Menarche Puberty and Menstrual Disorders Flashcards
What is the basic hypothalamic-pituitary-ovarian axis?
GnRH –> FSH and LH –> estrogen and progesterone from ovarian follicle
What separate the pituitary gland from the cranial cavity?
condensation of dura matter
What denotes the follicular phase?
begins w/ onset of menstruation –> ends w/ preovulatory surge of LH
What denotes the luteal phase?
begins w/ onset of preovulatory LH surge –> ends w/ first day of menses
what stimulates follicular growth?
general cycle:
decreasing levels of E and P from regressing corpus luteum of the preceding cycle –> increase in FSH –> follicular growth –> E secretion
What does LH stimulate?
What about FSH?
LH –> theca cells to produce androgens
FSH –> granula cells convert androgens into estrogens (E1 and E2)
What occurs hormonally in the luteal phase?
Both LH and FSH are depressed as E2 and P increase
if conception doesn’t occur –> no HcG –> corpus luteum regresses –> E and P will decrease –> FSH will then rise to initiate next cycle
How does estradiol affect the hypothalamus?
enhances the release of GnRH and induce midcycle LH surge
What are estrogen levels like in the ovarian cycle?
early = low
approx 1 week before ovulation –> E2 increases –> peaks 1 day before midcycle LH peak –> then drops again
reaches max in luteal phase 5-7 days after ovulation and returns to baseline before menstruation
Where does progesterone come from during follicular development?
ovary only secretes a small amount
bulk from peripheral conversion of pregnenolone to progesterone
corpus luteum secretes a lot and reaches peak 5-7 days afer ovulation –> returns to baseline before menstruation
When do oocytes become surrounded by precursor granulosa cells?
8-10 weeks of fetal dev
primordial follicle
What is the cumulus oophorus?
innermost 3-4 layers of granulosa cells surrounding the oocyte
become cuboidal
What is the corona radiata?
innermost layer of granulosa cells of the cumulus oophorus
What occurs during pre-ovulatory LH surge?
cells on follicular wall surface degenerate –> stigma forms –> follicular basement membrane bulges through stigma
How long is the normal functional life span of the corpus luteum?
9-10 days
What do you see in hormone levels during menopause?
lower E –> no neg feedback on FSH and LH
so you see increased FSH and LH
What are the 2 layers of the endometrium?
functionalis = where sprial arteries are, sloughed off during menstruation
basalis = unchanged during cycle, provides stem cells for functionalis renewal, contains basal As
What is the only part of the uterine/ovarian cycle that is visible externally?
menstrual phase
What occurs in the proliferative phase of ovarian cycle?
estrogen –> endometrial growth/proliferation
spiral As increase and length, can see numerus mitoses
What occurs in the secretory phase of ovarian cycle?
P from corpus luteum –> glandular cells secrete mucus, glycogen, etc.
glands become tortuous = sawtoothed pattern
stroma becomes edematous
mitosis rare
endometrial lining max thickness
When will the corpus luteum begin to regress?
if conception doesn’t occur by day 23
When does necrosis of endometrium occur?
1 day prior to onset of menstruation
caused by constriction of spiral arteries
What is required to restore the blood vessels in the endometrium?
successful interaction of platelets and clotting factors
When should an initial repro health visit for a female occur?
what happens at this visit?
13-15 yrs
build trust, just talk to pt
pelvic exam usually not indicated unless problem
talk about repro health-related topics for prevention
When should a pap smear first be performed?
age 21
What did the first gardasil vaccine protect against?
what about gardasil 9?
1 series age 9-45
gardasil: HPV 6, 11, 16, 18
G 9: 6, 11, 16, 18, 31, 33, 45, 52, 58
What is the median age of menarche?
12.43 yrs
10% at 11.11 yrs
90% menstruating by 13.75 yrs
What is thelarche?
breast budding
What defines primary amenorrhea?
absence of menarch by age 13 w/out 2ndary dev
OR
by 15 w/ secondary dev
When do cycles start to become regular?
by 3rd year after menarche: 80% 21-35 days long, as is typical in adults
What is mean cycle interval in 1st gyno year?
menstrual flow length?
Menstrual product use?
32.2 days
7 days or less
3-6 pads or tampons per day
what defines secondary amenorrhea?
absence of menstruation x 6 months
rare for girls and adolescents to remain amenorrheic for more than 3 mos –> workup if > 90 days
What are endocrine causes of menstrual irregularity?
poorly condrolled DM
PCOS
cushing’s
thyroid dysfunction
premature ovarian failure
late-onset CAH
What is mean blood loss per menstrual period?
What is associated w/ anemia?
avg = 30 cc = 3-6 pad changes per day
> 80 cc = assoc w/ anemia = changing pad q 1-2 hrs
What is polymenorrhea?
abnormally frequent menses at <21 days
Menorrhagia
excessive/prolonged menses occuring at regular intervals
metrorrhagia?
irregular episodes of uterine bleeding
menometrorrhagia
heave and irregular uterine bleeding
intermenstrual bleeding
scant bleeding at ovulation for 1-2 days
oligomenorrhea
menstrual cycles at > 35 day cycles
What are the structural causes for abnormal bleeding in repro-age women?
PALM
Polyp
Adenomyosis
Leiomyoma (submucosal or other)
Malignancy and hyperplasia
What are the nonstructural causes for AUB?
COEIN
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not yet classified
What is an endometrial polyp and how are they detected?
form from endometrium –> soft friable protrusion into endometrial cavity
can cause menorrhagia, spontaneous, or post menopausal bleeding
see on ultrasound = focal thickening of endometrial stripe
saline hysterosonography and hysteroscopy allows form better detection
What is Adenomyosis?
extension of endometrial glands and stroma into uterine musculature (>2.5 mm beneath basalis layer)
15% of ppl with it have endometriosis
see homogenous enlargement of the uterus
What are uterine leiomyomas?
“fibroids”
benign tumors derived from sm m cells of myometrium
most common neoplasm of uterus, rarely malignant
common in older women
most asymptomatic
subserosal, interstitial, or submucosal
What can cause leiomyomas to enlarge?
pregnancy causes dramatic enlargement
What are common symptoms of leiomyomas?
most asymptomatic
pelvic/low back pain
seve pain not common
freq of urination
prolonged/heavy bleeding (submucosal or intramural)
increased incidence of infertility
What is endometrial hyperplasia?
overabundance of growth of endometrium
usually result of unopposed persistent E2
What can cause endometrial hyperplasia?
PCOS
granulosa theca cells tumors - E2 producing
obesity - conversion of androgens to Es in adipose cells
exogenous estrogens
tamoxifen
What are the rules for risk of cancer w/ endo hyperplasia?
rule of 3s
simple w/out atypia - 1%
complex w/out atypia - 3%
simply w/ atypia - 9%
complex w/ atypia - 27%
what are the types of endometrial cancer discussed?
type 1: adenocarcinoma = most common
type 2: clear cell and papillary serous
What are the common presentations of endometrial hyperplasia?
postmenopausal bleeding = most common
irregular uterine bleeding - perimenopause
What lab tests would you do to evaluate AUB?
pregnancy test
CBC
targeted screening for bleeding disorders (von Willebrands profile, PT and PTT)
TSH
chlamydia trachomatis
what are indications for in office endo biopsy (EMBX)?
postmenopausal women - sample w/ any spotting or bleeding; endomedrial lining> 4mm
age 45 to menopause: any AUM
<45: any bleeding that occurs in setting up unopposed E2 exposure or prolonged amenorrhea
if + glandular cells on cervical cytology
What is an EMBX good for?
better when pathology is global (hyperplasia) rather than a focal polyp
What are absolute contraindications of an EMBX?
relative?
absolute = pregnancy
relative = bleeding diathesis
What are the medication treatments of AUB?
normalize prostaglandins (NSAIDs prior to and during menses)
antifibrinolytic therapy
coordinate endometrial sloughing (OCPs)
endometrial suppresion (progesterone continuous)
What are surgical tx for AUB?
polypectomy
myomectomy
dilation and currettage
uterine endo ablation
hysterectomy
What is a D and C used for?
diagnostic = for irregular bleeding or postmenopausal bleeding
therapeutic = to remove endometrial structural abnormalities
What is endometrial ablation?
uses radiofrequency to bipolar mesh electrode while at same time applying suction
perforation safety mechanism
ablation time is 90 sec
What are the 4 routes for hysterectomy?
- total abdominal hysto (TAH)
- vaginal hysterectomy (TVH)
- laparascopic assisted vaginal (small abdominal and vaginal incisions)
- da Vinci assisted (small abdominal and vaginal incisions)
How long is puberty?
when does it occur?
avg is 4-5 yrs
usually occurs btw 10-16 y/o (mean is 12.4)
When is the H-P-O axis suppressed?
btw ages 4-10
What occurs to onset puberty?
age 11: loss of sensitivity by gonadostat to negative feedback of sex steroids
sleep-associated increases in GnRH –> adult patterns
increase in GnRH –> ovarian follicle maturation and sex steroid production
by mid to late puberty - ovulatory cycles established
What is pubarche/adrenarche?
pubic hair/axillary hair development (requires androgens)
When does maximal growth/ height velocity occur?
1 yr before onset of menses (2 yrs earlier than boys)
What are the Tanner stages of breast development?
- preadolescent, elevation of papilla only
- breast bud, elevation of breast and papilla is small w/ enlargement of areolar region
- further enlargement of breast and areola w/out separation of their contours
- projection of areola and papilla to form secondary mound above breast
- mature stage, projection of papilla only, areola goes w/ general contour of breast
What are the Tanner stages of pubic hair?
- preadolescent, absence
- sparse hair along labia, hair downy w/ slight pigment
- hair spreads sparsely over jxn of pubes, darker and coarser
- adult-type hair, no spread to thighs
- adult-type hair w/ spread to medial thighs
