DSA Flashcards
Menstrual cycle occur with the maturation of the
__________
hypothalamic-pituitary-ovarian axis.
(GnRH) from the hypothalamus stimulate(FSH) and(LH) from the anterior pituitary, which stimulates ________ and _______ from the _______
estrogen and progesterone relase from ovarian follicle
What initiates an increase in FSH -> follcular growth and estradiol secretion at the begining of our period?
Decreasing levels of estradiol & progesterone from the regressing corpus luteum of the cycle b4
• LH stimulates
theca cells to make androgens (androstenedoine and testosterone)
• FSH stimulates
granulosa cells to convert androgens -> estrogens
• LUTEAL PHASE
levels of LH and FSH
supressed. d/t negative feedback of elevated cirulated estradoil and progesterone
what happens if conception does not occur
- CL regresses -> decreasing estrogen and progesternoe levels
- will eventually. cause a. rise in FSH
- FSH will stimulate. new follicular. growth
• 5 peptides or biogenic amines that affect the reproductive cycle have been isolated from the hypothalamus •
- Gonadotropin-releasing hormone (GnRH) •
- Thyrotropin-releasing hormone (TRH) •
- Somatotropin release inhibiting factor (SRIF) or somatostatin •
- Corticotropin-releasing factor (CRF) •
- Prolactin release-inhibiting factor (PIF) •
All exert specific effects on the hormonal secretion of the anterior pituitary gland.
released from arcuate nucleus in pulses bc short half life -> release LH and FSH
Estradiol appears to ______ the hypothalamic release of GnRH and induce the midcycle LH surge •
Gonadotropins have and ____ effect on GnRH release
enhance
inhibit
ESTROGEN •
During early follicular development estradiol levels are low • Approximately _____ before ovulation, estradiol (E2) levels begin to increase
1 wk before
Estrogen levels 1 day before ovulation
- Estrogen levels reach. max 1 day before the midcycle LH peak.
- After peak but before ovulation, there is a marked decrease
- During luteal phase, estradoil levels rise 5-7 days after ovulation -> goes to normal
Progesterone in the ovarian cycle
- Follicular stage: small amount of progesterone is made d/t peripheral conversion of adrenal pregnenolone and PG sulfate
- Unruptured luteinizing graafian follicle begins to make increasing amounts of progesterone
What happens as the graafian follicle is formed?
Granulosa cells differentiate
- Cumulus oophorus -> adheres to ovum
- Corona radiata -> innermost layers of granulosa cells that become elongated. released with oocyte. at ovulation
Hormonal changes in cycle
• The first day of menstruation is known as cycle day 1. What happens
Endometrial glands and stroma disintegrate
Leukocytes infiltrate
RBC invate
Proliferative phase
Characterized by endometrial growth/proliferation d/t ______.
What else happens
Estrogen
Increase in lgenth of spiral arties
Increase in mitosis
Secretory phase
1. progesterone secretion by the corpus luteum stimulate the glandular cells to secrete ___________.
2. Gland change:
3. Mitosis: ________
4. Endometrial lining:
- mucus, glycogen and other substances
- glands become totruos
- mitosis is rare
- endometrial lining: full thiccnes
1 day prior to the onset of menstruation____________ occurs resulting in ischemia of the endometrium, leukocytes infiltration and RBC extravasation.
spiral arteries constrict where they. meet. with straight.at. statum basale
Intact ______ pathway is important in regulating menstruation
coagulation
Menarch (period) occurs within 2-3 years _____ thelarche (breast budding) at Tanner stage ____, rare before Tanner stage ___
after
IV
III
By the age of ____ years old 98% of females will have had menarche
15
Primary amenorrhea is defined as:
- absence of menarche by age 13 years _without secondary sexual developmen_t
- OR by the age of 15 with secondary sexual development
Menstrual cycles are often _____ throughout adolescents, especially from first to the second cycle.
irregular
Most normal cycles range from _____ days even in first gynecologic year.
21-45
Secondary amenorrhea is defined
absence of menstruation for 6 months.
It is rare to not have pd for longer an 3 months. If so, workup is needed: check urine or serum B-hcG to rule out pregnancy.
Oligomenorrhea
Menstrual cycles at > 35 day cycles
Menorrhagia
Menorrhagia (hypermenorrhea): Regular intervals that are very heavy with excessive and/or prolonged menses (>80mL and > 7 daysvals)
Metrorrhagia
irregular bleeding intervals; often times in the middle of cycle
Menometrorrhagia
Heavy & irregular uterine bleeding
Intermenstrual bleeding
Scant bleeding at ovulation for 1 or 2 days
First menses is usually reported as medium flow. •
- Mean blood loss per menstrual period is ____ •
- Most report changing a pad____ times a day •
- Greater then ____ has been associated with anemia •
- Changing a pad ____ is considered excessive especially if bleeding is lasting > ___ days.
30cc
3-6
80cc
every 1-2 hours
more than 7 days
what. is the classification system for abnormal bleeding in reproductive-aged women
- PALM (structural causes)
- COEIN (nonstructural causes)
PALM (structural causes) of abnormal bleeding
AUB= abnormal uterine bleed
- Polp (AUB-P)
- Adenomyosis (AUB- A)
- Leiomyoma (AUB-L)
- submucosal myoma (AUB- L sm)
- othre myoma (AUB- L o)
- Malignancy and hyperplasia (AUB-M)
AUB-P
What happen:
Cause:
- Endometrial polyps form on endometrium and creat soft friable protrusion into endometrial cavity:
- causes menorhagia (heavy bleeding >80cc), spontaneous of post-menopausal bleeding.
AUB-A
-
Adenomyosis: endometrial glands and stroma break through the muscle wall of the uterus (myometrium) >2.5mm in basiis layer
- Cells that break through will not undergo proliferative/secretory cycles
- can cause endometriosis (15%)
- Sx: asymptomatic, secondary dysmenorrhea and menorhaggia
*
What is the MOST common neoplasm of the uterus?
AUB-L
Uterine leiomyomas (FIBROIDS)
Polyhydraminos
Oligohydraminos
too much fluid
too little fluid
AUB-L
Uterine Leiomyomas (fibroids)
Fibroids are benign tumors from the smooth muscles of the myometrium. 45% of wommen will have them by 5th decade.
Symptomatic fibroids can cause:
- Excessive uterine bleeding
- Pelvic pressure/pain
- Infertility
• Most common indication for hysterectomy is __________
SYMPTOMATIC FIBROIDS
• RISK FACTORS for developing fibroids
- Increasing age in reproductive years
- African-american women have a 2-3 fold increase
- Nulliparity (a woman who has never had a child)
- FH
Top 3. areas where fibroids occur
- Subserosal fibroid
- Interstitial fibroids
- Submucosal fibroids
Fibroid
Pathogenesis:
Sx:
- Pathogenesis: unknown, rarely form b4 mencarche or enlarge after menopause. Estrogen causes proliferation. of smooth muscle cells. can enlarge during pregnancy
- Sx: most are asymptomatic
- pelvic pain
- severe pain not. common unless undergoing acute infarction
- Frequency of urination bc presses on bladder
- Prolonged or heavy bleeded
- Increased incidence of infertility. (common d/t submucosal fibroids).
(aub-m)
ENDOMETRIAL HYPERPLASIA, a precursor to endometrial cancer.
Endomestrial lining keeps growing d/t persitant unopposed estrogen by granulosa theca cell tumors (make EST), obesity, exogenous estrogens, tamoxifin
• Hyperplasia- precursor to malignancy
Simple without atypia • (___& chance to develop cancer)…
Complex without atypia •
Simple with atypia •
Complex with atypia
Simple without atypia (1%)
Complex without atypia • (3%)
Simple with atypia • (9%)
Complex with atypia (27%)
most common type of endometrial hyperplasia?
Risk factors?
Presentation?
- Type 1: Endometrial adnenocarcinoma
- Obesity and unopposed estrogen
- Postmenopausal bleeding is the most common presentation
AUB-C
Coagulopathies, nonstructural cause, associated with heavy flow often d/t von willibrand factor disease
AUB-O
Ovulatory Dysfunction: unpredictable menses with variable flow often d/t polycystic ovarian syndrome
AUB-E
Endometrial Causes such as infection
AUB-I
Iatrogenic: IUD, IUS, exogenous hormones
AUB-N
Not Yet Classified
Reserved for entities that are poorly defined &/or not well examined, ex
treatment options for abnormal uterine bleeding.
1. Coordinate endometrial sloughing
- MPA (medoroxyprogesterone) or combined oral contraceptives (OCP’s):If someone has AUB: give progesterone, make it seem like she had her cycle, have her come off of progesterone, causing her to slough.
2. Endometrial supression
- Give progesterone daily, tricks body to think pregnany
- Continous OCPs, BC without placebo pills. Instead, start a new padk.
- IUS (intrauterine system)
Be familiar with the work up options for uterine bleeding.
Laboratory Tests
- Pregnancy test (blood or urine) •
- CBC
- Screening for bleeding disorders
- Von Willebrands profile
- PT and PTT
- TSH
- Chlamydia trachomatis
Available Tissue Sampling Methods (When indicated)
- Office endometrial biopsy
- Hysteroscopy directed endometrial sampling
What are indications for in office endometrial biopsy
- AUB in post-menopausal women
- Women 45-menopase with ANY AUB.
- Woman < 45: any bleeding that occurs d/t unopposed estrogen exposure; obesity, PCOS or prolonged amenorrhea
- glandular cells on cervical cytology test.
PUBERTY
• Average duration is ____ years. •
Usually occurs between ____y/o (mean is ___)
Puberty-> development of secondary. sex xharacteristics. and reproductive capability.
4-5
10-16
Mean: 12.4. years old
Stages of normal pubertal. development (4)
TAGM (thelarche, adrenarche, growth spurt, menses)
- 1. Thelarche (breast development) is the first sign of puberty and REQUIRES estrogen
- Pubarche/adrenarche (pubic hair/axillary hair develpment) REQUIRES androgens.
-
Max growth or peak height velocity.
* Occurs 2 years earlier in girls, 1 year before onset of menses.
-
Max growth or peak height velocity.
- Menses, requires pulsatile GnRH, FSH and LH, estrogen and progesterone from ovaries and normal outflow tract
what races go through puberty earlier
African american -> and hispanic
Tanner. stageing is the stages of breast development
- Stage 1: Preadolescent: papilla elevates
- Stage 2: breast bud form; breast and papilla elevate into a small mound with arealar region enlarging
- Stage 3: Breast.and areola get bigger w/o separation of countours
- Stage 4: areola and papilla project to to form a secondary mound above breasts
- Stage 5: mature stage: projection of papilla only, d/t retraction of areola.
Tanner. stageingis the stages of pubic hair development
- Stage 1: preadolescent: none
- Stage 2: sparse hair along labia with slight pigment
- Stage 3: hair spreads over junction of pubes
- Stage 4: adult type hair
- Stage 5: adult type hair that. spreads to medial thigh
