Menarch puberty and menstrual disorders Flashcards
What is primary amenorrhea
- absence of menarche by 13 without secondary sex development or by age of 15 with secondary sesx development
What is secondary amenorrhea
- absence of menstruation for 6 months
- rare for girls and adolescents to be amenorrhea for more than three months
- if greater than 90 days workup is indicated
- rare for girls and adolescents to be amenorrhea for more than three months
What is polymenorrhea
- abnormally frequent mensses with intervals of less than 21 days
what is oiligomenorrhea?
Menstrual cycless at greater than 35 days
what is menorrhagia
- excessive and prolongned menses occuring at regular intervals
what is metorrhagia
- irregular episodes of uterine bleeding
what is menometrorrhagia
- heavy and irregular uterine bleeding
What is intermenstrual bleeding
- bleeding at ovulation for 1-2 days
What does the follicular phase of ovary cycle begin with and end in?
- onset of menstruation
- ends with preovulatory surge of LH
What does the luteal phase of ovulatory cycle begin and end with?
- Begins onset of preovulatory LH surge
- Ends with first day of menses
What initiates an increase in FSH by NFB mechanism resulting in stimulation of follicle growth and estradiol secretion?
Decreasing levels of estradiol and progesterone from the regressing corpus luteum of the preceding cycle
What is the two cell theory of ovarian follicular development and estrogen production?
- Cells in the ovarian follicle hae separate cellular functions
- theca cell stimulated by LH produces Androstenedione and testosterone
- Granulosa cell stimulated by FSH will convert Androsetnedione into estrone and testosterone into estradiol via aromatization
When does the luteal phase occur, what do the hormones look like?
After ovulation occurs and FSH and LH are suppressed due to elevated progesterone estradiol levels
Durinng the luteal phase if fertilization doesen’t occur what happens to progesterone and estradiol levels?
- Declinne near the end of the phase as the CL is regressing
- FSH rises initiating the new follicular growth for the next cycle
What hormone is high when proliferative phase growth occurs?
When Estradiol is the dominant hormone
How is GnRH secreted throughout menstrual cycle, in luteal phase and in follicular?
- Secreted pulsatile fashion throughout menstrual cycle
- within the foilliclular phase pulses are more frequent with low amplitude
- In luteal phase pulses are high amplitude low frequency
- Estradiol enhances hypo release of GnRH
- FSH and LH inhibit it
When do estradiol levels rise?
- During early follicular development the levels are low but ~1 week begore ovulation the levels of E2 begin to rise
When do estrogen levels reach a maximum?
- 1 day before the midcycle LH surge
- After the peak and before oulation there is a significant fall, but durinng luteal phase it rises to maximum again 5-7 days after oulation and returns to baseline before menstruationn occurs
Describe progesterone secretionn durinng follicular development.
- ovary is only secreting small amounts
- most of progesteroe comes from peripheral conversion of adrenal pregnenolone and pregnenolone sulfate
When is progesterone secretion at its max and when does it fall?
- Max levels secreted by CL 5-7 days after ovulation
- Retuns to baselie before menstruation occurs
What is the cumulus oophorus?
Innermost 3-4 layers of granulosa cells that are cuboidal and adherent to ovum
What makes up the corona radiata?
Innermost layer of granulosa cells of he cumulus become elongated forming this, CR gets released with oocyte at ovulation
After ovuvlation what happens to the granulosa cells?
- Undergo lutenization, granulosa cells, theca cells capillaries and CT form the Corpus Luteum
How do you diagnose menopause?
elevated FSH
What are the two zones of endometrium?
- Outer functionalis layer: sloughed off during menstruation contains spiral arteries
- Inner basalis portion: unchanged during each cycle proides stem cells for renewal of fxnl layer after menstruation, contains basal arteries
What are the phases of the uterine cycle?
- Menstrual phase
- Proliferative (estrogenic phase)
- Secretory (progestational phase)
Describe menstrual phase
- Only portion of cycle that is visualized
- First day of menstruation is day 1
- Disruption anddisintergration of endometrial glands and stroma and leukocyte infiltation and RBC extravasation
- Slouging off functionalis layer and compression of the basalis layer
Proliferative phase?
- Endometrial growoth and proliferation secondary to estrogenic stimulation
- Increase in the length of the spiral arteries andn numerous mitoses can be seen
Secretory phase?
- Follows ovulation, progesterone secretion by CL stimulates the glandular cells to serete mucus & glycogen
- Glands become tortuous and lumens are dilated
- Stroma becomews edamatous
- Spiral arteris extend into superficial layer of endometrium and become convoluted
- endometrium reaches max thickness 8-14 mm
What happens if coonception doesn’t occur by 23 days
- CL regresses secretion of progesteronne and estradiol decreases and endometrium undergoes involution
What happens one day prior to menstruation?
- Constriction of the spiral arteries occurs resulting in ischemia of endometrium, leukocytes infiltrate, and RBC extravasation occurs
what is the median age of menarche?
12
What is thelarche? What is significant about this?
- Breast budding, menarche occurs 2-3 years after this
- unilateral devvelopment and tenderness are commonn
- Requires estrogen
In the first gynecologic year how can a cycle length range?
21 to 45 days
How much blood is lost per menstrual period?
30 cc
What is dysfunctional uterine bleeding (DUB)
- abnormal uterine bleedig not attributed to:
- Medications
- blood dyscrasias
- Systemic disesases
- trauma
- organic conditions
- Usually caused by aberrations in HPO axis resulting in anovulation
- Occurs around menarche or perimenopause
- now PALM COEIN
What is PALM COIEN?
- The new classification system for abnormal uterie bleeding
- Structural causes:
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy & hyperplasia
- Non structural:
- Coagulopathy
- Ovulatory dysfxn
- Endometrial
- Iatrogenic
- Not yet classified
Describe endometrial polyps. What does US show?
- Form from endometrium to create soft friable protrusion innto endometrial cavity, most polyps are benign, need to remove with hysteroscopy since cancers can also present as polyps
- US:
- shows focal thickening of endomeetrial stripe
- Saline hysterosonography and hysteroscopy allows better dissection
What is adenomyosis? (AUB-A)
- Extension of endometrial glands and stroma into the musculature
- 15% of pts with this have endometriosis also
- Sx:
- severe secondary dysmenorrhea and menorrhagia
- Can be assoc. with dyspareuni and deep penetration
- May also be asymptomatic
What is leiomyomas (AUB-L)?
- AKA Fibroids
- Benign tumors derived from sm mm of myometrium
- Most common neoplasm of the uterus
- Rarely malignant
- Most are asymptomatic, 45% women have them by 50
- symptomatic ones are excessive bleeding, pelvic pressure pain and infertility
- Most common indication for hysterectomy is symptomatic fibroids
What are the characteristics of uterinen leiomyomas?
- Usually spherical well circumscribed, white firm lesions with whorled appearance upon cutting
- May degenerate and caues pain
- May calcify in postmenopausal pts
What are sx of leiomyomas?
- Pelvic or lower back pain
- Severe pain not common unless undergoing acute infarction
- Frequent urination
- Prolonged heavy bleeding
- assoc with submucosal or intramural fibroids
- Increased inertility
- more common with submucosal
Endometrial hyperplasia? (AUB-M)
- Over growth of endometrial lining as result of persisten unopposed estrogen
- PCOS
- Granulosa thecal cell rumors producing estrogen
- Obesity secondadry to androgens to estrogegns in adipose cells
- Exogenous estrogens
- Tamoxifen
- Precursor to endometrial cancer
What types of hyperplasia are precursors to cancer?
- Simple without atypia
- Complex without atypia
- Simple with atypia
- Complex with atypia
What is the most comon type of endometrial cancer?
Type 1 Endometrial adenocarcinoma
What are risk factors for endometrial cancers and presentation?
- obesity
- unapposed estrogen
- Postmenopausal bleeding- most common sx
- Irreguar uterine bleeding-perimenopause
What are Coagulopathies ?
Von willebrand disease, assoc with heavy flow
What is ovulatory dysfxn?
Assoc wit hunpredictable menses with variable flow such as PCOS
what are endometrial causes of AUB?
Infections
Wrhat are iatrogenic AUB causes?
IUD, IUS, exogenous hormones
What are indications for in office endometrial biopsy?
- AUB
- postmenopausal women with any spotting or bleedinng or endo lining greater than 4 mm
- 45 to menopause
- any AUB including intermenstrual bleeding, menorrhagia
- Less than 45
- any bleeding in setting of unopposed estrogen exposure, such as obesity, PCOS, or prolonged amenorrhea
- Cerevical cytology results
- positive glandular cells on cervical cytology
What is EMBX? Side effects and contraindications?
In office endometrial biopsy
- Blind bipsy but adequate for 90% of patients
- Better when pathology is global rather than focal
- Side effects:
- cramping and uterine perforation
- Contraindications:
- pregnancy and relative bleeding diathesis
How do you treat AUB with medications?
- Normalize prostaglandins with NSAIDS
- Antifibriolytic therapy
- Coordinate endometrial sloughing
- Endometrial suppression
- progesterone daily
- continuous BC
- Intrauterine system
Surgical AUB treatemetns?
- polypectomy
- Myomectomy
- Dilation and currettage
- Uterinne endometrial ablation
- hysterectomy
What are two types of D&C?
- Diagnostic Dilate and Curette:
- performed for irregular menstrual bleeding or postmenopauseal bleeding to rule out endometrial hyperplasia or cancers
- Theraputic D&C:
- performed for endometrial structureal abnormalities
What is endomoetrial ablation?
- Uses radiofrequency in a bipolar mesh electrode while at same time applying suction
- Ablation time is 90 seconds
What is route for total abdominal hysterectomy?
Incision on abdomen
What is route for vaginal hysterectomy?
vaginal incision
What is laparoscopic assisted vaginnal hysterectomy?
small ab inisions and vaginal incisions
What is da vini assisted hysterectomy?
Small abdominal incisions and vaginal inisions with a robot
usually home by the end of the day
When does an infant acquire lifetime peak number of oocytes?
Mid gestation 16-20 weeks with 6-7 million
When is the HPO axis suppressed?
between ages 4 and 10
What are the two mechanisms for low levels of gonadotropins and sex steriods during prepubertal period?
- gonadostat sensitivity to the NFB of low estradiol
- Intrinsic CNS inhibition of hypothalamic GnRH
Between 8-11 theres an increase in sesrum concentrations of ___ and ___.
DHEA and DHEA-S
What are the stages of normal pubertal development?
TAGME:
- Thelarche
- Pubarche/Adrenarche
- Max growth spurt
- Menarche
What is tanner staging in regards to breast development?
- Stage one: preadolescent breast
- Stage 2: dev breast bug
- Stage 3: further enlargement of breast and areola without eparation of contorus
- Stage 4: projection of areola and papilla to orm secondary mount above breast
- Stage 5: mature breast projection of papilla only resulting from recession of areola to general contour of breast
What is tanner staging in regards to pubic hair?
- 1: no hair
- 2: sparse hair along labia
- 3: sparslly over pubic bone darker coarser
- 4: adult type hair no spread to thigh
- 5: adult type hair with spread to medial thigh, inverted triangle
