Menstrual Disorder I & II (Moulton) Flashcards
Briefly explain the hypothalamic-pituitary axis as it relates to the menstrual cycle.
GnRH from the hypothalamus stimulates FSH and LH from the anterior pituitary, those then stimulate estrogen and progesterone from the ovarian follicle.
The pituitary gland is contained within what bony cavity?
sella turcica
What hormones are secreted from the anterior pituitary?
FLAT PiG
FSH, LH, ACTH, TSH, PrL, GnRH
What hormones are secreted from the posterior pituitary?
Vasopressin and Oxytocin
What are the two phases of the ovarian cycle?
- Follicular phase (onset of menstruation to pre-ovulatory surge)
- Luteal phase (onset of pre-ovulatory surge to first day of menses)
LH stimulates which cells within the ovary?
theca cells; produce androgens (androstenedione and testosterone)
What hormones are produced by theca cells?
androgens (androstenedione and testosterone); stimulated by LH
FSH stimulates which cells within the ovary?
granulose cells; convert androgens into estrogen (E1 and E2)
Granulosa cells serve what function in the ovary?
convert androgens (produced by theca cells) into estrogen (E1 and E2); stimulated by FSH
Decapeptide
responsible for the synthesis and release of LH and FSH; synthesized in the arcuate nucleus
During early follicular phase, estrogen levels are what?
low; until 1 week before ovulation
When does estrogen levels start to increase in the follicular phase of the ovarian cycle?
1 week before ovulation
Right after the LH surge what happens to estrogen levels?
marked and precipitous fall
The corpus luteum is replaced by what if pregnancy does not occur?
avascular scar called corpus albicans
What labs are used to diagnose menopause?
FSH; levels will be elevated
What are the two zones of the endometrium?
functionalis (sloughed off) and basalis (unchanged)
Functionalis layer of the endometrium
outer portion; undergoes cyclic changes; shedded during menstruation; spiral arteries
Basalis layer of the endometrium
inner portion; remains unchanged; provides stem cells; basal or straight arteries
What are the three stages of the endometrium?
- Menstrual phase
- Proliferative or estrogenic phase
- Secretory or progestational phase
What is the only portion of the endometrium cyclic cycle visualized externally?
Menstrual phase; shedding
The first day of menstruation is what day in the ovarian cycle?
Day 1
Proliferative phase of the endometrium
estrogenic stimulation; increase in spiral arteries
Secretory phase of the endometrium
progesterone stimulated; endometrial reaches maximal thickness; tortuous glands; edematous stroma
At which phase does the endometrial lining reach its maximal thickness?
secretory phase
The endometrium undergoes involution if conception does not occur by which day?
Day 23
Primary amenorrhea
no menstruation by 13 yrs w/o secondary sexual development OR by the age of 15 yrs w/ secondary sexual characteristics
What is the median age for menarche to occur?
12 yrs
What is the normal menstrual cycle range in the first gynecological year?
21 to 45 days
What is the normal menstrual cycle range for typical adults?
21 to 35 days (28 +/- 7 days)
What is the normal menstrual product use in the typical adult?
3 to 6 pads or tampons per day
What is the typical age range for puberty to occur?
10-16 yrs (median is 12); earlier in obese children
How many oocytes do female infants typically have during mid gestation (16-20 weeks)?
6 - 7 million
What are the two functions of low levels of gonadotropins and sex steroids during the prepubertal period?
- gonadostat sensitivity to negative feedback of low circulating estradiol
- inhibition of GnRH secretion
Thelarche
breast development; first physical sign of puberty; requires estrogen
What is typically the first physical sign of puberty in young females?
thelarche (breast development)
Pubarche
pubic hair development; requires androgens
Adrenarche
axillary hair development; requires androgens
Menarche
onset of menses; requires pulsatile GnRH, FSH, LH and estrogen and progesterone
TAGME
stages for normal pubertal development;
T = Thelarche
A = Adrenarche
G = Growth/Height
ME = Menses
What is the median age for African Americans females to experience thelarche/aderenarche?
9.5 yrs
Tanner Staging in breast development
Stage 1: elevation of papilla only
Stage 2: breast and papilla enlargement around areolar region
Stage 3: further enlargement of breast and areolar
Stage 4: projection of areolar and papilla (secondary mound)
Stage 5: mature stage; projection of papilla only
Tanner Staging in pubic hair development
Stage 1: absence of hair
Stage 2: sparse hair along labia
Stage 3: hair sparsed around triangle; darker and coarser
Stage 4: no spread to medial thigh
Stage 5: hair spread to medial thigh
Precocious puberty
early puberty
What are the two major subgroups of precocious puberty?
- Heterosexual precocious puberty
- Isosexual precocious puberty
Heterosexual precocious puberty
development of secondary characteristics of the OPPOSITE sex; caused by virilizing neoplasms (Sertoli-Leydig cell origin), congenital adrenal hyperplasia (21- hydroxyls deficiency) or exposure to exogenous androgens
Isosexual precocious puberty
development of secondary characteristics of the APPROPRIATE sex; two types:
1. True isosexual precocity - premature activation of normal HPO axis
2. Pseudoissexual precocity - exposure to estrogens independent to HPO axis (estrogen producing tumors)
How do you diagnose true isosexual precocious puberty?
GnRH stimulation test - admin exogenous GnRH and see if normal rise in LH occurs; but if caused by CNS disorder (10%) diagnose with head MRI
How do you treat true isosexual precocious puberty?
GnRH agonist (leuprolide acetate); if left untreated 50% of girls will not attain an adult height of 5 feet
What typically occurs if true isosexual precocious puberty is left untreated?
will not attain an adult height of 5 feet; treated with GnRH agonist (leuprolide acetate)
What are the two common causes of pseudoissexual precocity?
- McCune-Albright syndrome (Polyostotic fibrous dysplasia)
- Peutz-Jeghers syndrome
When is puberty considered delayed?
- secondary characteristics have not appeared by 13 yrs
- thelarche has not occurred by 14 yrs
- no menarche by 15-16 yrs
- menses has not occurs 5 yrs after onset of thelarche
Hypergonadotropic Hypogonadism
FSH > 30mIU/mL; will see delayed puberty; gonadal dysgenesis; commonly see in Turner syndrome (45 X,O)
Definition of primary amenorrhea
no spontaneous uterine bleeding by age 13 w/o secondary sexual characteristics OR no menstruation by 15 w/ secondary sexual characteristics
Definition of secondary amenorrhea
patient w/ prior menses has absent menses for 6 months or more
Kallman syndrome
delated puberty; hypogonadotrophic hypogonadism (FSH and LH <5 IU/L); mut in KAL gene on X chromosome that prevents the migration of the GnRH neurons in the hypothalamus; patients will present with anosmia or hyosmia (decreased or absence smell)
Hypergonadotrpoic hypogonadism
think of Turner’s syndrome; get a karyotype test; results are 45 XO; most common form of female gomadal dysgenesis; no signs of secondary sexual characteristics; webbing of the neck; broad flat “shield” chest; short stature; streaked ovaries; **coarctation of the aorta
primary amenorrhea + secondary sexual characteristics + US with absent uterus, what is your next step?
karyotype analysis;
46 XY - androgen insensitivity syndrome
46 XX - mullerian agenesis
Androgen insensitivity syndrome
46 XY; there is a normal male level of testosterone, but defect in the androgen receptor; testes are in the abdominal wall; external female genitalia w/ absent pubic hair
Mullerian agenesis
46 XX; levels of testosterone consistent w females; primary amenorrhea, breast development; absence of normal uterus (Meyer-Rokitansky-Kuster-Hauser syndrome); failure of the mullerian ducts to fuse distally
Meyer-Rokitansky-Kuster-Hauser syndrome
46 XX; most common cause of primary amenorrhea in women w normal breast development; normal female range testosterone
primary amenorrhea + secondary sexual characteristics + US with uterus, what is your next step?
check for an outflow obstruction;
no - evaluate for secondary amenorrhea
yes - imperforate hymen or transverse vaginal septum
Definition secondary amenorrhea
absence of menstruation for 6 month; always get a urine hCG test! and check hormone levels (TSH, Prolactin and FSH)
patient with secondary amenorrhea w normal prolactin and abnormal TSH
thyroid disease
patient with secondary amenorrhea w abnormal prolactin and normal TSH
get MRI of head; really high prolactin >100 ng/mL - can be pituitary adenoma or empty sella syndrome
low prolactin <100 ng/mL - ectopic production (renal cell carcinoma)
Prolactinoma
(pituitary adenoma) - microadenoma vs macroadenoma >10 mm can be treated w dopamine agonist; galactorrhea is a common symptom; compresses optic chiasm and causes bitemporal hemianopia
Secondary amenorrhea with normal TSH and prolactin, what is the next step?
do a progesterone challenge test (PCT); positive = PCOS
What are some anatomic causes of secondary amenorrhea?
Asherman syndrome
cervical stenosis
Polycystic ovarian syndrome (PCOS)
female anovulatory infertility; insulin sensitivity; increased circulating testosterone; need 2 of the 3
1. oligomenorrhea or amenorrhea
2. LH to FSH 2:1
3. multiple small cysts on US “string of pearls”
Treatment for PCOS
weight loss; oral contraceptives; insulin-sensitizing agents (metformin)
Polymenorrhea
abnormal frequent menses at intervals at <21 days (occurring more often but for a shorter duration - ie two cycles lasting 3 days in one month)
Menorrhagia
excessive or prolonged bleeding >80mL occurring at normal intervals (HEAVY bleeding)
Menometrorrhagia
heavy and irregular uterine bleeding
Oligomenorrhea
menstrual cycles occurring >35 days (less often, one period every other month)
