20: Puberty, menstrual cycle, menopause

Question 1

The typical order of the events in puberty

Answer 1

accelerated growth (9-10, pk 12), thelarche (breast development, 10), pubarche (pubic hair development, 11), and menarche (onset of menstruation, 2.5 yrs after breast buds, 12-13)

Question 2

he ovary goes through a follicular and luteal phase at the same time that the endometrium goes through the ?

Answer 2

proliferative and secretory phases

Question 3

Fertilization of the ovum must occur within ? of ovulation.

Answer 3

24 hours

takes 3 to 4 days to be swept down to the uterus by the cilia lining the tube

Question 4

Menstruation occurs as the result of ?

Answer 4

decreasing progestin levels resulting in the sloughing of the endometrium.

Question 5

Perimenopause can begin ? years prior to menopause. It is characterized by ?

Answer 5

2 to 8 years
irregular menstrual cycles and milder, less frequent symptoms that are associated with menopause, such as hot flashes, night sweats, and mood swings, typ. disappear in 1st 1-2 yrs
-less inhibin B secretion from granulosa cells–>FSH rises, progesterone falls, estradiol is preserved

Question 6

The average age of menopause is ?
Menopausal patients present with ?
diagnose with ?
confirm diagnosis with?

Answer 6

51
amenorrhea, hot flashes, vaginal atrophy, and mood and sleep changes, all consistent with decreased levels of estrogen.
-12 months of amenorrhea and the above symptoms
-elevated levels of FSH

Question 7

Women who wish to use hormone replacement for menopausal symptoms and who still have a uterus in place should use ? to decrease risk of ?

Answer 7

both estrogen and progesterone therapy (HRT)

endometrial hyperplasia and endometrial cancer from unopposed estrogen exposure.

Question 8

2 major benefits of HRT and ERT

Answer 8

the prevention of bone loss and osteoporosis and the relief of symptoms associated with menopause.

Question 9

Combination hormone therapy (HRT) has been associated with an increased risk of ?

Answer 9

heart attacks, strokes, DVTs, PEs, and invasive breast cancer.

Question 10

When used alone, estrogen replacement therapy (ERT) has been associated with an increased risk of ?

Answer 10

strokes and DVTs.

Question 11

When used, HRT and ERT should be reserved for the treatment of what symptoms?
In general, HRT/ERT use should be used for the shortest period of time needed-usually ? at the lowest effective dose to treat symptoms.

Answer 11

vasomotor symptoms

1-5 years

Question 12

adrenarche

Answer 12

secretion of sex steroids: dehydroepiandrosterone sulfate (DHEAS), dehydroepiandrosterone (DHEA), and androstenedione
6-8 years up to 13-15

Question 13

gonadarche

Answer 13

pulsatile GnRH secretion from the hypothalamus is increased, leads to pulsatile LH/FSH
around age 8

Question 14

Precocious puberty

delayed puberty?

Answer 14

pubarche or thelarche before 7 years of age in Caucasian girls and before 6 years of age in African American girls

absent or incomplete breast development by the age of 12 years
-H/P, hormone assessment and bone age determination

Question 15

The Tanner Stages of Breast Development

Answer 15

Stage 1 Preadolescent: elevation of papilla only
Stage 2 Breast bud stage: elevation of breast and papilla, areolar enlargement
Stage 3 Further enlargement of breast and areola without separation of contours
Stage 4 Projection of areola and papilla to form a secondary mound
Stage 5 Mature stage: projection of papilla only as areola recesses to breast contour

Question 16

the follicular phase

Answer 16

release of FSH from the pituitary gland results in development of a primary ovarian follicle which produces estrogen, which causes the uterine lining to proliferate
-day 14: LH spike to following estrogen surge–>stimulates ovulation

Question 17

the luteal phase

Answer 17

corpus luteum is responsible for the secretion of progesterone, which maintains the endometrial lining in preparation to receive a fertilized ovum
If fertilization does not occur, the corpus luteum degenerates and progesterone levels fall–>menstruation
withdrawal of estrogen and progesterone during the luteal phase of the prior cycle causes a gradual increase in FSH–>stimulates the growth of approximately 5 to 15 primordial ovarian follicles, initiating the follicular phase again

Question 18

theca interna cells vs granulosa cells

Answer 18

theca interna cells produce androstenedione in response to LH stimulation
the granulosa cells convert this androstenedione to estradiol when stimulated by FSH

Question 19

if fertilization occurs, developing trophoblast synthesizes ? until the placenta produces it at ? wga

Answer 19

hCG which maintains the corpus luteum so that it can continue production of estrogen and progesterone to support the endometrium. This continues until the placenta develops its own synthetic function at 8 to 10 weeks’ gestation.

Question 20

A menstrual cycle less than ? or longer than ? or a menses that lasts more than ? merit further evaluation.

Answer 20

24 days
35 days
7 days

Question 21

Premature menopause resulting from premature ovarian failure is usually ?
If it occurs before age 30, rule out ? with ?

Answer 21

idiopathic or autoimmune

If it occurs before age 30, chromosomal studies can be ordered to rule out a genetic basis (e.g., mosaicism).

Question 22

Menopausal Symptoms and Long-Term Effects (Mnemonic: FSH > 40 IU/L)

Answer 22

F Flushes, forgetful (Alzheimer disease)
S Sweats at night, sad (depression) stroke, skeletal changes (accelerated bone loss leading to osteoporosis), skin changes, sexual dysfunction
H Headaches, heart disease
I Insomnia
U Urinary symptoms (stress and urge incontinence), urogenital atrophy (loss of pelvic floor muscles)
L Libido decreases
Remember that an FSH level >40 IU/L is the blood test to confirm menopause.

Question 23

how decreased estrogen during menopause affects CV system

Answer 23

increased risk for coronary artery disease and lose protective benefits on lipid profile (increased HDL and decreased LDL) and on the vascular endothelium (prevents atherogenesis, increases vasodilatation, and inhibits platelet adherence)

Question 24

both HRT and ERT reduce these menopausal symptoms
NOT for protection from ?
HRT also resulted in decreased risk of ?

Answer 24

vasomotor flushing, improvement in mood and sleep dysfunction, prevention of urogenital and vaginal atrophy, and improvement in skin and muscle tone, protection from osteoporotic fractures in the hip and the vertebra.
NOT for protection from CV disease, osteoporosis, dementia

HRT: reduced risk of colorectal cancer

Question 25

combination HRT use resulted in increased ?

Answer 25

coronary artery events, increased DVTs and PEs, and an increased risk of invasive breast cancer in women who used HRT for a prolonged period of time (i.e., >5 years’ duration)

Question 26

ERT is associated with an increased risk of ?

Answer 26

stroke (age independent) and DVTs. It did NOT impact heart attacks (age dependent) or the risk of colorectal cancer
-trend toward more PEs and fewer invasive breast cancers

Question 27

Contraindications to HRT

Answer 27

chronic liver impairment, pregnancy, known estrogen-dependent neoplasm (breast, ovary, uterus), history of thromboembolic disease (DVT, PE, CVA), and undiagnosed vaginal bleeding.

Question 28

Treatment options for CV changes

Answer 28

BP and lipid control medications, smoking cessation, weight loss, exercise

Question 29

management of osteoporosis risk

Answer 29

HRT/ERT, calcium, Vitamin D, bisphosphonates (etidronate, alendronate, risedronate), calcitonin, SERMS: raloxifene, tamoxifen, weight-bearing exercise

Question 30

management of Vasomotor Symptoms (Hot flashes, night sweats)

Answer 30

HRT/ERT, clonidine (Catapres), SSRIs (paroxetine-Paxil), SNRIs (venlafaxine-Effexor), gabapentin (Neurontin)

Question 31

management of Vaginal dryness/dyspareunia

Answer 31

Low-dose vaginal estrogen, water-based lubricant, vaginal moisturizers

Question 32

management of mood disturbances

Answer 32

HRT/ERT, SSRIs,