Menarche, Pubarche, and Mentrual Disorders Flashcards
4 cycles associated with female reproduction (i.e., sources of control)
Hypothalamic
Pituitary
Ovarian
Endometrial
The ideal menstrual cycle is ____ days, with ovulation occurring day _____
The first day of bleeding is cycle day _____
The average length of bleeding is _____
Average blood loss is _____
28; 14
1
3-7
30cc
Mean age of menarch = _____
Mean age of menopause = ____
13; 52
Normal menstrual cycles in young females in terms of menarche, mean cycle interval, menstrual cycle interval, menstrual flow length, and menstrual product use
Menarch = 12.43 yrs
Mean cycle interval = 32.2 days first year
Menstrual cycle interval = 21-45 days
Menstrual flow length = 7 days or less
Menstrual product use = 3-6 pads or tampons/day
During the luteal phase, the follicle is transformed into the corpus luteum. This phase is 12-14 days long, and the corpus luteum lasts _____ days
9-10
Menses occurs due to withdrawal of _____ and _____. Spiral arteries ______, resulting in necrosis/ischemia of endometrium
Progesterone (P4), estrogen (E2); constrict
During proliferative phase of endometrium, endometrial glands are deep within ____ layer
This phase is responsive to ______, which causes growth and thickening, elongation of spiral arteries, and glands appear straight
Basalis; estrogen
The secretory phase of the endometrium involves _____ stimulation from corpus luteum; secretions increase from glandular cells and they have sawtooth appearance
Progesterone
_____ is characterized by development of secondary sexual characteristics and reproductive ability
Puberty
What factors affect onset of puberty?
Genetics Geographic location Nutritional status Excessive exercise - Frisch theory Psychologic factors
T/F: age of menarch has increased through history
False, has decreased from age 17 in 1840, age 13 in 1979, and today age 12.4
During the fetal/newborn period, there is complex integration of negative feedback mechanisms. At 20 weeks gestation, there is _____ rise, as well as _______ rise to encourage organ dev’t
FSH/LH; glucocorticoid
Placental and maternal estrogen provide negative feedback for _______, this negative feedback is lost after delivery of the placenta
Gonadotropins
The fetal adrenal gland produces _____, which regresses after delivery. This precursor is used by the placenta and other pathways
DHEA-S
What axis is suppressed between the ages of 4-10 years old?
Hypothalamic-pituitary-ovarian axis
The hypothalamic-pituitary system regulating gonadotropin release is termed the ______
Gonadostat
Low levels of gonadotropins and sex steroids during this prepubertal period are the function of what 2 mechanisms?
Gonadostat - sensitive to the negative feedback of low circulating estradiol
Intrinsic CNS - inhibition of the hypothalamic gonadotropin-releasing hormone (GnRH) secretion
Between the ages of 8-11, there is an increase in ______, _____, and ______
Adrenal androgen production increases, and there is differentiation by the ____ ____ of the adrenal cortex
DHEA; DHEA-S, and androstenedione
Zona reticularis
The rise in adrenal androgens in late childhood leads to growth of _____ and _____
Axillary and pubic hair
Around 11 years of age, there is gradual loss of sensitivity by the _______ to negative feedback of sex steroids. Intrinsic loss of CNS inhibition of hypothalamic ____release
Gonadostat; GnRH
Sleep-associated increses in ____ secretion occur and gradually shift into adult type secretory patterns
GnRH
GnRH increases at onset of puberty lead to what changes?
Promotion of ovarian follicular maturation and sex steroid production
Secondary sexual characteristics
By mid to late puberty, the positive-feedback mechanism of _____ on LH release from AP gland is complete and ovulatory cycles are established
Estradiol
Physiology of puberty summary
HPA axis suppressed ages 4-10
Age 8-11 — androgens increase, adrenal cortex differentiation occurs, adrenarche starts (DHEA, DHEA-S)
Age 11-12 — negative feedback intrinsic control lessens, GnRH increases, role of leptin, gonadotropins increase, ovarian follicular maturation
______ is the first physical sign of puberty in females, which requires ______
Thelarche (breast development); estrogen
Pubarche/adrenarche (pubic hair/axillary hair development) requires ______
Androgens
Maximal growth or peak height velocity occurs 2 years earlier in _____; occurs about 1 year _____ onset of menses
Girls; before
Menarche requires ______ GnRH from the hypothalamus, FSH and LH from the _____, estrogen and progesterone from the ______, and a normal outflow tract
Pulsatile; AP; ovaries
Tanner staging based on breast tissue
Stage 1: preadolescent; elevation of papilla only
Stage 2: breast bud stage; elevation of breast and papilla as small mound with enlargement of areolar region
Stage 3: further enlargement of breast and areola without separation of their contours
Stage 4: projection of areola and papilla to form a secondary mound above the level of the breast
Stage 5: mature stage; projection of papilla only, resulting from recession of the areola to the general contour of the breast
Tanner staging based on pubic hair
Stage 1: preadolescent; absence of pubic hair
Stage 2: sparse hair along labia, hair downy with slight pigment
Stage 3: hair spreads sparsely over junction of pubis; dark and coarse
Stage 4: adult type hair; no spread to medial thigh
Stage 5: adult type hair with spread to medial thighs assuming inverted triangle pattern
Average duration of pubarche
4.5 years
The growth spurt that occurs with pubarche is mediated by what 3 hormones?
GH
Insulin
ILGF
Fusion of the long bones during pubarche is mediated by ____ production
Steroid
What is the difference in bone mass in males vs. females prior to vs. after puberty?
Prior to puberty: bone mass same in males/females
After pubterty: females have more body fat and less skeletal bone mass
Menarche occurs 2-3 years after ________, roughly tanner stage _____
Menarche is rare before tanner stage ____
Thelarche; IV
III
98% of females will have had menarche by age 15, if they do not, it is called ______
Primary amenorrhea
What is the purpose of the initial health visit to OB/GYN in females age 13-15?
PMH, PSH and FH
Review of normal dev’t
Educate on safe sex and STIs
Screen for at-risk behavior
Exam may be indicated
Vaccinations and HPV info
What is the purpose of regular preventative health visit for OBGYN?
Annual exam Cervical cancer screening Mammography Contraceptives Reproductive choices Vaccines Review of health history
What are the 4 most common causes of menstrual irregularity?
Pregnancy
Endocrine causes
Acquired conditions
Tumors
What are endocrine causes of menstrual irregularity?
Poorly controlled DM PCOS Cushing’s Thyroid dysfunction Premature ovarian failure Late onset congenital adrenal hyperplasia
Acquired conditions that cause menstrual irregularity
Stress-related hypothalamic dysfunction
Medications
Exercise-induced amenorrhea
Eating disorders
Tumors that cause menstrual irregularity
Ovarian tumors
Adrenal tumors
Prolactinomas
What are important considerations when evaluating abnormal uterine bleeding?
Good menstrual hx (frequency, irregularity, duration, blood loss)
Pelvic exam
Rule out pregnancy!!!
No menstruation has occurred by the age of 13 without secondary sexual development or by age of 15 with secondary sexual development
Primary amenorrhea
Absence of menses for 6+ months
Secondary amenorrhea
Abnormally frequent menses at intervals <21 days
Polymenorrhea
Excessive and/or prolonged menses (>80mL and >7days) occurring at regular intervals
Menorrhagia
Irregular episodes of uterine bleeding
Metrorrhagia
Heavy and irregular uterine bleeding
Menometrorrhagia
Scant bleeding at ovulation for 1-2 days
Intermenstrual bleeding
Menstrual cycles at >35 day cycles
Oligomenorrhea
Mnemonic for the causes of dysfunctional uterine bleeding
PALM (structural) COEIN (functional)
P = polyp A = adenomyosis L = leiomyoma M = malignancy and hyperplasia
C = coagulopathy O = ovulatory dysfunction E = endometrial I = iatrogenic N = not yet classified
Soft friable protrusion of endometrium into the endometrial cavity associated with menorrhagia, spontaneous, or post-menopausal bleeding
Endometrial polyps
What are ultrasound findings associated with endometrial polyps
Focal thickening of endometrial stripe
Saline hysterosonography and hysteroscopy allows for better detection
T/F: endometrial polyps are usually benign
True; more concerning if symptomatic or postmenopausal
Extension of endometrial glands and stroma into uterine musculature (>2.5 mm beneath basalis layer), sometimes associated with endometriosis, and the associated islands of cells do not participate in secretory cycles
Adenomyosis
Symptoms of adenomyosis
May be asymptomatic
Severe secondary dysmenorrhea and menorrhagia
Associated with dyspareunia with deep penetration
What is leiomyoma?
Uterine fibroids — benign tumors derived from smooth muscle of myometrium
Most common neoplasm of the uterus
Leiomyoma
Symptoms of leiomyoma
Excessive uterine bleeding, pelvic pressure, pelvic pain, infertility
Most are asymptomatic
What is the most common indication for a hysterectomy?
Leiomyoma
What are risk factors for developing uterine fibroids?
Increasing age during reproductive years
African american women have 2-3x risk
Nulliparity
Family hx
______means precursor to malignancy, can be simple or complex with or without atypia
Hyperplasia
Type 1 vs. type 2 malignancy in OB cancers, which one is most common?
Type 1 = endometrial adenocarcinoma — MOST COMMON
Type 2 = clear cell and papillary serous
Risk factors for malignancy
Obesity
Smoking (risk for type 2)
Unopposed estrogen
Genetic factors
What is the most common presentation of endometrial malignancy?
Postmenopausal bleeding
[or irregular bleeding with perimenopause]
Coagulopathies (AUB-C) are associated with heavy flow and ______ disease
Von willebrand
Ovulatory dysfunction (AUB-O) is associated with what changes in menses? What condition?
Unpredictable menses with variable flow
associated with PCOS
Endometrial causes (AUB-E)
Infection (endometritis)
Iatrogenic causes (AUB-I)
IUD, IUS, exogenous hormones
Evaluation of DUB
H and P
UPT
Labs: CBC, TSH, prolactin, coagulation studies
Imaging: TVUS, sonohystogram, MRI
Biopsy: endometrial, D and C, hysteroscopy
Indications for in-office endometrial biopsy
AUB (in postmenopausal women with spotting/bleeding, in age45-menopause with intermenstrual bleeding or menorrhagia, in less than 45 yrs with unopposed estrogen exposure like obesity or PCOS or prolonged amenorrhea
Cervical cytology results + glandular cells
Medications for AUB
NSAIDs to normalize prostaglandins
Antifibrinolytic therapy like tranexamic acid during menses
Coordinate endometrial sloughing with OCPs like MPA or COC
Endometrial suppression with progestin daily, extended cycling with COC, LNG-IUS
Surgical therapy for AUB
Polypectomy Myomectomy Uterine ablation D and C Hysterectomy
