Lecture 11: Menarche, Puberty and Menstrual Disorders Flashcards
Normal ovulatory cycle can be divided into 2 phases; when does each begin and end?
1) Follicular Phase:
- Begins w/ the onsetof menstruation and culminates in the preovulatory surge of LH
2) Luteal Phase:
- Begins w/ the onset of the preovulatory LH surge and end w/ the first day of menses
Decreasing levels of estradiol and progesterone from the regressing corpus luteum of the preceding cycle causes what?
Inititate an increase in FSH by a negative feedback mechanims, which stimulates follicular growth and estradiol secretion
There are separate cellular functions in the ovarian follicle, what does LH stimulate vs. FSH?
LH stimuates the theca cells to produce androgens (androstendione and testosterone)
FSH stimulates the granulosa cells to convert these androgens to into estrogen (E1 and E2)
During the luteal phase what are the levels of LH and FSH like; if conception does not occur what occurs?
- Both the LH and FSH are significantly suppressed through the negative feedback effect of the elevated circulating estradiol and progesterone
- If conception does not oocur progesterone and estradiol levels decline near the end of the luteal phase as a result of courpus luteal regression
- FSH will then rise which initiates new follicular growth for the next cycle
What 5 peptides or biogenic amines that affect the reproductive cycle have been isolated from the hypothalamus?
1) GnRH
2) CRF = corticotropin-releasing factor
3) TRH = thyroid-releasing hormone
4) SRIF = somatostatin
5) PIF = prolactin release-inhibiting factor
GnRH is what type of peptide and causes the release of what from the anterior pituitary; how are these hormones found within the pituitary gonadotrophs?
- Decapeptide
- LH ans FSH are present in 2 different forms (releasable and storage)
What affect does estradiol have on hypothalamus GnRH release and what does this lead to in the ovarian cycle?
- Appears to enhance the hypothalamic release of GnRH
- Induces the midcycle LH surge
What are estrogen levels like during early follicular development, 1 week before ovulation, at midcyle LH peak, and after ovulation?
- Estradiol levels are low during early follicular development
- Approximately 1 week before ovulation, estradiol (E2) levels begin to increase
- Estrogen levels generally reach a maximum 1 day before the midcyle LH peak, then fall, and rise to a maximum 5-7 days after ovulation, returning to baseline before menstruation
Where does the bulk of progesterone come from during follicular development?
- Ovary only making a small amount, bulk is coming from peripheral conversion of the adrenal pregnenolone and pregnenolone sulfate
When do we see increasing levels of progesterone from the ovaries?
- Prior to ovulation the unruptured luteinizing graafian follicle begins to produce increasing amounts of progesterone
- Secretion of progesterone by the corpus luteum reach a maximum 5-7 days after ovulatio and returns to baseline before menstruation
What is the number of oocytes at 20 weeks gestation and what occurs at birth and there on?
- 7 million at 20 weeks gestation
- Significant atresia of oogonia occurs so at birth only 1-2 millions remain
- At puberty w/ continued atresia only 400,000 are available w/ only 400 actually ovulating
What is cumulus oophorus?
- In adult ovary, a graafian follicle forms
- The innermost 3-4 layers of multiplying granulosa cells become cuboidal and adherent to the ovum this is know as cumulus oophorus
What occurs once a fluid filled antrum forms among the granulosa cells; how is the corona radiata formed; what occurs at ovulation?
- Antrum enlarges and the centrally located primary oocyte migrates to the wall of the follicle
- Innermost layer of the granulosa cells of the cumulus become elongated and form the corona radiata
- The corona radiata is release w/ the oocyte at ovulation
How and when is the corpus luteum formed; what does it produce; normal functional lifespan; what does it become if pregnancy does not occur?
- After ovulation the granulosa cells of the ruptured follicle undergo lutenization
- Lutenized granulosa cells, theca cells, capillaries, and CT FORM the corpus luteum
- Corpus luteum produces copious amounts of progesterone and estrogen
- Normal functional life span is 9-10 days
- No pregnancy = menses ensues and corpus luteum is gradually replaced by avascular scar called the corpus albicans
Once the corpus luteum dies, the estrogen and progesterone levels fall, what affect does this have on the anterior pituitary and what occurs next leading up to the LH surge?
- Pituitary responds by increasing FSH secretion
- FSH recruits cohort of large antral follicles to enter rapid growth phase and these follicles secrete low amounts of estrogen and inhibin
- Estrogen and inhibin neg. feedback on FSH
- Declining FSH levels progessively cause atresia of all but 1 follicle - leading to selection of dominant follicle, which produces high levels of estrogen
- High estrogen has positive feedback on gonadotrophs LH (and some FSH) surges
The endometrium is divided into 2 zone; what changes occur to each and what arteries are found in each?
- Outer portion or functionalis
- Cyclic changes in morphology during the menstrual cycle and is sloughed off at menstruation
- Spiral Arteries
2. Inner portion or basalis
- Remains unchanged during each cycle and provided stem cells for the renewal of the functionalis layer
- Basal arteries
What occurs to the endometrial glands, functionalis layer, and basalis layer during menstruation phase
- 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
During which phase does the endometrial lining reach its maximum thickness?
Secretory phase
If conception does not occur by which day does the corpus luteum begin to regress and what occurs 1 day prior to onset of menstruation?
- Day 23
- One day prior to menstruation = marked constriction of the spiral arteries occurs resulting in ischemia of the endometrium, leukocyte infiltration and RBC extravasation
- Resulting necrosis causes sloughing of the endometrium resulting in menstruation
Why are coagulation factors important in regulating menstruation and what can disrupt this pathway?
- Menstruation disrupts blood vessels, but with normal homeostasis, the injured vessels are rapidly repaired
- Medications such as Warfarin, Aspirin, Clopidogrel can impair the coagulation system and be associated w/ heavy bleeding
What age should initial reproductive visit occur?
Between ages of 13-15 years
ACOG recommends first Pap test at what age; how often there after?
- 21 years old
- Then every 3 years
What is the recommendation for HPV; what does it protect against; what are the 2 types and what genotype covered by each?
- One series between the ages of 9-26
- Offers protection against cervical cancer, cervical dysplasia, vulvar or vaginal dysplasia and genital warts
- Gardasil HPV genotypes: 6, 11, 16 and 18
- Gardasil 9-covers genotypes: 6, 11, 16, 18, 31, 33, 45, 52 and 58
What is the median age of menarche?
- Median = 12.43 years
- 10% menstruate at 11.11 years
- 90% menstruate by 13.75 years
Menarche occurs within how many years of Thelarche and at what Tanner stage?
- Occurs within 2-3 years after Thelarche at Tanner stage IV
- Rare before Tanner stage III
By what age will 98% of females have had their first menarche?
15
Primary amenorrhea is defined as?
- Absence of menarche by age 13 years w/o secondary sexual development
- OR by the age of 15 w/ secondary sexual development
What is the median length of first cycle after menarche and how long did these females bleed?
- Median length was 34 days
- Most females bled 2-7 days during first menstruation
Most normal cycles range ______ days even in first gynecologic year; by the third year after menarche approximately 80% of menstrual cycles are ______days long, as is typical adults?
- Most normal cycles range from 21-45 days even in first gynecologic year
- By the 3rd year = 21-35 days long, as is typical adults
Normal menstrual flow length in young females is how many days?
7 days or less
What can endometrial polyps (AUB-P) cause; what is used to detect; how do we treat?
- Menorrhagia, spontaneous or post menopausal bleeding
- Saline hysterosonography and hysteroscopy allow for best detection
- Most polyps are benign
- Need to remove with hysteroscopy since endometrial hyperplasia and carcinoma may also present as polyps
Adenomyosis (AUB-A) is defined as what; 15% of adenomyosis patients have what; common symptoms?
- Defined as the extension of endometrial glands and stroma into the uterine musculature >2.5mm beneath the basalis layer
- 15% of patients w/ adenomyosis have endometriosis
- May be asymptomatic, severe secondary dysmenorrhea and menorrhagia
- Can be associated with dyspareunia w/ deep penetration
What are the 3 common places in uterus where fibroids are found?
1) Subserosal fibroid
2) Interstitial fibroid
3) Submucosal fibroid
How effective is a in office EMBX; better pathology when; and contraindications?
- Blind biopsy but adequate sample obtained in 90% of patients
- Better when pathology is global (hyperplasia) rather then focal (polyp)
CONTRAINDICATED:
Absolute: Pregnancy
Relative: Bleeding diathesis
What is endometrial ablasian?
- Uses radiofrequency to a bipolar mesh electrode while at the same time applying suction
- Perforation safety mechanism
- Ablation time 90 secs
What are the 5 Tanner stages of breast development?
- Preadolescent; elevation of papilla only
- Breast bud stage; elevation of breast and papilla as a small mound w/ enlargement of the areolar region
- Further enlargement of breast and areola w/o separation of their contours
- Projection of areola and papilla to form a secondary mound above the level of the the breast
- Mature stage; projection of papilla only, resulting from recession of the areola to the general contour of the breast
What are the 5 Tanner stages of pubic hair development?
- Preadolescent; absence of pubic hair
- Sparse hair along the labia; hair down w/ slight pigment
- Hair spreads sparsely over the junction of the pubes; hair is darker and coarser
- Adult-type hair; there is no spread to the medial surface of thighs
- Adult-type hair w/ spread to the medial thighs assuming an inverted triangle pattern
