10: Puberty, Menstrual Disorders Flashcards
Ovarian cycle - follicular phase
Onset of menstruation to LH surge
Ovarian cycle - luteal phase
LH surge to 1st day menses
At what point in the menstrual cycle does estrogen peak?
Just prior to LH surge
At what point in the menstrual cycle does progesterone peak?
5-7 days after ovulation
Corpus luteum
Formed after ovulation and secretes progesterone
Corpus albicans
Avascular scar that replaces corpus luteum in absence of pregnancy
Menstrual phase
RBC extravasation, sloughing of functionalis layer and compression of basalis layer
Proliferative phase
Endometrial growth, estrogenic stimulation, increase in arteries, increase in mitoses
Secretory phase
Following ovulation, progesterone secretion increases, glands are tortuous, mucus and glycogen secreted, endometrial lining at maximum thickness
Median age of menarche
12.43 years
Primary amenorrhea
No menstruation by 13 y/o without secondary sexual development OR by 15 years with secondary sexual characteristics
When is menses likely associated with anemia?
Greater than 80cc blood loss/changing pad q1-2 hours
Stages of normal pubertal development
TAG-ME: Thelarche, Adrenarche, Growth, MEnarche
Thelarche
Breast development; 1st sign puberty, requires estrogen
Adrenarche
Development of pubic/axillary hair; requires androgens
Maximal growth
Occurs ~1 year before onset menses
Menarche
Onset of menses
Tanner stage 1
Breast: Preadolescent, elevation of papilla only
Hair: Preadolescent, absence of pubic hair
Tanner stage 2
Breast: Breast bud, small mound with enlarged areola
Hair: Sparse hair along labia, downy/slight pigment
Tanner stage 3
Breast: Further enlargement of breast/areola without contour separation
Hair: Spreads sparsely over unction of pubes, darker and coarser
Tanner stage 4
Breast: Projection of areola from papilla to form secondary mound
Hair: Adult-type hair, no spread to medial thigh
Tanner stage 5
Breast: Mature, projection of papilla only
Hair: Adult-type hair with spread to medial thighs
Precocious puberty
Development of secondary sexual characteristics prior to an age 2.5 standard deviations earlier than expected age of pubertal onset (8 y/o in girls)
Causes of heterosexual precocious puberty
Virulizing neoplasms, CAH, exposure to androgens
Causes of isosexual precocious puberty
Constitutional or organic brain disease; often idopathic
Treatment of isosexual precocious puberty
GnRH agonist (Leuprolide) to suppress FSH/LH - prevents stunted growth
McCune-Albright syndrome
Polyostotic fibrous dysplasia; present with bone defects, cafe au lait spots, adrenal hypercortisolism
Peutz-Jeghers syndrome
Gastrointestional poyposis and mucocutaneous pigmentation
Hypergonadotropic hypogonadism
FSH is elevated, gonadal dysgenesis; Turner’s
Hypogonadotropic hypogonadism
FSH and LH are low; many causes
Secondary amenorrhea
Patient with prior menses has absent menses for 6+ months
Treatment of microadenomas and macroadenomas causing prolactinemia
Bromocriptine (Dopamine agonist)
Progesterone challenge test
Given in secondary amenorrhea if normal TSH/PRL
Positive: bleeding - PCOS
Negative: inadequate estrogenization or outflow tract abnormality
Estrogen/progesterone challenge test
Given after negative PCT
Negative: outflow tract obstruction
Positive: abnormality in HPA or ovaries
Leading cause of female anovulatory infertility
PCOS
Diagnostic criteria for PCOS
At least 2 of the following:
- Oligomenorrhea/amenorrhea
- Biochemical or clinical signs of hyperandrogenism
- US revealing multiple small cysts beneath cortex of ovary
Treatment of PCOS
Weight loss, OC, clomiphene citrate, spironolactone, metformin
Polymenorrhea
Abnormally frequent menses at intervals of less than 21 days
Menorrhagia
Excessive and/or prolonged bleeding (>80 mL and 7 days) at normal intervals
Metrorrhagia
Irregular episodes of uterine bleeding
Menometrorrhagia
Heavy and irregular uterine bleeding
Intermenstrual bleeding
Scant bleeding at ovulation for 1-2 days
Oligomenorrhea
Menstrual cycles occurring >35 days but less than 6 months
PALM-COEIN
Polyp-Adenomyosis-Leiomyoma-Malignancy
Coagulopathy-Ovulatory dysfunction-Endometrial-Iatrogenic-Not yet classified
Treatment of abnormal uterine bleeding
Massive: hospitalization and transfusions, hormones
Moderate: combination OCPs, Mirena
Unresponsive to conservative therapy: D&C, polypectomy, myomectomy, endometrial ablation, hysterectomy
