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Block 5 AR > Menopause, Puberty, Contraception > Flashcards

Menopause, Puberty, Contraception Flashcards

1
Q

When does menopause occur? And what is the average?

A

45-60 years

Average 51-52

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2
Q

Why does the menopause occur?

A

Decline in ovarian oestrogen production
1.2 million follicles at birth, 1000 left by menopause
Mostly lost by atresia which increases from age 35

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3
Q

What are the sources of oestrogen? And what is the significance of this?

A

Ovarian 90%
Adipose 10%. Overweight women may have less symptoms of menopause as they have alternate sources of oestrogen to combat the decline from the ovaries

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4
Q

When is the Climacteric/perimenopause?

A

+/- 5 years from menopause

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5
Q

When is the biggest decline in fertility in women of child bearing age? And why?

A

Fertility wanes from age 37
Risks of miscarriage increase due to Meiotic non-disjunction
Eggs are stuck in metaphase of meiosis I
Spindle may have become sticky or disjointed over years and so daughter cells more likely to be triploid eg downs the older you are when you concieve

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6
Q

Why do the symptoms of menopause occur?

A

Falling levels of oestrogen

So symptoms will reduce over time

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7
Q

What blood test can be used to confirm menopause?

A

Increased FSH > 20IU/L

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8
Q

What happens to periods in menopause?

A

Oligomenorrhoea and eventually cease

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9
Q

What is the classic symptom triad of the menopause?

A

Hot flushes
Sweats
Vaginal Dryness

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10
Q

What proportion of women are bothered and affected by the menopause?

A

Affects 80%
Bothers 45%
>5years 25%

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11
Q

What can be non specific symptoms of menopause?

A 
Headaches 
Migraines 
Palpitations 
Disturbed sleep
Tired
No energy
Loss of libido
Cant cope
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12
Q

What are urogenital symptoms of menopause?

A

Vaginal dryness
Cystitis
Urinary frequency
Urinary incontinence

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13
Q

What are psychological symptoms of menopause?

A 
Loss of concentration
Poor memory 
Irritability 
Loss of libido 
Panic attack
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14
Q

What does atrophy of connective tissue in menopause lead to?

A 
Skin thinning 
Hair loss 
Brittle nails 
Aches and pains
Osteoporosis
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15
Q

What are the effects of osteoperosis?

A 
Loss of bone matrix
Loss of height 
Deformity 
Fractures 
Economic cost
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16
Q

How do the sex hormones travel in the circulation?

A

Steroid hormones
Binding Proteins: Sex hormone binding globulin, Albumin
Unbound fraction active

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17
Q

What is the site of action of the sex hormones?

A

Intracellular

Receptors specific

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18
Q

Describe oestrogen receptors and what can be used to modulate them?

A

Specific transcription factors
Tissue dependent
Target specificity
Selective Estrogen Receptor Modulators—SERMS

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19
Q

What is Clomiphene?

A

SERM

Induces ovulation

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20
Q

What is Tamoxifen?

A

SERM used in breast cancer treatment

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21
Q

What are functions and properties of oestrogen?

A

Structural / Proliferative: Endometrium, myometrium, bone,breast, skin
Coagulation
Lipid management
Suppression of HPO axis

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22
Q

What local preparations of hormone therapies can be used in menopause?

A

Creams, gels, Vaginal rings

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23
Q

What systemic preparations of hormonal therapies can be used in menopause treatment?

A

Oral
Transdermal patches
Implants

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24
Q

What hormones can hormone therapies for menopause contain?

A

Oestrogen alone
Combined Oestrogen and Progestin
SERM
Androgen

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25
What different time schedules can be used for menopause treatment?
Taken daily Continuous Cyclic or sequential
26
What are benefits of HRT in menopause?
Improves vasomotor symptoms: hot flushes Improves urogenital symptoms: vaginal dryness, less infections Reduces fracture risk / osteoporosis
27
What are the risks of HRT for menopause?
``` Breast cancer Coronary event ( e.g. MI) Venous thromboembolism Stroke Gall bladder disease Death from lung and ovarian cancer Dementia Endometrial cancer (oestrogen alone) ```
28
What are recommendations for HRT use?
``` Full discussion with patient Assessment of risks / benefits Lowest possible dosages/ route Shortest durations Progesterone if intact uterus Continued surveillance Not first line for bones ```
29
What can be other uses of HRT?
Premature Menopause:
30
What causes premature menopause?
Idiopathic: chromosomal, autoimmune, enzyme Iatrogenic: Surgery, chemo, radiation Infectious: viral, TB
31
How can SERMs be used in breast cancer treatment?
Many breast cancers express oestrogen receptors and proliferate under oestrogen stimulation SERM used as antagonist in breast tissue Effects are tissue dependent Tamoxifen- antagonist in breast but an agonist in endometrium
32
What is the menopause?
Cessation of menses
33
What change in the endometrium of a woman taking Tamoxifen do you need to be aware of?
Endometrial proliferation: Bleeding or spotting. Can monitor with transvaginal USS. Look for thickness
34
What should always be considered when planning tests, treatments, medications or surgery with women of reproductive age?
Possibility of early pregnancy
35
In whom should a menstrual history be taken?
All women of reproductive age
36
What are the components of a detailed menstrual history?
``` LMP…date of first day of last bleed Cycle length / frequency /regularity How heavy is flow? Tampons &/or pads Dysmenorrhea (pain) ( primary & secondary) Amenorrhea (primary & secondary) Clots &/or flooding Intermenstrual bleeding Post coital bleeding Age of menarche / menopause Post menopausal bleeding ```
37
What are components of a contraceptive history?
Method used: Hormonal contraceptives will influence menstrual cycle Any unprotected intercourse Consider method of contraception when planning tests, treatments, medications or surgery
38
What are key components of an obstetric history?
Previous medical & surgical conditions Previous obstetric complications Identify possible risks to the pregnancy and delivery Formulate management plan for pregnancy and delivery ICE remember this is a natural process
39
What are important parts of a first trimester history?
Personal information LMP & menstrual history: EDD Gravidity, how many pregnancies? Parity (>24weeks +
40
What is Naegele’s Rule?
Way to estimate the due date of a pregnancy | Add one year and seven days to LMP and subtract three months
41
What are key parts to a mid trimester history?
Monitor maternal health / physiologic changes Monitor fetal growth & well being / fetal movements Enquire about new problems Continue advice and education Review results of scans / blood work / screening Confirm EDD
42
What are key factors of a third trimester history?
``` Monitor maternal health Monitor fetal growth & well being Expectations of labour…ICE Plans for delivery Plans for feeding Advice & education ```
43
What are pregnancy notes?
Hand held green notes Carried by the mother during her pregnancy Contain all the information gathered including test results Contains a lot of information about choices: delivery plans / expectations Contains post natal plans / feeding
44
What is an Intrapartum Record?
Partogram Pictorial record Reduces problems during labour as it is a lengthy process and this allows consistent monitoring
45
What does a birth record contain?
``` Delivery details Management of Third Stage (delivery of the placenta) Perineum Apgar Score Initial exam of newborn Security / Identification ```
46
What is an apgar score?
Quick / Replicable / determines whether baby needs help One min score (how did baby tolerate birth process) Five min score (how is baby doing outside of uterus) Five Categories: Score 0-2 Appearance ( Skin colour / cyanosis) Pulse rate Grimace (reflex irritability) Activity (muscle tone) Respiratory effort Scores of 7,8,9 normal 10 is unusual…
47
What is the trigger for puberty?
Increased levels of pulsatile GnRH trigger puberty and maturation of the HPG axis
48
What factors could have an effect on the onset of puberty?
Weight: low BMI Malnutrition Chronic diseases: renal failure, CCF, Crohns Exercise in females- athletes, ballerinas Endocrine: thyroid, adrenal Genetic factors: Black girls develop earlier than white with same SES Psychological: emotional deprivation
49
What changes occur in puberty?
``` Endocrine hormonal changes: GnRH &HPG Physical changes (observable changes) Tanner staging Bone/skeletal changes Genetic anomalies may become apparent ```
50
What is the average range of onset of menarche?
Girls 10-14 | Boys 12-16
51
What physical changes occur in males in puberty?
External genitalia: Increase size of penis, scrotal pigmentation, rugal folds Hair growth: Facial hair, male pattern hair on head, Pubic hair with male escutcheon, Body and peri-anal hair, axillary hair Linear growth: 5cms per year pre-puberty, growth spurt 8cms per year Accessory sex organs: Prostate palpable and seminal vesicles develop secretory activity Voice: Increase size larynx (Adam’s apple) and thickening of vocal cords, deepening of voice
52
What physical changes occur during puberty in females?
``` External genitalia: labia majora thickens Hair growth Linear growth: earlier than boys Breast development Menstruation, menarche ```
53
What is tanner staging?
``` Stage One…pre-pubertal Stage Two Stage Three Stage Four Stage Five… adult form and function ```
54
Describe the tanner staging of breast development
1: No palpable glandular tissue, areola not pigmented 2: Glandular tissue palpable. Nipple and areola project as single mound—breast bud 3: Increased glandular tissue, breasts enlarge, increased size areola, contours breast and areola remain in a single plane 4: Further breast enlargement, increased pigmentation areola. Areola and nipple form a secondary mound above the breast 5: Mature form. Areola and nipple no longer project from breast
55
Describe the tanner staging of female pubic hair growth
1. None 2. Occasional wispy strands, usually along labia 3. More, darker, coarser hair extending superiorly over pubis 4. Dark, coarse, curly hair covering mons pubis in adult pattern, but not extending to medial aspects of thigh 5. Mature form, hair extends to thigh
56
When do growth spurts tend to peak in boys and girls?
Girls 12 years | Boys 14 years
57
How can you assess puberty?
Monitor normal changes Education / reassurance Support / Intervene if needed
58
What effects does obesity have on puberty?
Moderate obesity: advanced puberty | Morbid obesity: delayed puberty
59
What size would you expect a testicle to be pre pubertally and in an adult?
Pre puberty: 1-6ml | Adult: 15-25ml
60
Describe the sequence of secondary sexual development in males
Testis Pubic hair Penis Growth spurt
61
Describe the development of secondary sexual characteristics in females
Breast Growth spurt Pubic hair Menarche
62
How can bone age be used in puberty?
X-ray of left wrist Compares skeletal age with chronologic age Used in conjunction with clinical information Useful in evaluation and treatment of growth and puberty disorders, a biological marker
63
What is Hypergonadotropic hypogonadism?
Problem in gonads Turners syndrome Klinefelters syndrome Gonadal dysgenesis
64
What is hypogonadotrophic Hypogonadism?
``` Problem in brain Tumours Gonadotrophin deficiency Pituitary deficiencies Anorexia nervosa ```
65
Is constitutional delay more common in boys or girls?
Boys
66
How many children have delayed puberty?
3%
67
How can you treat constitutional delay?
Short term low dose sex steroid treatment
68
How can you treat hypergonadotrophic Hypogonadism?
Sex steroid replacement
69
How can you treat hypogonadotrophic Hypogonadism?
Sex steroid replacement | GnRH administration
70
What could be causes of patients being short in stature and fat?
``` Hypopituitarism Growth hormone deficiency Hypothyroidism Cushings syndrome Pseudohypoparathyroidism ```
71
What could be causes of a developing child being short stature and thin?
``` Mental retardation Congenital heart disease Cystic fibrosis Asthma TB Malabsorptive disease Renal failure Anorexia ```
72
What is precocious puberty?
Signs of puberty before age 8 in girls, 9 in boys More common in girls, Often unknown reason Underlying medical condition more often in boys Abnormally high levels of sex steroids
73
What are disadvantages of contraception?
Changes in sexual habits Increased promiscuity Medical complications Cost
74
What are advantages of contraception?
Reproductive choice Decrease in unwanted pregnancy/children Health benefits Population control
75
What considerations should be made in a contraceptive consultation?
``` Age (Gillick competency) Health Desire for fertility (time scale) Social/ Religious/Ethical Education (do they need training to use it) Compliance Cost ```
76
What are the different contraceptive methods?
``` Natural/Physiological Barrier Hormonal Surgical Overlap ```
77
What are the natural contraceptive methods that people use?
Rhythm method: prevent sperm / egg interaction Coitus interruptus: prevent sperm/ egg interaction Lactation: prevent ovulation
78
What is the basis of the rhythm method of contraception?
Ovum has limited period of fertility | Avoid intercourse in fertility window, 4-5 days prior and 1-2 days after a predicted ovulation
79
How can the fertility window be predicted?
Measure basal body temperature which rises after ovulation | Spinbarkeit (spinnability) of cervical mucus thinnest around ovulation
80
What are advantages and disadvantages of the rhythm method?
``` Cheap No side effects Education-(3-6 months) required No medical contraindication No religious/ethical issues ```
81
What is coitus interruptus? And what are advantages and disadvantages?
Penile withdrawal before ejaculation Significant failure rate due to leakage of sperm/pre ejaculate Cheap No medical contraindication
82
How does lactation create a natural contraceptive?
Regular Breastfeeding Prolactin high levels Suppresion HPO axis so no ovulation Six months
83
What are some barrier methods of contraception?
Condom Diaphragm and cervical cap Spermicide
84
What are advantages and disadvantages of condoms?
``` Cheap/available Education Latex allergy Some sensation loss STD protection ```
85
What are advantages and disadvantages of the diaphragm and cap?
Requires Professional fitting Patient Education on how to correctly insert Spermicides
86
What are hormonal methods of contraception?
Combination pills (oestrogen & progesterone) Progesterone only pills (mini-pill) Injectables / Implants / LARC (long acting reversible contraceptive) Patches Rings
87
Describe the combination pill and how they work
``` Oestrogen/progesterone mono/bi/tri/phasic-to reduce hormone doses 60ug-20ug Oestrogen 21/28/90 day pill pack HPO and ovulation suppression Cervical mucus thickening Endometrial effects Excellent efficacy Lots of benefits ```
88
What are the benefits of the combination pill?
``` Quality of Life improved due to loss of ovarian cycling Decrease ovarian cysts/ ovarian cancer Decrease anaemia Decrease dysmenorrhea Decrease PMT Decrease endometrial cancer Decrease ectopic ```
89
What are side effects of the combination pill?
Major source of non-compliance Resolve after a few cycles Education Progesterone: acne, increase appetite, decrease libido Oestrogen: Nausea and vomiting, Breast tenderness, vaginal spotting
90
What are risks with combination pills?
Much less as doses have declined View risks in context of pregnancy risk Mainly thromboembolic: oestrogen DVT/PE/MI/Stroke Generally not used in women at risk for vascular disease: hx of DVT, lupus, some diabetics, smokers > 35
91
What are absolute contraindications to combination pill use?
Undiagnosed vaginal bleeding Documented pregnancy Breast Cancer Chronic liver disease
92
Describe progesterone only pills and how they work
Mini-pill, Low dose progesterone 28 active pills Used for women that have contraindication to oestrogen Prevention of sperm/egg interaction Mainly mucus effects and endometrial effects HPO-inhibition with suppression of ovulation 20%
93
What are issues with the progesterone only pill?
Very few-due to low dose Compliance-VERY IMPORTANT UNFORGIVING-need back-up if >3 hours
94
Describe the issues with pill failure
Major factor in pill failure is compliance Educate-how to take it, side effects, benefits Combo pills -forgiving-can miss upto two tabs Mini-pills- less forgiving Failure rate: less than 1/100 women years Upto 15/100 women years in teens
95
What are alternative hormonal methods to the pill?
``` Vaginal ring Patch Injectables / Implants / LARC Moderate/High-dose Progesterone Preps IM injections-3 months Subdermal implants-5 years ```
96
How do implants and injectables exert their contraceptive effects?
Ovulation suppression Mechanism of action– HPO inhibition Mucus / endometrial effects
97
What are side effects of implants and injectables?
``` Mainly progesterone related Decreased libido Increased weight Irregular bleeding Amenorrhea-may be beneficial Cost Invasive ```
98
What can be benefits of injectables or implants?
``` Long term Amenorrhea Decrease dysmenorrhea Hygiene Partner unaware ```
99
How does the IUCD work?
Inert-plastic Prevent implantation: Mechanical / inflammatory / pharmacologic Cu7- embryotoxic or Progesterone-endometrial/cervical mucus effects-some ovulation suppression
100
When should an IUCD be used? And what are disadvantages?
``` Longlasting 1-10yrs Compliance issues with other methods Cost Older/Parous: probably most people VLE: Preventing implantation ```
101
What factors are important in an IUCD insertion?
``` Sterile Follicular phase so not pregnant Post Abortion or Post coital emergency Assess size and position of uterus, retroverted retroflexed? Check string after each period ```
102
What can be complications with an IUCD?
Expulsion Perforation Infection Ectopic
103
What are side effects of an IUCD?
Bleeding Cramping Usually love or hate
104
Describe emergency contraceptive pills
Suppress ovulation/ implantation High dose progesterone Side effects - nausea vomitting
105
Describe sterilisation
``` Prevent sperm / egg interaction by surgical interruption Tubal ligation, Vasectomy Consider irreversible Counselling Cost Invasive FAILURES ```
106
Describe termination
Failure of contraception Excellent chance to educate Surgical - vacuum aspiration or dilation & curettage D & C Medical- mifepristone / misoprostol
107
What effect on stature would you expect in a girl with precocious puberty?
Growth spurt begins earlier and is terminated earlier, so epiphyses close at an earlier stage of growth, making the individual shorter
108
A 16 yr old girl attends clinic with her mother. They are both anxious because the girl has not yet started her periods. What would you need to find out in the history?
Development & timing of secondary sexual characteristics Any cyclic pain? History of significant illnesses / weight gain/weight loss/ medications Family History autoimmune / endocrine disorders
109
A 16 yr old girl attends clinic with her mother. They are both anxious because the girl has not yet started her periods. What would you look for on examination?
Hgt/ Wgt/ BMI/ Breast/ Axilla /Pubic hair/ Tanner staging/ Turner’s stigmata/external genitalia, clitoromegaly /imperforate hymen
110
What things would you want to exclude in a 16 year old girl presenting with primary amenorrhoea?
``` Exclude abnormality of HPO axis Ensure normal gonad / internal / external genitalia Exclude pregnancy ( would be rare in this scenario but not unheard of) ```
111
What investigations might help to understand what is going on in a girl with primary amenorrhoea?
HPO axis: FSH, Oestrogen Gonad &Genitalia: exam / ultrasound /karyotype Pregnancy: pregnancy test
112
If a girl with primary amenorrhoea shows results as follows History: quite well but has some abdominal cramping every month or so, began to wear a bra when she was 14 Exam, Normal BMI, pubic hair and breasts at Tanner stage 4, Normal external genitalia with tense bulging hymen at vaginal orifice. What would be your likely diagnosis?
Imperforate hymen with hematocolpos ( blood in vagina)
113
What do you do to fix an Imperforate hymen with hematocolpos ( blood in vagina)?
Incise hymen
114
16 year old girl anxious because she hasn’t started to wear a bra History: She is quite well, not yet had any menstrual periods Exam: Height 1.35 m, Breasts Tanner stage 1, normal female external genitalia Tanner stage 1 Blood tests: FSH and LH both significantly elevated Where do these findings suggest the problem is and why? And what type of delayed puberty is this?
Gonad: Her pituitary gonadotropins have risen as they are not subject to any negative feedback from the gonad Hypergonadotrophic Hypogonadism
115
What is turners syndrome?
Ultrasound shows streak gonads and the karyotype is 45XO Genetic condition where one of X chromosomes does not function normally and in many cases ovaries do not develop normally (ovarian dysgenesis)
116
``` 16 year old woman with primary amenorrhea Small breasts Bilateral inguinal masses Dimple vagina with slight clitoromegaly Karyotype XY What type of gonad is present? ```
Testis
117
What is androgen insensitivity syndrome?
External genitalia appear female despite testis and male internal genitalia. Lack adequate androgen receptor to differentiate along the male line
118
Why in androgen insensitivity syndrome would she have some breast development?
Breast development may be normal or enhanced as small amount of gonadal oestrogen and adrenal oestrogen not opposed by androgen. Body hair is normal to scant
119
A 15yo boy is brought to you by his parents; they are concerned that he is behind his classmates in pubertal development. ​How might you begin to assess his stage of puberty?
History: Medical illnesses, medications, Family history Exam: Height, weight, body hair, external genitalia
120
What is constitutional delay?
Slow development of male characteristics, benign Represents normal variation - often familial Eventually undergo a normal puberty and attain normal height
121
What factors in a boys history might reassure you that he is experiencing constitutional delay of puberty?
Good general health and nutrition Growth curve remained on track Brother was a late developer
122
Explain what is meant by ‘bone age’. Would it be helpful in a boy with constitutional delay?
Accelerated bone growth is one of earliest signs of precocious puberty Bone age can be determined with hand-wrist films and compared with standards for patient's chronologic age If boy’s bone age is consistent with his chronologic age then constitutional delay is likely
123
You want to assess where a boy is in his pubertal growth spurt. How will you do so?
Growth spurt in boys is approx 10cm/year | height comparisons over time are useful by plotting his growth curve
124
When does the growth spurt occur in relation to the other events of puberty in boys?
Growth spurt starts about 12 months after first signs of puberty (increase in testicle size due to FSH induced increase in seminiferous tubules)
125
Why may parents not have noticed the early stages of change in boys puberty?
Early signs of puberty in boys are increase size of testis followed by reddening of scrotal skin and elongation of penis parents may not be aware that these changes are occurring
126
Will a boy with constitutional delay be producing sperm?
High intra-testicular levels of testosterone are needed for spermatogenesis, so it is doubtful
127
What will be the possible consequences of early puberty?
Short stature due to premature growth spurt and epiphyseal closure
128
Where are lesions found that might cause early puberty?
True precocious puberty (premature secretion of gonadotrophins leading to testicular androgen production, sperm production and virilisation) mostly idiopathic but can be caused by CNS lesions, thus evaluation and follow-up is needed

Block 5 AR (7 decks)

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