3) Puberty & Abnormalities of Menstruation Flashcards by Lauren Croft

At what age does puberty take place in girls?

8-13 years

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At what age does puberty take place in boys?

9-14 years

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What changes take place in a boy at puberty?

Genital development begins
Adrenarche (pubic hair growth)
Spermatogenesis begins
Growth spurt (10cm/year)

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What changes take place in a girl during puberty?

Thelarche - breast bud development, 1st sign of puberty
Adrenarche - pubic hair growth
Growth spurt (9cm/year)
Menarche - onset of menstrual cycles

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Puberty is under hormonal control. Which hormones are involved?

Onset of puberty:
Rise in FSH & LH (brain initiates)
due to Pulsatile GnRH secretion

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What is the significance of body weight and puberty?

Body weight most important factor in timing of puberty

47kg critical weight for menarche

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What happens to the reproductive cycle if body weight falls significantly below 47kg?

Reproductive cycle ceases

May be signalled to brain by leptins

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At what weight does the growth spurt start in boys & girls?

30kg girls

55kg boys

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What is adrenarche and how does it occur?

Pubic and axillary hair growth
Depends on androgens in both sexes
From adrenal glands in girls

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What causes the growth spurt in girls & boys during puberty?

Growth hormone & Steroids
Ended by epiphyseal fusion
Oestrogen closes epiphyses earlier in girls
Growth spurt earlier & shorter in girls

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What is thelarche?

Breast development

dependant on oestrogen

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What is male genital development dependant on?

Testosterone

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What is precocious puberty?

Development of signs of puberty before 8yrs in girls or 9yrs in boys

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What causes precocious puberty?

Unknown
Can be due to:
Neurological causes, inappropriate GnRH secretion
- Pineal tumours, meningitis
Uncontrolled gonadotrophin or steroid secretion
- Hormone secreting tumours

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What happens during pre-menopause and what age does it occur?

>40 years
Changes in menstrual cycle
Follicular phase shortens, ovulation early or absent
Less oestrogen secreted
Less -ve feedback - FSH & LH rise
FSH rises more - loss of inhibin too
Reduced fertility

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What changes occur during menopause?

Cessation of menstrual cycles
Average age 49-50
Female has run out of follicles
Oestrogen falls dramatically
Less -ve feedback - FSH & LH rise
FSH rise dramatically - loss of inhibin

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What are the vascular effects of menopause?

Hot flushes (80%)
Transient rises in skin temp
Relieved by oestrogen treatment

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What are the effects of menopause on oestrogen sensitive tissues?

Uterus: regression of endometrium, shrinkage of myometrium
Thinning of cervix
Vaginal rugae lost (thinner, less distensible)
Involution of some breast tissue
Changes in skin
Reduction in bladder tone

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What are the effects of menopause on bone?

Bone mass reduces by 2.5% per year for several years
Increased reabsorption relative to production
Osteoporosis (limited by oestrogen therapy)

What are positives and negatives about Hormone Replacement Therapy (HRT)?

Relieves symptoms of menopause
Orally/topically by patch/gel
Can limit osteoporosis
Not advised for cardio-protection

What is amenorrhoea?

Absence of periods for at least 6 months

What is primary amenorrhoea?

Never had a period
Absence of menses by 14 with abscence of secondary sexual characteristics e.g. thelarche
or Absence by age 16 with normal SSC

What is secondary amenorrhoea?

Established menstruation has ceased for 3 months in woman with history of regular cyclical bleeding
9 months in a woman with a history of irregular periods
Normally aged 40-55

What is oligomenorrhoea?

Infrequent periods occurring at intervals of 35days - 6months

What is dysmenorrhoea?

Painful periods

What is menorrhagia?

``` Heavy vaginal bleeding that is not DUB Heavy periods Excessive >80ml Prolonged >7 day uterine bleeding Usually ovulatory ```

What is cryptomenorrhoea?

Periods occur but not visible due to obstruction in outflow tract

What is dysfunctional uterine bleeding(dub)?

Abnormal bleeding, no obvious organic cause

What are anovulatory cycles?

No ovulation/luteal phase | Oligo/Amenorrhoea +/- Mennorhagia

What are ovulatory cycles?

Normal menstrual cycles + dysmenorrhoea/mastalgia (sore breasts)

What causes amenorrhoea?

Origin is Hypothalamic/Pituitary, Ovarian or Outflow tract (uterus, vagina, cervix)

How do problems with the hypothalamus/pituitary cause amenorrhoea?

Inadequate levels of FSH Inadequately stimulated ovaries Ovaries fail to produce enough oestrogen to stimulate the endometrium of uterus Hypo/hyperthyroidism may cause secondary

Name a cause of primary hypothalamic amenorrhoea

Kallmann syndrome - Inability to produce GnRH (& FSH subsequently)

Name some causes of secondary hypothalamic amenorrhoea

Exercise amenorrhoea Stress amenorrhoea Eating disorders & weight loss (obesity, anorexia, bulimia) Fall below critical weight 47kg & menses ceases

Name some causes of secondary pituitary amenorrhoea

Sheehan syndrome - hypopituitarism Hyperprolactinaemia Haemochromatosis - 'Iron overload'

What is hypergonadotrophic amenorrhoea?

Ovarian amenorrhoea, ovary doesn't respond to pituitary stimulation - low oestrogen levels Lack of -ve feedback - elevated FSH levels in the menopausal range

Name some causes of primary gonadal/end-organ amenorrhoea

Gonadal dysgenesis - e.g. Turner's syndrome (45,X) Androgen Insensitivity Syndrome Receptor abnormalities for FSH & LH Specific forms of congenital adrenal hyperplasia

Name some causes of secondary gonadal/end-organ amenorrhoea

``` Pregnancy Anovulation Menopause (or premature menopause) Polycystic Ovarian Syndrome Drug-induced ```

What is outflow tract amenorrhoea?

Hypothalamic-Pituitary-Ovarian Axis is functional FSH level normal Problem with uterus/vagina/cervix

Name some causes of primary outflow tract obstruction (amenorrhoea)

Uterine - Mullerian agenesis (15% primary) | Vaginal - Vaginal atresia, cryptomenorrhoea, imperforate hymen

Name a cause of secondary outflow tract obstruction (amenorrhoea)

Intrauterine Adhesions (Asherman's syndrome)

How is amenorrhoea managed?

Depends on cause: Hormone replacement Modification of lifestyle factors (exercise, weight loss)

Explain what happens when dysfunctional uterine bleeding (DUB) occurs when ovulation is not occurring

90% CL does not form to release progesterone Oestrogen is produce continuously - overgrowth of uterine endometrium & subsequent bleeding

Explain what happens when dysfunctional uterine bleeding (DUB) occurs when ovulation is occurring

10%? Progesterone secretion prolonged as oestrogen levels are low Irregular shedding of uterine lining & erratic bleeding

How is dysfunctional uterine bleeding (DUB) diagnosed?

``` Exclusion of other causes: hCG, TSH - Exclude pregnancy, thyroid Coagulation workup Smear if appropriate - Exclude cancer Sample endometrium ```

Name some causes of menorrhagia

Usually secondary to distortion of uterine cavity Uterus unable to contract down on open venous sinuses in zona basalis Or organic, endocrine, haemostatic, iatrogenic (fibroids, hypothyroidism)

How is menorrhagia managed?

Progesterone