Menarche, Puberty and menstrual disorders Flashcards
what is the hypothalamic, pituitary, and ovarian axis?
Gonadotropin releasing hormone (GnRH) from the hypothalamus stimulates the follicle stimulating hormone (FSH) and the lutenizing hormone (LH) from the anterior pituitary that stimulate estrogen and progesterone from the ovarian follicle
how can the normal ovulatory cycle be divided into?
Follicular phase
-begins with the onset of menstruation and culminates in the preovulatory surge of LH
Luteal phase
-begins with the onset of the preovulatory LH surge and ends with the first day of menses
what does the regressing corpus luteum mean for the ovulatory cycle?
Decreasing levels of estradiol and progesterone from regressing corpus luteum of the preceding cycle will initiate an increase in FSH by a negative feed back mechanism which stimulates follicular growth and estradiol secretion
what does LH and FSH stimulate in the ovarian follicle?
LH stimulates:
-the theca cells to produce androgens (androstenedione and testosterone)
FSH stimulates:
-the granulosa cells to convert the androgens made by the theca cells to estrogens (E1 estrone and E2 estradiol)
what occurs in the luteal phase?
Both the LH and FSH are significantly suppressed through the negative feedback effect of the elevated circulating estradiol and progesterone
If conception does not occur progesterone and estradiol levels decline near the end of the luteal phase as a result of corpus luteal regression
FSH will then rise which initiates new follicular growth for the next cycle
this always occurs 14 days after ovulation
characteristics of Gonadotropin releasing hormone?
Decapeptide synthesized in the arcuate nucleus
Responsible for the synthesis and release of LH and FSH
-both LH and FSH are present in 2 different forms (releasable and storage) within the pituitary gonadotrophs
GnRH reaches the anterior pituitary and stimulates the synthesis and release of FSH and LH into the curculation
Estradiol appears to enhance the hypothalamic release of GnRH and induce the midcycle LH surge
Gonadotropins have an inhibitory effect on GnRH release
how does estrogen levels behave in the ovarian cycle?
during the the follicular development estradiol levels are low
one week prior to ovulation estradiol (E2) levels begin to increase and will reach a maximium 1 day prior to the midcycle LH surge
after the peak and before ovulation there is a marked and precipitous fall
During the luteal phase, estradiol rises to a maximum 5 to 7 days after ovulation and returns back to baseline when the corpus luteum regresses
how does progestins levels behave in the ovarian cycle
During the follicular development the ovary secretes only very small amounts of progesterone
-the bulk of the progesterone comes from the peripheral conversion of the adrenal pregnenolone and pregnenolone sulfate
Prior to ovulation the unruptured luteinizing graafian (mature) follicle begins to produce increasing amounts of progesterone
secretion of progesterone by the corpus luteum reaches a maximum 5-7 days after ovulation and returns to baseline before menstruation
what is a graafian follicle?
it is a mature follicle in an adult ovary that is the dominant follicle
the innermost 3-4 layers of multiplying granulosa cells become cuboidal and adherent to the ovum this is known as the cumulus oophorus
A fluid filled antrum forms along the granulosa cells
- will enlarge 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 rdiata
- the corona radiata is released with the oocyte at ovulation
what does the preovulatory LH surge initiate?
sequence of biochemical and structural changes that result in ovulation
cells on the follicular wall surface degenerate and a stigma forms, the follicular basement membrane bulges through the stigma
when this ruptures the oocyte is expelled into the peritoneal cavity and ovulation has occured
Function of the corpus luteum?
After ovulation the granulosa cells of the ruptured follicle undergo luteinization
The luteinized granulosa cells, theca cells, capillaries and connective tissue form the corpus luteum
Corpus luteum produces copious amounts of progesterone and some estradiol that functions for 9-10 days
if pregnancy does not occur, menses ensues and the corpus luteum is gradually replaced by an avascular scar called the corpus albicans
what are the two zones of the endometrium?
Endometrium is responsive to circulating progestins, androgens, and estrogens
Outer portion or Functionalis:
- this layer undergoes cyclic changes in morphology during the menstrual cycle and is sloughed off at menstruation
- contains spiral arteries
Inner portion of basalis
- this layer remains relatively unchanged during each cycle and after menstruation provides stem cells for the renewal of the functionalis layer
- contains basal arteries
endometrial changes in the menstrual cycle?
only portion of the cycle that is visualized externally
the first day of menstruation is known as cycle day 1
- Disruption and disintegration of the endometrial glands and stroma, leukocyte infiltration and red blood cell extravasion
- sloughing of the functionalis layer and compression of the basalis layer
Endometrial changes in the proliferative phase
Characterized by endometrial growth/proliferation secondary to estrogenic stimulation
increase in the length of the spiral arteries and numerous mitoses can be seen in these tissues
endometrial changes in the secretory phase
Following ovulation, progesterone secretion by the corpus luteum stimulates the glandular cells to secrete mucus, glycogen and other substances
glands become tortuous and lumen are dilated and filled with these substances
stroma becomes edematous
mitosis is rare
Spiral arteries continue to extend into superficial layer of the endometrium and become convoluted
endometrial lining reaches its maximal thickness
if conception does not occur by day 23 the corpus luteum begins to regress, secretion of progesterone and estradiol declines, and the endometrium undergoes involution
what medications can affect the coagulation pathway that would affect menstruation?
Warfarin, Aspirin, Clopidogrel can impair coagulation system and be associated with heavy bleeding
What occurs in an initial reproductive health visit?
occurs between the ages of 13-15 years
- important for building trust between physician and patient
- provide preventative health care services
- informational and guidance rather than problem focused
age appropriate discussion of:
- pubertal development
- normal menses
- timing of visits
- STIs
- Pregnancy prevention
- sexual orientation and gender identitiy
- rape prevention
a general exam, visual exam, and external pelvic exam may be indicated
when is the first pap test recommended?
recommended by ACOG at the age of 21 years
what is an importan vaccine that women and men should get to prevent cervical cancer?
at the ages of 9-26 they should look into the human papillomavirus vaccine
offers protection against cervical cancer, cervical dysplasia, vulvar or vaginal dysplasia, and genital warts associated with:
- Gardasil HPV genotypes 6,11,16, and 18
- Gardasil 9 genotypes 6, 11, 16, 18, 31, 33, 45, 52, and 58
when does menarche begin?
Median age of menarche is 12.43 years
- 10% at 11.11
- 90% at 13.75
occurs within 2-3 years after thelarche (breast budding) at tanner stage IV and is rare before tanner stage III
what is primary amenorrhea
absence of menarche by age 13 years without secondary sexual development or by the age of 15 with secondary sexual development
Cycle length and ovulation?most cycles are 21-35 days which is typical of adults
Menstrual cycles are often irregular throughout adolescents especially from the first to the second cycle
median first cycle is 34 days and bleed 2-7 days
Most normal cycles frange from 21-45 days even in first gynecologic year
by the third year
Normal mestrual cycles in: Menarche median age mean cycle interval menstrual cycle interval Menstrual flow length menstrual product use
Menarche median age: 12.43years
mean cycle interval: 32 days in first gynecologic year
menstrual cycle interval: typically 21-45 days
Menstrual flow length: 7 days or less
menstrual product use: 3-6 tampons per day
what is secondary amenorrhea? and what are some possible causes
absence of menstruation for 6 months
it is rare for girls and adolescents to remain amenorrheic for more than 3 months
-need to rule out pregnancy
causes:
- Pregnancy
- Endocrine causes: DM, Polycystic Ovary syndrome, CD, Thyroid dysfunction, premature ovarian failure, adrenal hyperplasia
- Aquired conditions: stress related hypothalamic dysfunction, medications, exercise induced, eating disorder
- Tumors: ovarian or adrenal tumor, prolactinomas
what is considered excessive menstrual flow?
Mean blood loss per menstrual period is 30cc
-most report changing pad 3-6 times a day
Greater than 80cc has been associated with anemia
-cheanging a pad every 1-2 hours is considered excessive especially if bleeding is lasting longer than 7 days
this is considered Menorrhagia or hyerpmenorrhea
what is the PALM-COEIN classification system for abnormal bleeding?
PALM = structural causes:
- Polyp (AUB-P)
- Adenomyosis (AUB-A)
- Leiomyoma (AUB-L) can be submucosal (sm) or other(o)
- Malignancy and hyperplasia (AUB-M)
COEIN = Nonstructural causes
- Coagulopathy (AUB-C)
- Ovulatory dysfunction (AUB-O)
- Endometrial (AUB-E)
- Iatrogenic (AUB-I)
- Not yet classified (AUB-N)
Abnormal bleeding definitions: Primary amenorrhea Secondary amenorrhea Polymenorrhea Metrorrhagia Menometrorrhagia Intermenstrual bleeding Oligomenorrhea
Primary amenorrhea: no menstruation has occured by the age of 13 without sceondary sexual development or by the age 15 with secondary sexual development
Secondary amenorrhea: the absence of menses for 6 months or more
Polymenorrhea: abnormal frequent menses at intervals less than 21 days
Metrorrhagia: irregular episodes of uterine bleeding
Menometrorrhagia: heavy and irregular uterine bleeding
Intermenstrual bleeding: scant bleeding at ovulation for 1-2 days
Oligomenorrhea: menstrual cycles greater than 35 day cycles
What are endometrial polyps?
AUB-P
Endometrial polyps form from endometrium to create soft friable protrusion into the endometrial cavity
can cause menorrhagia and spontaneous or post menopausal bleedings
may reveal focal thickening of the endometrial stripe
-saline hysterosonography and hysteroscopy allows for better detection
most polyps are benign but need to remove with hysteroscopy since endometrial hyperplasia and carcinoma may also present as polyps
what are adenomyosis
AUB-A
Defined as the extension of endometrial glands and stroma into the uterine musculature
-greater than 2.5 mm beneath the basalis layer
15 percent of patients with adenomyosis have endometriosis
these islands of adenomyosis do not participate in the proliferative and secretory cycles
symptoms:
- can be asymptomatic
- severe secondary dysmenorrhea and menorrhagia
- can be associated with dyspareunia with deep penetration
what are uterine Leiomyomas?
AUB-L
also known as fibroids
Benign tumors derived from smooth muscle cells of the myometrium
- most common neoplasm of the uterus
- greater than 45% of women in 5th decade will have them
- rarely malignant
- most are asymptomatic
Symptoms fibrinoids can cause:
- excessive uterine bleeding, pelvic pressure, pelvic pain, and infertillity
- most common indication for a hysterectomy
Risk factors for developing fibroids:
- increasing age
- African american at higher risk
- nulliparity
- family history
what are possible locations of fibroids?
submucosal at the side of the uterus
intersitial in myometrium
subserosal at top of uterus
cervical in the cervix
Characteristics and symptoms of Leiomyomas
Fibroids
AUB-L
rarely form before menarche or enlarge after menopause
- estrogen stimulates the proliferation of smooth mm cells
- enlarges during pregnancy
Usually spherical, well circumscribed, white firm lesions with a whorled apperance on cut sections
may cause pain and degenerate and may calcify in post menopausal patients
Symptoms:
- most asymptomatic
- pelvic or lower back pain
- frequent urination
- severe pain not common unless inflammed
- prolonged or heavy bleeding
- increased incidence of infertillity
what is endometrial hyperplasia? and the 2 types
AUB-M
Represents an overabundance growth of the endometrial lining usually as a result of persistent unopposed estrogens
- PCOS
- Granulosa theca cell tumors (estrogen producing)
- Obesity via peripheral conversion of androgens to estrogens via fat cells
- exogenous estrogens without progestins
- Tamoxifen
precursor to endometrial cancer
Hyperplasia:
- simple without atypia
- complex without atypia
- simple with atypia
- complex with atypia
can be type 1 = endometrial adenocarcinoma
type 2 = clear cell and papillary serous
presentation:
- Postmenopause bleeding is most common]
- irregular uterine bleeding during premenopause
Coagulopathies
AUB-C
associated with heavy flow
-Von willebrand disease
Ovulatory dysfunction
AUB-O
Associated with unpredictable menses with variable flow
-polycystic ovarian syndrome
Endometrial causes
AUB-E
infection
Iatrogenic
AUB-I
IUD, IUS, exogenous hormones
Not yet classified abnormal uterine bleeding
AUB-N
reserved for entities that are poorly defined and or not well examined
-arteriovenous malformation
what are some laboratory and available diagnostic tests to run when evaluating abnormal uterine bleeding?
Labratory tests:
- Pregnancy test
- CBC
- Targeted screening for bleeding disorder (PT, PTT)
- TSH
- Chlymadia trachomatis
Diagnostic or imaging tests
- transvaginal ultrasonography
- saline infusion sonography
- MRI
- Hysteroscopy
Indications for a in office endometrial biopsy and contradictions
Abnormal uterine bleeding
- postmenopausal women that have spotting or bleeding or have endometrial lining greater than 4 mm
- age 45 to menopause that have any AUB
- less than 45: any bleeding that occurs in the setting of unopposed estrogen exposure
Cervical cytology results indicated positive glandular cells on cervical cytology
Contradictions:
- absolute pregnancy
- relative bleeding diathesis
what are AUB treatments with medication?
Normalize prostaglandins
-NSAIDS prior to and during menses
Antifibrinolytic therapy
-tranexamic acid
Coordinate endometrial sloughing
- Medoroxyprogesterone MPA
- Combined oral contraceptives
Endometrial suppression:
- Progesterone daily
- continuous OCP
- intrauterine system
AUB treatment with surgical options
Polypectomy Myomectomy Dilation and currettage uterine endometrial ablation hystorectomy
Diagnostic and suction D and C
Dilation and Currettage
Diagnostic D and C:
-performed for irregular menstrual bleeding or postmenopausal bleeding to rule out endometrial hyperplasia or cancer
Therapeutic D and C
-performed for endometrial structural abnormalities (Polyps, small pedunculated submucosal fibroids)
Endometrial ablation
Uses radiofrequency to the bupolar mesh electrode while at the same time applying suction
perforation safety mechanism
ablation time 90 seconds
What are the 4 different routes for Historectomys?
Total abdominal hysterectomy (TAH)
-incision above the abdomen
Vaginal hysterectomy (TVH) -vaginal incision
Laparoscopic assisted vaginal hysterectomy (LAVH)
-small abdominal incisions and vaginal incisions
da Vinci assisted hysterectomy:
-small abdominal incisions and vaginal incisions
when is puberty, how long is it, and what are some factors affecting when it starts?
Encompasses the development of secondary sexual characteristics and the acquisition of reproductive capabillity
duration is 4-5 years
Usually occurs between 10-16 years old and mean is 12
onset determined by:
- genetic factors (hispanic and AA girls earlier
- geographic location (metropolitian or at altitudes/sea level earlier)
- Nutrition (obese have earlier, malnourished is later)
how does childhood keep pubery suppressed
HPO is suppressed between ages of 4-10 years
low levels of gonadotropins and sex steroids during prepubertal period are due to 2 functions:
- gonadostat sensitivity to the negative feedback of low circulating estradiol
- intrinsic central nervous system inhibition of the hypothalamic gonadotropin releasing hormone (GnRH)
what occurs in late childhood that leads to start of puberty?
between ages of 8-11 there is an increase in serum concentrations of dehydroepiandrosterone (DHEA and dehydroepiandrosterone sulfate (DHEA-S) and androstenedione
rise in adrenal androgens causes growth of axillary and pubic hair
at age 11
-gradual loss of sensitivity by the gonadostat to the negative feedback of sex steroids and loss of inhibition of GnRH
these increase in GnRH lead to production of ovarian follicular maturation and sex steroid production to develop the secondary sexual characteristics
by late puberty the positive feedback mechanism of estradiol on LH release from the anterior pituitary gland is complete and ovulatory cycles are established
what are the stages of normal pubertal development?
Thelarche (breast development
- first sign of puberty
- unilateral development and tenderness in first 6 months not uncommon
- requires estrogen
Pubarche/adrenarche
- pubic hair and axillary hair development
- requires androgens
Maximal growth or peak height velocity
- occurs 2 years earlier in girls
- occurs 1 year before menses
Menarche
- onset of menses
- requires pulsatile GnRH, FSH, and LH from pituitary, estrogen and progesterone from ovaries
5 stages of Tanner staging for breast development
Stage 1: preadolescent elevation of the papilla only
stage 2: breast bud stage; elevation of the breast and papilla as a small mound with enlargement of the areolar region
stage 3: furthur 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
5 stages of Tanner staging for pubic hair
Stage 1: preadolescent absence of pubic hair
stage 2: sparse hair along the labia; hair downy with slight pigment
stage 3: hair spreads sparsely over the junction of the pubes; hair is darker and coarser
stage 4: adult type hair; there is no spread to the medial surface of the thighs
stage 5: Adult type hair with spread to the medial thighs assuming an inverted triangle pattern
