38- Menarche/Puberty/Menstrual Disorders

Question 1

Menstrual cycle occurs with the maturation of what axis?

Answer 1

Hypothalamic – Pituitary – Ovarian Axis

Question 2

________ from the hypothalamus stimulate ________ and ________ from the anterior pituitary, which stimulates ________ and ________ from the ovarian follicle.

Answer 2

GnRH
FSH
LH
Estrogen
Progesterone

Question 3

FSH and LH are synthesized and stored in cells called _________.

Answer 3

Gonadotrophs

Question 4

The normal ovulatory cycle can be divided into what phases?

Answer 4

Follicular Phase

Luteal Phase

Question 5

This ovulatory cycle phase begins with the onset of menstruation and culminates in the preovulatory surge of LH.

Answer 5

Follicular Phase

Question 6

This ovulatory cycle phase begins with the onset of the preovulatory LH surge and ends with the first day of menses.

Answer 6

Luteal Phase

Question 7

Decreasing levels of ________ and ________ from the regressing corpus luteum of the preceding cycle initiate an increase in ________ by a negative feedback mechanism, which stimulates follicular growth and estradiol secretion for the next cycle.

Answer 7

Estradiol
Progesterone
FSH

Question 8

Separate cellular functions occur in the ovarian follicle. LH stimulates the _______ cells to produce androgens (androstenedione and testosterone). FSH stimulates the ________ cells to convert these androgens into estrogens (E1 and E2).

Answer 8

Theca

Granulosa

Question 9

Both the LH and FSH are significantly suppressed through the negative feedback effect of the elevated circulating ________ and _________. If conception does not occur, these levels will decline near the end of the luteal phase as a result of corpus luteal regression. ________ with then rise which initiates new follicular growth for the next cycle.

Answer 9

Estradiol
Progesterone
FSH

Question 10

What are the 5 peptides or biogenic amines from the hypothalamus that affect the reproductive cycle?

Answer 10

– Gonadotropin-releasing Hormone (GnRH)

– Thyrotropin-releasing Hormone (TRH)

– Somatotropin Release Inhibiting Factor (SRIF) or Somatostatin

– Corticotropin-releasing Factor (CRF)

– Prolactin Release-Inhibiting Factor (PIF)

Question 11

_________ appears to enhance the hypothalamic release of GnRH and induce the midcycle LH surge.

Answer 11

Estradiol

Question 12

Gonadotropins have an (INHIBITORY/STIMULATORY) effect on GnRH release.

Answer 12

Inhibitory

Question 13

During early follicular development estradiol levels are low. About 1 week before ovulation, estradiol (E2) levels begin to increase. They generally reach a maximum 1 day before the midcycle _______ peak. After this there is a marked and precipitous fall.

Answer 13

LH

Question 14

During the luteal phase, _________ reaches a maximum 5-7 days after ovulation and returns to baseline before menstruation.

Answer 14

Estradiol

Question 15

During follicular development, the ovary secretes only a very small amount of _________. The bulk of it comes from the peripheral conversion of the adrenal pregnenolone and pregnenolone sulfate.

Answer 15

Progesterone

Question 16

Prior to ovulation, the unruptured luteinizing graafian follicle begins to produce increasing amounts of progesterone. Secretion of progesterone by the ________ ________ reaches a maximum 5-7 days after ovulation and returns to baseline before menstruation.

Answer 16

Corpus Luteum

Question 17

The number of oocytes is approx. 7 million at 20 weeks gestation. Significant atresia of oogonia occurs so at birth only 1-2 million remain. At puberty with continued atresia only _________ oocytes are available for ovulation with only ________ actually ovulating.

Answer 17

400,000

400

Question 18

After puberty, primordial follicles undergo sequential development, differentiation, and maturation until a mature graafian follicle is produced. The follicle then ruptures, releasing an ________. Subsequent luteinization of the ruptured follicle produces the ________ ________.

Answer 18

Ovum

Corpus Luteum

Question 19

At about 8-10 weeks of fetal development, oocytes become surrounded by precursor granulosa cells. This oocyte-granulose cell complex is called a…

Answer 19

Primordial Follicle

Question 20

In the adult ovary, a graafian follicle forms. The innermost 3-4 layers of multiplying granulosa cells become cuboidal and adherent to the ovum, this is known as the ________ ________.

Answer 20

Cumulus Oophorus

Question 21

A fluid filled ________ forms among the granulosa cells. This enlarges and the centrally located primary oocyte migrates to the wall of the follicle. The innermost layer of the granulosa cells of the Cumulus Oophorus become elongated and form the ________ ________. This is released with the oocyte at ovulation.

Answer 21

Antrum

Corona Radiata

Question 22

Preovulatory ______ surge initiates a sequence of biochemical and structural changes that result in ovulation.

Answer 22

LH

Question 23

Cells on the follicular wall surface degenerate and a _______ forms. The follicular basement membrane bulges through this and when it ruptures, the oocyte is expelled into the peritoneal cavity and ovulation has occurred.

Answer 23

Stigma

Question 24

After ovulation the granulosa cells of the ruptured follicle undergo luteinization. The luteinized granulosa cells, theca cells, capillaries, and CT form the ________ ________ which produces copious amounts of __________ and some __________.

Answer 24

Corpus Luteum
Progesterone
Estradiol

***Normal functional lifespan of Corpus Luteum is 9-10 days!

Question 25

If pregnancy does not occur, menses ensues and the Corpus Luteum is gradually replaced by an avascular scar called _______ _______.

Answer 25

Corpus Albicans

Question 26

Put the following steps of the ovarian cycle in order -- A. The corpus luteum progressively becomes less sensitive to basal LH and dies if levels of LH-like activity (i.e., hCG) do not increase. B. LH surge induces meiotic maturation, ovulation, and luteinization. The corpus luteum produces high P, along with E and inhibin. C. FSH recruits a cohort of large antral follicles to enter rapid growth phase. Follicles secrete low amounts of E and inhibin. D. Pituitary responds to falling E and P by increasing FSH secretion. E. High P, E, and inhibin negatively feedback on LH and FSH, returning them to basal levels. F. Declining FSH levels progressively cause atresia of all but 1 follicle, leading to selection of dominant follicle which produces high levels of E. G. Corpus luteum dies, E and P levels fall. H. High E has positive feedback on gonadotropes, LH (and some FSH) surges. I. E and inhibin negatively feedback on FSH.

Answer 26

1) G. 2) D. 3) C. 4) I. 5) F. 6) H. 7) B. 8) E. 9) A.

Question 27

The endometrium is responsive to circulating progestins, androgens, and estrogens. It is divided into 2 zones, which are...

Answer 27

- - Functionalis (Outer Portion) | - - Basalis (Inner Portion)

Question 28

This layer of the endometrium undergoes cyclic changes in morphology during the menstrual cycle and is sloughed off at menstruation. Contains spiral arteries.

Answer 28

Functionalis (Outer Portion)

Question 29

This layer of the endometrium remains relatively unchanged during each cycle and after menstruation provides stem cells for the renewal of the other layer. Contains basal arteries.

Answer 29

Basalis (Inner Portion)

Question 30

The cyclic changes in histophysiology of the endometrium can be divided into 3 stages, which are...

Answer 30

1. Menstrual Phase 2. Proliferative or Estrogenic Phase 3. Secretory or Progestational Phase

Question 31

What endometrial phase is being described below? -- Only portion of the cycle that is visualized externally. -- Disruption and disintegration of the endometrial glands and stroma, leukocyte infiltration, and RBC extravasation. -- Sloughing of the functionalis layer and compression of the basalis layer.

Answer 31

Menstrual Phase

Question 32

What is considered cycle day 1?

Answer 32

First day of menstruation

Question 33

This endometrial phase is characterized by endometrial growth and proliferation secondary to estrogenic stimulation. There is an increase in length of the spiral arteries and numerous mitoses can be seen in these tissues.

Answer 33

Proliferative Phase

Question 34

During this endometrial phase, following ovulation the secretion of progesterone by corpus luteum stimulates the glandular cells to secrete mucus, glycogen, and other substances. Glands become tortuous and lumens are dilated and filled with these substances. Stroma becomes edematous and mitosis are rare.

Answer 34

Secretory Phase

Question 35

During the Secretory Phase, spiral arteries continue to extend into the superficial layer of the endometrium and become convoluted. At this point endometrial lining reaches its maximal _________.

Answer 35

Thickness

Question 36

If conception does not occur by day ______ (secretory phase) the Corpus Luteum begins to regress, secretion of progesterone and estradiol declines, and the endometrium undergoes involution.

Answer 36

23

Question 37

1 day prior to the onset of menstruation, marked constriction of the _________ arteries occurs resulting in ischemia of the endometrium, leukocytes infiltration, and RBC extravasation. The resulting necrosis causes sloughing of the endometrium resulting in menstruation.

Answer 37

Spiral

Question 38

The _________ cycle is a terminal event of a physiologic process that enables the uterus to be prepared to receive another conceptus.

Answer 38

Menstrual

Question 39

Intact coagulation pathway is important in regulating menstruation. Menstruation disrupts blood vessels, but with normal homeostasis the injured vessels are rapidly repaired. Restoration of blood vessels requires successful interaction of ________ and ________ ________.

Answer 39

Platelets | Clotting Factors

Question 40

Medications such as Warfarin, Aspirin, and Clopidogrel can impair the coagulation system and be associated with...

Answer 40

Heavy bleeding

Question 41

Initial reproductive health visit should occur between ages ________ years. Provides an opportunity to start patient-physician relationship, build trust, and counsel pt's and parents regarding healthy behavior. Primary goal of this visit is to provide preventative health care services, including educational information and guidelines, rather than problem-focused care. A general exam, breast exam, and external exam may be indicated.

Answer 41

13-15

Question 42

An internal exam is not routinely performed unless indicated. Recommended first Pap test is at the age of _______.

Answer 42

21

Question 43

This vaccine is one series for those who are not previously immunized between the ages of 9-26. It offers protection against cervical cancer, cervical dysplasia, vulvar or vaginal dysplasia, and genital warts.

Answer 43

Human Papillomavirus Vaccine -- called Gardasil ***Specifically Gardasil 9!

Question 44

Median age of menarche is ________ years, with 10% of females menstruating at 11.11 years and 90% menstruating by 13.75 years.

Answer 44

12.43

Question 45

Menarche occurs within 2-3 years after _________ (breast budding) at Tanner stage IV, rare before Tanner stage III.

Answer 45

Thelarche

Question 46

By the age of _______ years old 98% of females will have had menarche.

Answer 46

15

Question 47

_______ _______ is defined as absence of menarche by age 13 without secondary sexual development OR by age 15 with secondary sexual development.

Answer 47

Primary Amenorrhea

Question 48

What is the menstrual cycle interval for young females? Adults?

Answer 48

Young females = 21-45 Days | Adult females = 21-35 Days

Question 49

What is the menstrual flow length of young females?

Answer 49

7 days or less ***Use 3-6 tampons per day!

Question 50

________ ________ is defined as the absence of menstruation for 6 months. It is rare for girls and adolescents to remain amenorrheic for more than 3 months, need to check urine or serum B-hcG for pregnancy.

Answer 50

Secondary Amenorrhea ***A LOT of things can make a period irregular!

Question 51

The first menses is usually reported as medium flow, and mean blood loss per menstrual period is 30cc. Greater than 80cc has been associated with ________.

Answer 51

Anemia ***Changing a pad every 1-2 hrs is excessive, especially if bleeding more than 7 days!

Question 52

This is defined as abnormal uterine bleeding that cannot be attributed to medications, blood dyscrasias, systemic disease, trauma, or organic conditions. It's usually caused by aberrations in the H-P-O axis resulting in anovulation.

Answer 52

Dysfunctional Uterine Bleeding (DUB) ***Most occurs around years of menarche (11-14 yo) or perimenopause (45-50 yo)!

Question 53

This is the term for abnormally frequent menses at intervals < 21 days.

Answer 53

Polymenorrhea

Question 54

This is the term for excessive and/or prolonged menses (> 80 mL and > 7 days) occurring at regular intervals.

Answer 54

Menorrhagia (Hypermenorrhea)

Question 55

This is the term for irregular episodes of uterine bleeding.

Answer 55

Metrorrhagia

Question 56

This is the term for heavy and irregular uterine bleeding.

Answer 56

Menometrorrhagia

Question 57

This is the term for scant bleeding at ovulation for 1 or 2 days.

Answer 57

Intermenstrual Bleeding

Question 58

This is the term for menstrual cycles at > 35 day cycles.

Answer 58

Oligomenorrhea

Question 59

For the PALM-COEIN classification system for abnormal bleeding in reproductive-aged women, list the PALM (structural causes).

Answer 59

P = Polyp (AUB-P) A = Adenomyosis (AUB-A) L = Leiomyoma (AUB-L) --- Submucosal myoma (AUB-L sm) or Other myoma (AUB-L o) M = Malignancy and hyperplasia (AUB-M)

Question 60

For the PALM-COEIN classification system for abnormal bleeding in reproductive-aged women, list the COEIN (nonstructural causes).

Answer 60

``` C = Coagulopathy (AUB-C) O = Ovulatory Dysfunction (AUB-O) E = Endometrial (AUB-E) I = Iatrogenic (AUB-I) N = Not yet classified (AUB-N) ```

Question 61

Endometrial ________ form from the endometrium to create soft friable protrusion into the endometrial cavity. Can cause menorrhagia, spontaneous or post-menopausal bleeding.

Answer 61

Polyps ***AUB-P

Question 62

For endometrial polyps, ultrasound findings may reveal focal thickening of the endometrial stripe. _________ _________ and _________ allow for better detection.

Answer 62

Saline Hysterosonography | Hysteroscopy

Question 63

Most polyps are benign, need to remove with _________ since endometrial hyperplasia and carcinoma may also present as polyps.

Answer 63

Hysteroscopy

Question 64

This is defined as the extension of endometrial glands and stroma into the uterine musculature ( > 2.5mm beneath the basalis layer). 15% of patients with this have endometriosis. These islands do not participate in the proliferative and secretory cycles.

Answer 64

Adenomyosis (AUB-A)

Question 65

Adenomyosis (AUB-A) may be asymptomatic, cause severe secondary dysmenorrhea and menorrhagia, and can be associated with _________ with deep penetration.

Answer 65

Dyspareunia ***Pain with intercourse

Question 66

These are benign tumors derived from smooth muscle cells of the myometrium. Most common neoplasm of the uterus. Over 45% of women will have them by 5th decade. They are rarely malignant and mostly asymptomatic.

Answer 66

Uterine Leiomyomas (Fibroids) ***AUB-L

Question 67

Symptomatic fibroids can cause excessive uterine bleeding, pelvic pressure, pelvic pain, and infertility. Most common indication for _________ is symptomatic fibroids.

Answer 67

Hysterectomy

Question 68

Risk factors for developing ________ include: - - Increasing age during reproductive years - - African American women have a 2-3 fold increase risk - - Nulliparity - - Family history

Answer 68

Fibroids

Question 69

Factors that initiate leiomyomas are unknown. They rarely form before menarche or enlarge after menopause. Estrogen stimulates the proliferation of smooth mm cells, so they can dramatically enlarge during _________.

Answer 69

Pregnancy

Question 70

Leiomyomas (fibroids) are usually spherical, well circumscribed, white firm lesions with a whorled appearance on cut sections. May degenerate and cause pain, and can _________ especially in postmenopausal patients.

Answer 70

Calcify

Question 71

This represents an overabundance growth of the endometrial lining usually as a result of persistent unopposed estrogen. It is a precursor to endometrial cancer.

Answer 71

Endometrial Hyperplasia (AUB-M)

Question 72

What can be caused by the following things -- -- PCOS -- Granulosa theca cell tumors - estrogen producing tumors -- Obesity - secondary to peripheral conversion of androgens to estrogens in adipose cells -- Exogenous estrogens - without progestins -- Tamoxifen

Answer 72

Endometrial Hyperplasia (AUB-M)

Question 73

What are the classifications of endometrial hyperplasia, and which are more likely to develop cancer?

Answer 73

Simple without atypia Complex without atypia Simple with atypia Complex with atypia ***Simple and complex WITH atypia are most likely to develop into cancer!

Question 74

This type of endometrial cancer is endometrial adenocarcinoma and is most common.

Answer 74

Type 1

Question 75

This type of endometrial cancer is clear cell and papillary serous.

Answer 75

Type 2

Question 76

The most common presentation of endometrial hyperplasia is _________ bleeding.

Answer 76

Postmenopause ***Irregular uterine bleeding called perimenopause!

Question 77

This nonstructural cause for abnormal bleeding is associated with heavy flow (i.e., Von Willebrand disease).

Answer 77

Coagulopathies (AUB-C)

Question 78

This nonstructural cause for abnormal bleeding is associated with unpredictable menses with variable flow (i.e., polycystic ovarian syndrome).

Answer 78

Ovulatory Dysfunction (AUB-O)

Question 79

This nonstructural cause for abnormal bleeding can be due to infection.

Answer 79

Endometrial Causes (AUB-E)

Question 80

This nonstructural cause for abnormal bleeding can be due to IUD, IUS, or exogenous hormones.

Answer 80

Iatrogenic (AUB-I)

Question 81

This nonstructural cause for abnormal bleeding is reserved for entities that are poorly defined and/or not well examined (i.e., arteriovenous malformation).

Answer 81

Not Yet Classified (AUB-N)

Question 82

What are the available tissue sampling methods for diagnostic evaluation of abnormal uterine bleeding?

Answer 82

- - Office endometrial biopsy | - - Hysteroscopy directed endometrial sampling

Question 83

This type of tissue sampling method is a blind biopsy but adequate sample is obtained in 90% of patients. Better when pathology is global (hyperplasia) rather than focal (polyp). Side effects include cramping and uterine perforation (more serious).

Answer 83

In office EMBX

Question 84

What is absolute and relative contraindication for in office EMBX?

Answer 84

``` Absolute = pregnancy Relative = bleeding diathesis ```

Question 85

What are the treatments for AUB with medication?

Answer 85

-- Normalize prostaglandins (NSAIDS prior to and during menses) -- Antifibrinolytic Therapy (Tranexamic Acid) -- Coordinate Endometrial Sloughing (MPA or OCP's) -- Endometrial suppression (Progesterone daily, continuous OCP's, IUS)

Question 86

What are the surgical treatments for AUB?

Answer 86

``` Polypectomy Myomectomy Dilation and Curettage (D & C) Uterine endometrial ablation Hysterectomy ```

Question 87

What are the instruments for a D & C?

Answer 87

Dilators | Curettes

Question 88

This type of D & C is performed for irregular menstrual bleeding or postmenopausal bleeding to rule out endometrial hyperplasia or cancer.

Answer 88

Diagnostic D & C

Question 89

This type of D & C is performed for endometrial structural abnormalities (polyps, small pedunculate submucosal fibroids).

Answer 89

Therapeutic D & C

Question 90

This is the name for the treatment for endometrial ablation. It uses radio frequency to a bipolar mesh electrode with at the same time applying suction. Perforation safety mechanism. Ablation time is 90 seconds.

Answer 90

NovaSure

Question 91

This type of hysterectomy is done by an incision on the abdomen.

Answer 91

Total Abdominal Hysterectomy (TAH)

Question 92

This type of hysterectomy is done by a vaginal incision.

Answer 92

Vaginal Hysterectomy (TVH)

Question 93

This type of hysterectomy is done by small abdominal incisions and vaginal incisions.

Answer 93

Laparoscopic Assisted Vaginal Hysterectomy (LAVH) Da Vinci Assisted Hysterectomy (TLH)

Question 94

This encompasses the development of secondary sexual characteristics and the acquisition of reproductive capability. Average duration is 4-5 years, occurring between 10-16 yo.

Answer 94

Puberty

Question 95

Onset of puberty is determined primarily by...

Answer 95

- - Genetic factors including race - - Geographic location - - Nutritional status

Question 96

Low levels of gonadotropins and sex steroids during this prepubertal period are a function of 2 mechanisms, which are...

Answer 96

1) Gonadostat sensitivity to the negative feedback of low circulating estradiol. 2) Intrinsic CNS inhibition of hypothalamic GnRH secretion. ***During 11 yo, these 2 mechanisms are lost!

Question 97

Between the ages of 8-11 there is an increase in serum concentrations of ________, ________, and ________.

Answer 97

DHEA DHEA-S Androstenedione

Question 98

In general, adrenal androgen production and differentiation by the Zona Reticularis of the adrenal cortex are the initial endocrine changes associated with puberty. Rise in adrenal androgens causes growth of ________ and _______ hair.

Answer 98

Axillary (Adrenarche) | Pubic (Pubarche)

Question 99

At the onset of puberty, ________-associated increases in GnRH secretion occur and gradually shift into adult type secretory patterns.

Answer 99

Sleep

Question 100

Increase in ________ promotes ovarian follicular maturation and sex steroid production, which leads to the development of secondary sexual characteristics.

Answer 100

GnRH

Question 101

By mid to late puberty, the positive-feedback mechanism of _________ on LH release from the anterior pituitary gland is complete and ovulatory cycles are established.

Answer 101

Estradiol

Question 102

What are the 4 stages of normal pubertal development?

Answer 102

1) Thelarche (Breast development) 2) Pubarche/Adrenarche (Pubic hair/Axillary hair development) 3) Maximal growth or peak height velocity 4) Menarche (Onset of menses)

Question 103

This stage of pubertal development is the first physical sign of puberty. Unilateral development and slight tenderness in first 6 months is not uncommon. Requires estrogen.

Answer 103

Thelarche (Breast development)

Question 104

This stage of pubertal development requires androgens.

Answer 104

Pubarche/Adrenarche (Pubic hair/Axillary hair development)

Question 105

This stage of pubertal development occurs 2 years earlier in girls and about 1 year before onset of menses.

Answer 105

Maximal growth or peak height velocity

Question 106

This stage of pubertal development requires pulsatile GnRH from the hypothalamus, FSH and LH from the pituitary, estrogen and progesterone from the ovaries, normal outflow tract.

Answer 106

Menarche (Onset of menses)

Question 107

Put the following Tanner stages of breast development in order from 1 to 5: A. Projection of areola and papilla to form a secondary mound above the level of the breast. B. Breast bud stage; elevation of breast and papilla as a small mound with enlargement of the areolar region. C. Preadolescent; elevation of papilla only. D. Mature stage; projection of papilla only, resulting from recession of the areola to the general contour of the breast. E. Further enlargement of breast and areola without separation of their contours.

Answer 107

1) C. 2) B. 3) E. 4) A. 5) D.

Question 108

Put the following Tanner stages of pubic hair development in order from 1 to 5: A. Hair spreads sparsely over the junction of the pubes; hair is darker and coarser. B. Adult-type hair; there is no spread to the medial surface of the thighs. C. Preadolescent; absence of pubic hair. D. Adult-type hair with spread to the medial thighs assuming an inverted triangle pattern. E. Sparse hair along the labia; hair downy with slight pigment.

Answer 108

1) C. 2) E. 3) A. 4) B. 5) D.