Adolescence and Female Puberty Flashcards
What is the first sign of puberty in females?
Breast and papilla buds begin (thelarche)
- usually in SMR 2 (11.5-13 yrs)
there is 5% of females that develop pubarche first, but the majority is thelarche
- *also can show physiologic leukorrhea at the same time (clear vaginal discharge)**
- signals onset of menarche within 6 months
When does menses usually begin
Usually within 3yrs after thelarche (3-4 SMR)
- ages 12.5 is average
- age range = 9-15 yrs
Timing is almost always determined by genetics
- can also be influenced by obesity, chronic illness, nutritional status and physical/psychosocial environment
Early menarche is usually anovulatory and have irregular cycles (range from 21-45 days with 3-7 days of menstration)
When does growth spurt start for females
peak height velocity is usually at SMR 2/3, roughly 6 months before menarche is to begin
PHV = 8-9cm/yr
Growth spurt begins dismally and comes centrally
Normal menses
21-35 days between 1 period -> next period
- during first 3 years are superior irregular though
- if periods are being skipped need to work this up
Normal menses actually lasts <7 days usually
Normal menstration should be 6 or fewer soaked pads or tampons per day
Average age of menarche = 12.5 yrs
- slightly older for non-Hispanic whites
- slightly younger in blacks and Hispanics
Factors that affect onset of menarche
Weight exercise level, chronic medical conditions
there is a close concordance of age of menarche between mother and daughter
Severe dysmenorrhea or prolonged menstrual bleeding with menses
Needs more aggressive management and potential referral to gynecology
What are the history requirements for patients with menstrual irregularities
Timing of pubertal milestones
- especially pubic, axillary hair growth and breast development
- detailed patient menstrual history
- age of menarche
- overall menstrual pattern of mother and sisters
- family history of gynecologic problems
Complete ROS (below are really important)
- headaches, vision changes
- galactorrhea
- diet changes
- exercise and sports participation
3 types of abnormal uterine bleeding
AUB-O = Ovulatory dysfunction
AUB-C = coagulopathy
AUB-N = not classified
When should you do a Pelvic exam on an adolescent female
Only when they have delayed menses (>16 yrs old) and if they are sexual active with symptoms of an infection
Primary vs secondary amenorrhea in adolescence
Primary = no menstration within 3yrs of the onset of puberty
Secondary = no menstration for the length of 3 previous cycles in a postmenarche patient
When to evaluate for puberty delay
Lacks any signs of puberty by age 13
In sexual active patients with symptoms of pathology with 1 or 2 missed cycles
In patients whose breast development started between 8-9 yrs old
- usually observe for 3 yrs first and then go from there
Causes of primary and secondary amenorrhea
Pregnancy
Functional hypothalamic causes (stress, weight loss, malnutrition, etc)
Female athlete triad
Eating disorders
Premature ovarian insufficiency
Hypothalamic or pituitary damages
Thyroid disease (both can cause by hypo is more likely)
Prolactinoma
Systemic diseases (sickle cell, CF, celiac, IBD, congenital heart disease)
Hyperandrogenism (POCS and adrenal hyperplasia/tumor)
Drugs and medications (atypical antipsychotics and hormones are most common)
Tuner syndrome
Anatomic abnormalities
- imperforate hymen
- transverse vaginal septum
- mullarian abnormalities
Constitutional delay
Labs to get for amenorrhea
hCG pregnancy test
Serum levels of prolactin
TSH levels
FSH levels
Treatment of menstral abnormalities
Usually need to refer out or work together with other professions to actually get the disorder under control
- depends on the issue
Amenorrhea/PCOS treatment in children
OCPs (combo of estrogen and progesterone)
Lifestyle modifications = obesity and insulin resistance treatment
Patient with abnormal glucose tolerance (2 hr OGTT shows higher than 150) = metformin
Spironolactone for hirsutism if present
Amenorrhea/eating disorders treatment
1st line = normalizing weight and improving nutritional status
2nd line = short term use of transdermal estrogen (E2) therapy (must fail first line first!)
Amenorrhea/ovarian insufficiency treatment
1st line = low dose transdermal estrogen at 10-12 yrs and then increase doses until you can put on OCP combo therapy
you need to put them on exogenous hormones to get pubertal development
Secondary amenorrhea treatment
Not recommended to be put on OCPs initially
- this will mask the patients subsequent menstrual pattern
if they have normal estrogen levels, can be put on medroxyprogesterone 10mg daily in order to help induce shedding of the endometrial lining and prevent build up
Turner syndrome (45 XO)
1: 2500 live-born phenotypic females are affected
- most Turner syndrome patients die in utero
Results in ovarian dysgenesis
Characteristics
- short stature
- delayed puberty
- webbed neck
- protuberant ears
- low hairline in back
- shield chest (widespread nipples)
- short 4th metacarpal and nail hypoplasia
- transient congenital lymphedema
- normal developmental and intelligence (10% are not though)
- coarctation of aorta and aortic dissection risk is increased**
always have ovarian dysgenesis which causes amenorrhea and infertility
- *classically as infants show infantile congenital lymphadema also**
- if you see this = work up with Karotype and other causes
Treatment
- requires urgent cardiology evaluation with chest pain and aortic dilation present (usually need BP monitored)
- endocrinologist diagnosis with somatropin or low dose oxandrolone supplement = growth development
- estrogen replacement therapy = for secondary sex characteristics
- **MOST are infertile no matter what(ovarian dysgenesis)
Common organ anomalies with Turner syndrome
Bicuspid aortic valves, aortic coarctation = 45%
Renal agenesis or horseshoe kidney = 40%
Hypothyroidism = 5-10%
Osteoporosis and fractures
Central obestiy
Growth delay in Turner syndrome
Usually begins in early childhood but often isnt picked up until 5-10yrs of age where the patient starts to fall off the growth chart/curve
How long does it take on average for adolescents to seek health care after intimating sex?
6-12 months
- many become pregnant or acquire a STI during this time
Tiers of contraceptive effectiveness
Tier 1:
- most effective
- <1 pregnancy per 100
- includes IUDs and implants
Tier 2:
- 4-7 pregnancy per 100
- injectable contraception, OCPs, OC patches and vaginal ring
Tier 3:
- least effective
- > 13 per 100
- male and female condom
- diaphragm
- withdrawal and sponge use
- fertility awareness-based methods
What are the most common methods of contraception used by teenagers
Condoms = #1
Then withdrawal And the pill in 3rd
most effective = IUD and implantable
What should be encouraged in teenage girls
Duel protection
- use depo, IUD, OCPs or implantable for pregnancy inhibition
- use condoms for STI protection
PCOS
Most common endocrinopathy affecting women in adolescence
- overproduction of theca cells and hyperinsulinemia due to excessive LH and decreased FSH (inhibin). Hyperinsulinemia causes decreased SHBG’s which increases free testosterone
Symptoms
- menstrual dysfunction (primary, oligomenorrhea, dysmenorrhea)
- androgenic alopecia (crown thinning of hair caused by excessive DHT)
- hyperandrogenism
- obesity
- acne with resistance to treatments
- metabolic disturbances
- dyslipdiemia
- depression
Needs a 3 syndrome criteria
- hyperandrogenism
- ovarian dysfunction
- presence of ovarian cysts
also need to rule out other causes
Lab testing in PCOS
Free testosterone is high
LH:FSH ratio is elevated (>2)
Always get TSH, thyroxine, prolactin, cortisol and estradiol levels to rule out other causes
always get 17-hydroxyprogesterone levels (usually high anyways but super high = may be CAH)
Management of PCOS
Always first line = OCPs
- can be combo or progestin pill only
- if contraindicated to combined OCPS = progestin
If they want to try getting pregnant = clophrene or letrozole
Hirtuism - spironolactone add on
Hyperinsulinemia = add metformin
always recommend weight loss in obese PCOS patients
