923
see also infertility; subfertility
fertilization 967
fetal haemoglobin 103
fetus 105
adrenal activity 109
blood 105
circulation 106, 107
gaseous exchange 103
heart 107
physiology 1067
fluid intake, restricted 17
follicle-stimulating hormone (FSH) 13, 15
and delayed puberty 77
and gonadal function 81, 87
and menstruation 83
follicles
Graafian 78, 79, 81, 93
thyroid 27, 29, 33, 35
foramen ovule (FO) 107
foreign bodies 93
fracture 43
functional groups 51
G-cells 9
gall bladder 9
gametes 97
gametogensis 789
gaseous exchange, placental 102, 103, 107
gastric inhibitory peptide (GIP) 9
gastrin 9
gastrointestinal (GI) enzymes 67
gastrointestinal (GI) hormones 89
gastrointestinal (GI) tract 3
genes 73
genotypes 73, 77
glands 3
see also specific glands
glibenclamide 67
gliclazide 67
glucagon 59, 601
glucagonoma 61
glucocorticoid disease 52, 53
glucocorticoids 49, 523
glucose 9, 19
control of 69
fasting venous plasma glucose level 64, 65
home monitoring 65
homeostasis 601
uptake 67
glycoproteins 97
glycosuria 61
goitre 33, 35
goitrogens 32, 33
gonadal sex steroid hormones 75, 77
gonadotrophin 93
gonadotrophin-releasing hormone (GnRH) 11
and delayed puberty 77
and female gonadal function 80, 81
and puberty 75
gonads 75, 77
function 801, 867
Graafian follicles 78, 79, 81, 93
Graves disease 3, 33, 34, 35
growth 1819, 31
growth hormone (GH) 3, 11, 13, 15, 18
and glucose homeostasis 61, 63
hypersecretion 18, 19
hyposecretion 18, 19
and puberty 75
regulation 19
secretion 19, 20, 21
growth hormone-releasing hormone (GHRH) 11
growth spurt, adolescent 75
gut 43
haemoglobin, fetal 103
haemolytic anaemia 105
INDEX 116
hair growth, axillary/pubic 75
haploid set 79, 85, 97
Hashimotos thyroiditis 33
heart, fetal 107
heart defects, congenital 106, 107
heat transfer 103
hermaphroditism, secondary 76, 77
homeostasis 39, 601
hormonal control systems 4, 5
hormone replacement therapy (HRT) 93
hormone-receptor complex 7
hormones 2
see also specific hormones
of the adrenal medulla 567
biological responses to 5
biologically active 31
definition 3
excess secretion 3
feedback systems 5
gastrointestinal 89
of labour 108, 109
pancreatic 59
peptide 6, 103
pituitary 1215
plasma content 5
polypeptide 7
of pregnancy 100, 101, 103
protein 7, 23, 24
types 7
urine content 5
water solubility/insolubility 7
human chorionic gonadotrophin (hCG) 101,
103
human placental lactogen (hPL) 103
hydrochloric acid (HCl) 9
hydroxyapatite 39
1 alpha-hydroxylase 41
21-hydroxylase deficiency 51
1-hydroxylation, defective 41
25-hydroxylation, defective 41
hypercalcaemia 40, 41, 53
hyperglycaemia 601
hypergonadotrophic hypogonadism 77
hyperkalaemia 55
hyperlipidaemia 69
hypersecretion 3, 1719, 523, 55, 57
hypertension 53, 55, 57
hyperthyroidism 31, 33
symptoms 345
treatment 367
hypocalcaemia 413
hypoglycaemia 601, 65, 69
postprandial 61
hypogonadotrophic hypogonadism 77
hyposecretion 3, 1819, 545, 57
hypotension 55
hypothalamic hormones 13
hypothalamic inhibiting factors 11
hypothalamic osmoreceptors 17
hypothalamic releasing factors 11
hypothalamic-pituitary axis 1011, 35, 87
hypothalamic-pituitary-adrenal axis 57
hypothalamus 3, 1011
anterior pituitary control 13
and delayed puberty 77
fetal 109
and gonadal function 801, 867
lesions 33
nuclei 17, 21
hypothyroidism 32, 33
causes 33
symptoms 345
treatment 37
immune system, in pregnancy 103,
104, 105
immunoassays 5
immunoglobulin G (IgG) 35, 103,
105
immunoglobulin M (IgM) 103, 105
implantation 100, 101
implants, progestogen 112
in vitro fertilization (IVF) 97
infertility 77
infradian/pulsatile release 13
inhibin 87, 101
insulin 59, 601
deficiency 63
inactivation 67
release 67
requirements 67
secretion 9, 63
insulin resistance 63, 67
insulin sensitivity 19
insulin therapy 63, 667
insulin-like growth factors (IGFs) 18, 19
interleukins 41
interstitium (testes) 85
intracellular effects 6, 7
intracellular receptors 31, 41
intracytoplasmic sperm injection (ICSI)
97
Index 117
intrauterine device (IUD) 98, 99
iodine 29, 33, 37
islets of Langerhans 59, 63
ketoacidosis 69
kidney 17, 41, 43, 55, 69
see also renovascular disease
Klinefelters syndrome 77
knock-knees 43
labour 105, 107, 1089
lactation 17, 105, 11011
leptin 223
Leydig cells 85, 87
libido, loss of 91, 93
light/dark cycle 21, 53
liothyronine 37
lipids 18, 19, 31
lipolysis 53
lipophilia 7
longer term variation (release pattern) 13
lung, fetal 107
luteinizing hormone (LH) 13, 15
and delayed puberty 77
and gonadal function 79, 81, 87
and menstruation 83
malignancy 55, 93
see also tumour
maternal blood 103, 105
maternal physiology 1045
median eminence 13
meiosis 85, 97
melanocyte-stimulating hormone (MSH) 15
melatonin 21
menarche 75
menopause 923
menstrual cycle 79, 81, 823
follicular phase 81
luteal phase 81, 83
oestrogen and androgen effects 89
menstruation 82, 83
metabolic acidosis 55
metabolic rate 31, 35, 53
metformin 67
methyl groups 51
midline thickening 17
mineralocorticoids 49, 545
mitosis 85
Mixtard 67
monoamine oxidase A + B (MAO A + B) 57
monoiodotyrosine (MIT) 29
mosaicism 77
muscle contraction 39
myometrial contractions 109
myxoedema, pretibial 35
Na
+
55
Na
+
K
+
ATPase 31
neoplasia, of the reproductive tract 93
nervous control systems 4, 5
neural crest 47
neuroendocrine cells 13
neuroglycopenic symptoms 61
neuropathy, diabetic 69
nipple 17
noradrenaline 53, 567
nucleus 7, 9
nurse cells 85
nutrient transfer, placental 103
O
2
31, 103, 107
obesity 23, 63
oestradiol 81, 83, 87, 103
oestriol 103
oestrogen/oestrogens 81, 93
and labour 109
and lactation 111
physiological effects 889
and pregnancy 103
1,25(OH)
2
D 41
25-OH-D 41
oocyte 79, 97
see also ovum
oogenesis 789
oral glucose tolerance test (OGTT) 65
oral hypoglycaemics 63, 67
organs
see also specific organs
endocrine 3
target 3
orgasm 91
osmotic pressure 17
osteoblasts 41
osteoclasts 41
osteomalacia 42, 43
ovary 3, 7783
function 823
hypothalamic control 80, 81
ovum 79
see also oocyte
oxytocin 16, 17, 109
INDEX 118
pain, bone 43
pancreas 3, 9, 5869
anatomy 589
cell types 59, 63
diabetes mellitus 61, 629
endocrine cells (islets of Langerhans) 58, 59
exocrine cells 59
glucose homeostasis 601
pancreatic duct 59
pancreatic polypeptide 59
pancreaticoduodenal arteries
inferior 59
superior 59
parathyroid glands 257
anatomy 267
congenital malformations 27
function 3841
parathyroid hormone (PTH) (parathormone) 27, 39, 40,
41
paraventricular nucleus of the hypothalamus 17
parietal cells, gastric 9
patent ductus ateriosus (PDA) 107
peptide hormones 6, 103
peptides 9
perinatal physiology 1067
peripheral vascular disease 69
peroxidase 37
pH 9
phaeochromocytoma 57
pharyngeal cavity 27
pharyngeal pouches 27
phenytoin 43
phosphate 389, 41
physical exercise 65
pineal gland 21
pituicytes 17
pituitary adenoma 3, 53
pituitary gland 1017
anterior (adenohypophysis) 3, 1113, 29, 81, 87, 111
control 13
function tests 11
microscopic structure 11
posterior (neurohypophysis) 3, 11, 1617
pituitary hormones 1215
pituitary portal vessels 13
pituitary tumour 33
placenta 79, 1003
function 1023, 107
structure and development 1001
plasma
calcium levels 41
glucocorticoid levels 53
glucose levels 61, 64, 65
hormone levels 5
potassium levels 55
plasma albumin 55
plasma osmolality 17
plateau stage (sexual arousal) 91
polypeptide hormones 7
polyps 93
post-menopausal bleeding 92, 93
potassium 55
PP cells 59
prednisolone 53
pregnancy 79
endocrine systems 104, 105
fetal and perinatal physiology 1067
hormones of 100, 101, 103
maternal physiology 1045
oestrogen and androgen effects 88, 89
placenta 1003
primary gonadal failure 77
progesterone 79, 81, 83
and labour 109
and lactation 111
physiological effects 88, 89
and pregnancy 101, 103
progestogen-only pill (POP) 112
prolactin (PRL) 1315, 111
prolactin-inhibiting factor (dopamine) 11
propanolol 37
propylthiouracil (PTU) 36, 37
prostaglandins 41, 83, 109
protein hormones 7, 23, 24
proteins
binding of steroid hormones to 7
and glucocorticoids 53
and growth hormone 18, 19
serum proteins 29
synthesis 7, 24
provocative tests 11
puberty 747
abnormalities of 767
delayed 76, 77
in females 74, 75
initiation 74, 75
in males 74, 75
oestrogen and androgen effects 88, 89
and spermatogenesis 85
pubic hair 75
pulmonary stenosis (PS) 107
pupil dilatation 57
Index 119
radioiodine 37
radiotherapy 33
Rathkes pouch 11
reabsorption 17, 41
receptors 3, 5
binding affinity 5
intracellular 31
leptin 23
specificity 5
steroid 7, 31
relative refractory period 91
relaxin 101, 103, 109
renin-angiotensin-aldosterone pathway 54
renovascular disease 69
reproductive tract
development/ageing 7194
female 725, 7883, 8894
fertility 923
hypothalamic control of female gonadal function 801
hypothalamic control of male gonadal function 867
male 725, 79, 847, 8891, 93, 94
menopause 923
oogenesis 789
ovarian function 823
physiological effects of androgens 889
physiological effects of oestrogens 889
puberty 747
sexual behaviour and response 901
sexual differentiation 723, 94
spermatogenesis 845
resolution stage (sexual arousal) 91
respiration, at birth 106, 107
retinopathy 69
Rh anti-D prophylaxis 105
Rh-negative mothers 105
Rh-positive fetus 105
rhesus isoimmunization 105
rickets 42, 43
rosiglitazone 67
second messenger systems 6, 7
secondary sexual characteristics 75
secretin 9
secretory cells 6, 7
seminiferous tubules 84, 85
senescence 93
Sertoli cells 85, 87
serum proteins 29
sex hormones 75, 77
sex-determining region on the Y chromosome (SRY) gene
73, 77
sex-hormone-binding globulin (SHBG) 87
sexual arousal disorders 91
sexual behaviour and response 901
sexual determination 72, 73
sexual differentiation 723, 94
abnormalities of 767
sexual dysfunction 90, 91, 93
shunts 107
smoking 65
somatostatin 3, 11, 59
specific regulatory effects 3
spermatids, haploid 85
spermatocytes, primary 85
spermatogenesis 845
spermatogonia 85
spermatozoon 84, 85
acrosome reaction 97
capacitation 96, 97
glycoprotein stripping 97
tail movements 97
splenic artery 59
sterilization 99
steriodogenesis 4951
steroid hormones 6, 7, 47, 49
chemical structure 51
and menstruation 83
of pregnancy 103
sex hormones 75, 77
steriodogenesis 4951
testicular 86
urine levels 5
vitamin D 41
steroid receptors 7, 31
steroids, exogenous 53
stimuli 3
stomach 9
stratum basale 83
stratum functionale 83
stress response 53, 57
striae 53
stroke 69
subfertility 96, 97
suckling 17, 110, 111
sulphonylureas 67
suppression tests 11
suprachiasmatic nucleus of the hypothalamus 21
supraoptic nucleus of the hypothalamus 17
surfactant 107
surgery, thyroid 37
Syndrome of Inappropriate ADH Secretion (SIADH) 16,
17
INDEX 120
tachycardia 61
testicular androgens 85, 87, 88, 89
testicular feminization syndrome 77
testicular steroid hormones 86
testis 3, 77
formation 73
function 85
structure 84, 85
testosterone 75, 77
and ageing 21, 93
physiological effects 89
thelarche 75
thiazolidinediones 67
thyroglobulin 27, 29, 37
thyroid epithelium 27
thyroid gland 3, 2537
anatomy 267
congenital malformations 26, 27
development 27
dysfunction 327
enlargement (goitre) 33, 35
thyroid hormones 2831
thyroid hormones 2831
see also thyroid-stimulating hormone; thyroxine;
triiodothyronine
thyroid peroxidase 29
thyroid-stimulating antibodies 35
thyroid-stimulating hormone (TSH) 13, 15, 289, 31,
33, 35, 75
thyroiditis 33
thyrotoxicosis 35
thyrotrophin-releasing hormone 11
thyroxine (T4) 3, 289, 31, 35
free/active form 29
protein-bound 29
replacement 37
timing cues 21
toxic nodular goitre (benign neoplasm) 33
transport mechanisms 103
triglyceride (TAG) 69
triiodothyronine (T3) 289, 31, 37
trophoblast (placenta) 101
tuberculosis 55
tumour 33, 53, 55, 77
Turners syndrome 77
tyrosol 29
urine
concentrated 17
dilute 17
hormone content 5
uterus 109
vaginal stimulation 17
vaginismus 91
vaginitis 93
vanilmaldelic acid (VMA) 57
vasopressin see antidiuretic hormone
ventricular septal defects (VSD) 107
vitamin D 41, 43
vitamin D receptor (VDR) 41
waste production, placental 103
water permeability 17
water reabsorption 17
water retention 17
water solubility/insolubility 7
water-deprivation tests 17
weight loss 63
Wolffian ducts 77
X chromosome 73
X-linked disorders 43
XX genotype 73
XY genotype 73, 77
Y chromosome 73
zona fasciculata 47, 49
zona glomerulosa 47, 49
zona pellucida 97
zona reticularis 47, 49
ZP2 97
ZP3 97
zygote 97
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