Menarche, Puberty And Menstrual Disorders Flashcards
Decreasing levels of estradiol and progesterone from the regressing CL fo the preceding menstrual cycle initiate what?
An increase in FSH by negative feedback mechanism which stimulates follicular growth and estradiol secretion
What is the two cell theory of ovarian follicular development and estrogen production?
Separate cellular functions in the ovarian follicles
LH stimulates the theca cells to produce androgens (andresteniodone and testosterone)
FSH stimulates the granulosa cells to convert these androgens into estrogen (E1 and 2)
Describe the luteal phase
Both the LH and FSH are significantly suppressed through the neg feedback effect of the elevated circulating estradiol and progesterone
If conception does not occur progesterone and estradiol level decline near the end of the luteal phase as a result of CL regression
FSH will then rise which initiates new follicular growth for the next cycle
Describe GnRH
Decapeptide synthesized in the arcuate nucleus
Responsible for the synthesis and release of LH and FSH (both are present in different forms wihtin the pituitary gonadtrophs)
Reaches the ant pit and stimulates the synthesis and release of FSH and LH into the circulation
Estradiol enhances the hypothalamic release of GnRH and induces the LH surge
When are estrogen levels low?
During early follicular development
1 week before ovulation levels begin to increase
Reach max 1 day before LH surge - after the peak and before ovulation there is a fall
During the luteal phase estradiol rises to a max 5-7 days after ovulation and returns to baseline before menstruation
Describe progestins during the ovarian cycle
During follicular development the ovary secretes only a small amount of progesterone
Bulk of progesterone comes from the peripheral conversion of adrenal pregnenolone and pregnenolone sulfate
Prior to ovulation there is an increase
Secretion by CL reaches a max 5-7 days after ovulation and returns to baseline before menstruation
Describe the menstrual phase of the uterine cycle
Only portion of the cycle that is visualized externally
The first day of menstruation is known as cycle day 1
During this phase there is disruption and disintegration of the endometrial glands and stroma, leukocyte infiltration, RBC extravasation
Sloughing of the functionalis layer and compression of basalis layer
Describe the proliferative phase of uterine cycle
Characterized by endometrial growth/proliferation secondary to estrogenic stimulation
Increase in the length of the spiral A and numerous mitosis can be seen in these tissues
Describe the secretory phase
Following ovulation progesterone secretion by the CL stimulates the glandular cells to secrete mucus, glycogen and other substances
Glands become tortuous and lumens are dilated and filled with these substances
Stroma become edematous; mitosis is rare
Spiral arteries continue to extend into superficial layer of the endometrium and become convoluted
If conception does not occur by day 23 what occurs?
The CL begins to regress, secretion of progesterone and estradiol declines and the endometrium undergoes involution
What is important in regulating menstruation?
Intact coagulation pathway
Menstruation disrupts blood vessels but with normal hemostasis the injured vessels are repaired
Restoration of blood vessels require successful interaction of platelets and clotting factors
Meds such as warfarin, aspirin, clopidogrel can impair this system and be associated with heavy bleeding
What is the primary goal of the initial reproductive health visit?
Should occur between ages 13-15
Provide preventative health care services including educational information and guidance rather than problem focused
Describe the human papillomavirus vaccine
One series for those who are not previously immunized between the ages of 9-45
Offers protection against cervical cancer, cervical dysplasia, vulvar or vaginal dysplasia and genital warts associated with Gardasil covers genotypes 9, 11, 16. 18. 31. 33. 45, 53 and 58
When does menarche occur?
Median age is 12 years of age
Occurs within 2-3 years after thelarche (breast budding) at tanner stage IV, 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
What is the average menstrual cycle length?
21-45 days in adolescents
21-35 days in adults (32 days is the mean in the first gynecological year)
What is secondary amenorrhea?
Defined as the absence of menstruation for 6 months
It is rare for girls and adolescents to remain amenorrheic for more than 3 months
If more than 90 days further work up is indicated (check urine or serum B-hCG to rule out pregnancy)
What are some causes for menstrual irregularity?
Pregnancy, endocrine causes, acquired conditions, tumors
What is dysfunctional uterine bleeding (DUB)?
Abnormal uterine bleeding that cannot be attributed to medications, blood dyscrasias, systemic disease, trauma, organic conditions
Usually caused by aberrations in the HPA axis resulting in anovulation
What is polymenorrhea?
Abnormally frequent menses at intervals at <21 days
What is menorrhagia (hypermenorrhea)?
Excessive and/or prolonged menses (>80mL and >7 days) occurring at regular intervals
What is metrorrhagia?
Irregular episodes of uterine bleeding
What is menometrorrhagia?
Heavy and irregular uterine bleeding
What is intermenstrual bleeding?
Scant bleeding at ovulation for 1 or 2 days
What is oligomenorrhea?
Menstrual cycles at >35 days cycles
What is the PALM-COEIN classification system?
For abnormal bleeding in reproductive aged women
What does PALM stand for?
Polyp (AUB-P)
Adenomyosis (AUB-A)
Leiomyoma (AUB-L) - can be submucosal or other
Malignancy and hyperplasia (AUB-M)
What does COEIN stand for?
Coagulopathy (AUB-C) Ovulatory dysfunction (AUB-O) Endometrial (AUB-E) Iatrogenic (AUB-I) Not yet classified (AUB-N)
A size of what indicates endometrial cancer?
Polyp greater than 4mm
What are endometrial polyps?
Form from the endometrium to create soft friable protrusion into the endometrial cavity
Can cause menorrhagia, spontaneous or post menopausal bleeding
Ultrasound findings include focal thickening of the endometrial stripe - saline hysterosonography and hysteroscopy allows for better detection
Most are benign
What is adenomyosis?
Extension of the endometrial glands and stroma into the uterine musculature
>2.5mm beneath the basalis layer
Don’t participate in proliferative and secretory cycles
Sx: may be asymptomatic, severe secondary dysmenorrhea and menorrhagia, can be associated with dyspareunia
What are uterine leiomyomas (fibroids)?
Benign tumors derived from smooth muscle of the myometrium
Rarely malignant; most women have them by 5th decade
Most are asymptomatic but can cause excessive uterine bleeding, pelvic pressure, pelvic pain, infertility
MC indication for hysterectomy
Risk factors include increasing age during reproductive years, African americans, nulliparity, family hx
What is the pathogenesis of uterine leiomyomas “fibroids”?
Factors that initiate leiomyomas are unknown
Rarely form before menarche or enlarge after menopause
Estrogen stimulates the proliferation of smooth muscle cells
Can dramatically enlarge during pregnancy
What are the characteristics of fibroids?
Usually spherical well circumscribed, white firm lesions with a whorled appearance on cut sections
May degenerate and cause pain
May calcify especially in post menopausal pts
What are the sx of leiomyoma?
Symptomatic women complain of pelvic or lower back pain, severe pain is not common unless it is undergoing an acute infarction (red degeneration), frequency of urination if it’s pressing on the bladder, prolonged or heavy bleeding (associated with submucosal or intramural fibroids), increased incidence of infertility
What is endometrial hyperplasia?
Represents an over abundance growth of the endometrial lining usually as a result of persistent unopposed estrogen during PCOS, granulosa cell tumors (produce estrogen), obesity, exogenous estrogens and tamoxifen
A precursor to endometrial cancer
What is the presentation for endometrial hyperplasia?
Post menopause bleeding (MC)
Irregular uterine bleeding (perimenopause)
Describe coagulapathies (COEIN)
Associated with heavy flow
I.e. Von-willebrand disease
What are iatrogenic causes of AUB?
IUDs, IUS, exogenous hormones
What are indications for in office endometrial biopsy (EMBX)?
AUB
Post menopausal women - sample with any spotting or bleeding and if endometrial lining is >4mm
Age 45 to menopause - any AUB, including intermenstrual bleeding, menorrhagia
<45 y/o - any bleeding that occurs in the setting of unopposed estrogen exposure (obesity, chronic anovulation/PCOS, or having prolonged amenorrhea)
Describe in office EMBX
Cervical cytology results = + glandular cells on cervical cytology
Potential procedural side effects: cramping and uterine perforation is the most serious side effect
Contraindications: absolute = pregnancy; relative = bleeding diathesis
What are surgical options for AUB treatment?
Polypectomy, myomectomy, dilation and currettage, uterine endometrial ablation, hysterectomy
What is a diagnostic D and C?
Preformed for irregular menstruated bleeding or post menopausal bleeding to rule out endometrial hyperplasia or cancer
What is a therapeutic DandC?
Performed for endometrial structural abnormalities (polyps, small pedunculated submucosal fibroids)
What is endometrial ablation?
Uses radio frequency to the bipolar mesh electrode while at the same time applying suction
Has a perforation safety mechanism (prevents perforation of the uterus)
Ablation time 90 seconds
What are the different types of hysterectomy?
Total abdominal (TAH - incision on abdomen) Vaginal hysterectomy (TVH - vaginal incision) Laprascopic assisted vaginal hysterectomy (LAVH - small abdominal incisions and vaginal incisions) Da Vinci assisted hysterectomy (TLH - small abdominal incisions and vaginal incisions)
Onset of puberty is determined by what?
Genetic factors including race (African American and Hispanic usually begin earlier) Geographic location (metropolitan areas, altitudes near sea level begin earlier) Nutritional status (obese children have earlier onset, malnourished have layer onset)
What is the gonadostat?
The hypothalamic pituitary system regulating gonadotropin release
What are the stages of normal pubertal development?
Thelarche (breast development) Pubarche/adrenarche Maximal growth or peak height velocity (occurs 2 years earlier in girls, occurs about 1 year before onset of menses) (growth spurt) Merarche TAGME
What is thelarche?
First physical sign of puberty
Unilateral development and slight tenderness in first 6 months is not uncommon
Requires estrogen
What is pubarche/adrenarche?
Pubic hair/axillary hair development Requires androgens (caused by an increase in androgens)
What is menarche?
Onset of menses
Requires pulsatile GnRH from the hypothalamus, FSH and LH from the pituitary, estrogen and progesterone from the ovaries, normal outflow tract
Describe tanner staging for breast development
- Preadolescent - elevation of papilla only
- Breast bud stage - elevation of breast papilla as a small mound with enlargement of the areolar region
- Further enlargement of breast and areola without separation of their contours
- Projection of areola and papilla to form a secondary mound above the level of the breast
- Mature stage - projection of papilla only resulting from recession of the areola to the general contour of the breast
Describe tanner staging for pubic hair development
- Preadolescent - absence of pubic hair
- Sparse hair along the labia - hair downy with 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 the thighs
- Adult type hair with spread to the medial thighs assuming an inverted triangle pattern
