Menopause, Puberty, Contraception Flashcards
When does menopause occur? And what is the average?
45-60 years
Average 51-52
Why does the menopause occur?
Decline in ovarian oestrogen production
1.2 million follicles at birth, 1000 left by menopause
Mostly lost by atresia which increases from age 35
What are the sources of oestrogen? And what is the significance of this?
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
When is the Climacteric/perimenopause?
+/- 5 years from menopause
When is the biggest decline in fertility in women of child bearing age? And why?
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
Why do the symptoms of menopause occur?
Falling levels of oestrogen
So symptoms will reduce over time
What blood test can be used to confirm menopause?
Increased FSH > 20IU/L
What happens to periods in menopause?
Oligomenorrhoea and eventually cease
What is the classic symptom triad of the menopause?
Hot flushes
Sweats
Vaginal Dryness
What proportion of women are bothered and affected by the menopause?
Affects 80%
Bothers 45%
>5years 25%
What can be non specific symptoms of menopause?
Headaches Migraines Palpitations Disturbed sleep Tired No energy Loss of libido Cant cope
What are urogenital symptoms of menopause?
Vaginal dryness
Cystitis
Urinary frequency
Urinary incontinence
What are psychological symptoms of menopause?
Loss of concentration Poor memory Irritability Loss of libido Panic attack
What does atrophy of connective tissue in menopause lead to?
Skin thinning Hair loss Brittle nails Aches and pains Osteoporosis
What are the effects of osteoperosis?
Loss of bone matrix Loss of height Deformity Fractures Economic cost
How do the sex hormones travel in the circulation?
Steroid hormones
Binding Proteins: Sex hormone binding globulin, Albumin
Unbound fraction active
What is the site of action of the sex hormones?
Intracellular
Receptors specific
Describe oestrogen receptors and what can be used to modulate them?
Specific transcription factors
Tissue dependent
Target specificity
Selective Estrogen Receptor Modulators—SERMS
What is Clomiphene?
SERM
Induces ovulation
What is Tamoxifen?
SERM used in breast cancer treatment
What are functions and properties of oestrogen?
Structural / Proliferative: Endometrium, myometrium, bone,breast, skin
Coagulation
Lipid management
Suppression of HPO axis
What local preparations of hormone therapies can be used in menopause?
Creams, gels, Vaginal rings
What systemic preparations of hormonal therapies can be used in menopause treatment?
Oral
Transdermal patches
Implants
What hormones can hormone therapies for menopause contain?
Oestrogen alone
Combined Oestrogen and Progestin
SERM
Androgen
What different time schedules can be used for menopause treatment?
Taken daily
Continuous
Cyclic or sequential
What are benefits of HRT in menopause?
Improves vasomotor symptoms: hot flushes
Improves urogenital symptoms: vaginal dryness, less infections
Reduces fracture risk / osteoporosis
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)
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
What can be other uses of HRT?
Premature Menopause:
What causes premature menopause?
Idiopathic: chromosomal, autoimmune, enzyme
Iatrogenic: Surgery, chemo, radiation
Infectious: viral, TB
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
What is the menopause?
Cessation of menses
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
What should always be considered when planning tests, treatments, medications or surgery with women of reproductive age?
Possibility of early pregnancy
In whom should a menstrual history be taken?
All women of reproductive age
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
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
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
What are important parts of a first trimester history?
Personal information
LMP & menstrual history: EDD
Gravidity, how many pregnancies?
Parity (>24weeks +
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
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
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
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
What is an Intrapartum Record?
Partogram
Pictorial record
Reduces problems during labour as it is a lengthy process and this allows consistent monitoring
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
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…
What is the trigger for puberty?
Increased levels of pulsatile GnRH trigger puberty and maturation of the HPG axis
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
What changes occur in puberty?
Endocrine hormonal changes: GnRH &HPG Physical changes (observable changes) Tanner staging Bone/skeletal changes Genetic anomalies may become apparent
What is the average range of onset of menarche?
Girls 10-14
Boys 12-16
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
What physical changes occur during puberty in females?
External genitalia: labia majora thickens Hair growth Linear growth: earlier than boys Breast development Menstruation, menarche
What is tanner staging?
Stage One…pre-pubertal Stage Two Stage Three Stage Four Stage Five… adult form and function
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
Describe the tanner staging of female pubic hair growth
- None
- Occasional wispy strands, usually along labia
- More, darker, coarser hair extending superiorly over pubis
- Dark, coarse, curly hair covering mons pubis in adult pattern, but not extending to medial aspects of thigh
- Mature form, hair extends to thigh
When do growth spurts tend to peak in boys and girls?
Girls 12 years
Boys 14 years
How can you assess puberty?
Monitor normal changes
Education / reassurance
Support / Intervene if needed
What effects does obesity have on puberty?
Moderate obesity: advanced puberty
Morbid obesity: delayed puberty
What size would you expect a testicle to be pre pubertally and in an adult?
Pre puberty: 1-6ml
Adult: 15-25ml
Describe the sequence of secondary sexual development in males
Testis
Pubic hair
Penis
Growth spurt
Describe the development of secondary sexual characteristics in females
Breast
Growth spurt
Pubic hair
Menarche
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
What is Hypergonadotropic hypogonadism?
Problem in gonads
Turners syndrome
Klinefelters syndrome
Gonadal dysgenesis
What is hypogonadotrophic Hypogonadism?
Problem in brain Tumours Gonadotrophin deficiency Pituitary deficiencies Anorexia nervosa
Is constitutional delay more common in boys or girls?
Boys
How many children have delayed puberty?
3%
How can you treat constitutional delay?
Short term low dose sex steroid treatment
How can you treat hypergonadotrophic Hypogonadism?
Sex steroid replacement
How can you treat hypogonadotrophic Hypogonadism?
Sex steroid replacement
GnRH administration
What could be causes of patients being short in stature and fat?
Hypopituitarism Growth hormone deficiency Hypothyroidism Cushings syndrome Pseudohypoparathyroidism
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
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
What are disadvantages of contraception?
Changes in sexual habits
Increased promiscuity
Medical complications
Cost
What are advantages of contraception?
Reproductive choice
Decrease in unwanted pregnancy/children
Health benefits
Population control
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
What are the different contraceptive methods?
Natural/Physiological Barrier Hormonal Surgical Overlap
What are the natural contraceptive methods that people use?
Rhythm method: prevent sperm / egg interaction
Coitus interruptus: prevent sperm/ egg interaction
Lactation: prevent ovulation
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
How can the fertility window be predicted?
Measure basal body temperature which rises after ovulation
Spinbarkeit (spinnability) of cervical mucus thinnest around ovulation
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
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
How does lactation create a natural contraceptive?
Regular Breastfeeding
Prolactin high levels
Suppresion HPO axis so no ovulation
Six months
What are some barrier methods of contraception?
Condom
Diaphragm and cervical cap
Spermicide
What are advantages and disadvantages of condoms?
Cheap/available Education Latex allergy Some sensation loss STD protection
What are advantages and disadvantages of the diaphragm and cap?
Requires Professional fitting
Patient Education on how to correctly insert
Spermicides
What are hormonal methods of contraception?
Combination pills (oestrogen & progesterone)
Progesterone only pills (mini-pill)
Injectables / Implants / LARC (long acting reversible contraceptive)
Patches
Rings
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
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
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
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
What are absolute contraindications to combination pill use?
Undiagnosed vaginal bleeding
Documented pregnancy
Breast Cancer
Chronic liver disease
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%
What are issues with the progesterone only pill?
Very few-due to low dose
Compliance-VERY IMPORTANT
UNFORGIVING-need back-up if >3 hours
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
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
How do implants and injectables exert their contraceptive effects?
Ovulation suppression
Mechanism of action– HPO inhibition
Mucus / endometrial effects
What are side effects of implants and injectables?
Mainly progesterone related Decreased libido Increased weight Irregular bleeding Amenorrhea-may be beneficial Cost Invasive
What can be benefits of injectables or implants?
Long term Amenorrhea Decrease dysmenorrhea Hygiene Partner unaware
How does the IUCD work?
Inert-plastic
Prevent implantation: Mechanical / inflammatory / pharmacologic
Cu7- embryotoxic or Progesterone-endometrial/cervical mucus
effects-some ovulation suppression
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
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
What can be complications with an IUCD?
Expulsion
Perforation
Infection
Ectopic
What are side effects of an IUCD?
Bleeding
Cramping
Usually love or hate
Describe emergency contraceptive pills
Suppress ovulation/ implantation
High dose progesterone
Side effects - nausea vomitting
Describe sterilisation
Prevent sperm / egg interaction by surgical interruption Tubal ligation, Vasectomy Consider irreversible Counselling Cost Invasive FAILURES
Describe termination
Failure of contraception
Excellent chance to educate
Surgical - vacuum aspiration or dilation & curettage D & C
Medical- mifepristone / misoprostol
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
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
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
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)
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
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)
What do you do to fix an Imperforate hymen with hematocolpos ( blood in vagina)?
Incise hymen
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
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)
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
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
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
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
What is constitutional delay?
Slow development of male characteristics, benign
Represents normal variation - often familial
Eventually undergo a normal puberty and attain normal height
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
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
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
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)
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
Will a boy with constitutional delay be producing sperm?
High intra-testicular levels of testosterone are needed for spermatogenesis, so it is doubtful
What will be the possible consequences of early puberty?
Short stature due to premature growth spurt and epiphyseal closure
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
