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gynaecology > physiology of menstruation, menopause, puberty > Flashcards

physiology of menstruation, menopause, puberty Flashcards

1
Q

Describe the physiology and endocrinology of the menstrual cycle (the axis)

A

the hypothalamus produces GnRH
GnRH stimulates the anterior pituitary to produce LH and FSH
LH acts on theca cells of ovaries causing them to produce androgen
FSH acts on granulosa cells causing them to express an enzyme that converts the androgens to oestrogen. Also produce inhibin

when O is low or with P it can inhibit the axis to maintain constant FSH and LH levels
when O is high (in absence of P) it can stimulate - positive feedback for ovulation
inhibin inhibits FSH selectively

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2
Q

what are the 3 phases of the ovarian cycle?

A

follicular
ovulation
luteal phase

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3
Q

what happens in the follicular phase of the ovarian cycle?

A

this marks the start of the cycle - LH and FSH and O+P are all low. less negative feedback so LH and FSH slowly rise. O slowly rises and the follicles slowly grow

one follicle eventually dominates and the rest regress
now there is a high level of O and low P and thus positive feedback of the axis - LH surge

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4
Q

describe the physiology behind ovulation

A

This starts with the LH surge which induces the follicle to rupture and oocyte to mature. the oocyte is the released (ovulation) and is transported to the fallopian tubes by fimbria
can be fertilised for up to 24 hours within the fallopian tube
the LH surge also causes granulosa cells to become lutinised (remaining follicle now called corpus luteum) and express LH receptors. LH now causes the granulosa cells to produce progesterone.
P starts to rise and can act with O to maintain axis by negative feedback (stalls axis in anticipation for fertilisation)

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5
Q

what is the luteal phase of the ovarian cycle?

A

corpus luteum continues to secrete O +P to maintain conditions for fertilisation/ implantation until the placenta can take over.

at 14 days the corpus luteum spontaneously regresses (unless hCG from pregnancy maintains it for up to 4 months)

once corpus luteum regresses, drop in O and P and so less negative feedback so LH and FSH can again continue to slowly rise.

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6
Q

what are the phases of the uterine cycle?

A

proliferative phase
secretory phases
menses

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7
Q

what happens in the proliferative phase of uterine cycle?

A

this runs alongside the follicular phase of ovarian cycle.
Oestrogen prepares for fertilisation/ implantation
- fallopian tube maturation
- endometrium thickening (functional layer grows, basal stays the same),
- increases growth and motility of myometrium
- thin alkaline cervical mucus - sperm friendly

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8
Q

what happens during the secretory phase of the uterine cycle?

A

alongside luteal phase of ovarian cycle

progesterone further prepares the endometrium

  • glandular secretory form
  • further thickening of myometrium

progesterone also promotes thick acidic cervical mucus - prevent polyspermy. also changes to mammary tissue

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9
Q

describe the physiology behind menses?

A

corpus luteum regresses and O and P reduced

P can no longer maintain endometrium so it sheds and bleeds.

  • lack of P leads to prostaglandin release which casues:
    - spiral artery vasospasm nd ischaemic necrosis of superficial layers of endometrium
    • increased myometrial contractions
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10
Q

what are the physiological mechanisms to stop bleeding in menses?

A

spiral artery vasospasm
platelet plugging
repairing of endometrium

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11
Q

what is classed as normal frequency, frequent and infrequent menses?

A

normal - around 28 days (24-32)

frequent - <24 days
infrequent . >38 days

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12
Q

what is classed as a normal duration, short and prolonged duration of menses

A

5 days = normal
>8 days = prolonged
<4.5 days = short

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13
Q

what is the average blood loss in menstruation. what defines menorrhagia, and oligomenorrhagia?

A

average = 40 ml
menorrhagia >80 ml
light <5ml

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14
Q

when is menarche usually?

A

between 11-15 yrs

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15
Q

when is menopause usually?

A

between 45 -55

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16
Q

what factors affect menstrual blood loss

A

age
hereditary
parity
uterine pathology

17
Q

what defines menopause and pre-menopause?

A

pre-menopause: defined as from the beginning of symptoms of menopause to the start of having no periods for 12 months. in this part, periods become less regular

menopause - the absence of periods for 12 months

18
Q

what are the hormonal changes in menopause?

A

reduced oestrogen from ovaries results in less negative feedback and thus rise in LH/FSH

reduced sensitivity of ovaries to LH/FSH so oestrogen remains low (this is because fewer follicles and thus less binding sites = loss of ovarian follicular activity)
increased number of anovulatory cycles

inhibin is increased and so FSH rises more so than LH
progesterone is also low

19
Q

how is menopause diagnosed?

A

history - >45 years old and symptoms

blood test - high FSH

  • FSH >40ml U / ml
  • only need this diagnosis if <45 and menopause suspected
    - not reliable if on POP/COCP or HRT

LH, O and P not routinely used for diagnosis but expect LH to be high and O and P to be low

20
Q

what are the symptoms of peri menopause?

A

hot flushes - usually head, neck and chest. associated with peripheral vasodilation and transient rise in body temperature
dyspareunia - loss of oestrogen results in vaginal atrophy and thining of myometrium. also dryness.

urinary incontinence - atrophy of bladder and urethra
(also increased UTIs)

irregular vaginal bleeding - small amount of O causes endometrium to grow, no P and thus cant be maintained so break through bleed every 14 days. (also some normal ovulation can cause bleeding)

fracture/ osteoporosis (oestrogen inhibits osteoclasts)
ischaemic heart disease (oestrogen is protective)
irritable, depression, reduced concentration
loss of libido

21
Q

how is menopause managed?

A

give advice of what symptoms to expect, long term health implications of menopause and advantages/ disadvantages of HRT

HRT
osteoporosis prophylaxis

22
Q

what HRT can be offered in menopausal women?

A

types: upposed O, O and P (continuous or biphasic)

delivery method: tablet, transdermal path, vaginal ring

23
Q

what are the risks of HRT?

A 
breast cancer
endometrial cancer and ovarian cancer (for unopposed O)
DVT risk 
heart disease
ischaemic stroke 
uterine bleeding 
adverse lipid profile and risk of T2D

but bone protection

24
Q

what osteoporosis protection can be given in menopause

A

bisphosphonates, exercise, ADCAL, raloxifene (SERM)

25
Q

how can we treat the:

  • psychological symptoms of menopause
  • sexual dysfunction
  • urogenital atrophy

associated with menopause?

A

a) CBT or HRT
b) HRT, testosterone
c) vaginal oestrogen (can be used on top of systemic HRT). use moisturisers and lubricants

26
Q

how should you stop HRT?

A

slowly reduce dose

27
Q

when does puberty normally begin?

A

8-14yrs in girls

10-16 in boys

28
Q

describe the physiology behind onset of puberty

A

activation of HPG axis:
- LH and FSH are low in childhood but slowly rise due to increase in GnRH cycles and amplitude.
LH and FSH stimulate sex steroid hormone production which stimulate ovaries and testes for gametogenesis and stimulate secondary sexual characteristics

29
Q

what physical changes occur in puberty?

A

thelarche
pubarche - pubic hair first and then axillary 2 yrs later
menarche - first period around 12-14

30
Q

what is thelarche?

A

breast development

typically occurs around 9-10

31
Q

what staging system classifies breast development?

A

tanner stages
classed I- V
(also used for testicles)

32
Q

what occurs in males at puberty?

A

testicles grow = often first sign
first ejaculation
pubarche - pubic hair
voice changes due to vocal cord and larynx enlargement

33
Q

what defines precocious puberty?

A

onset <8 in girls

<9 in boys

34
Q

what is precocious puberty caused by

A

iatrogenic - external oestrogen use
early maturation of HCG - may be due to hypothyroid, tumours etc
may be independent of GnRH (oestrogen high alone)

35
Q

what defines delayed puberty?

A

absence of secondary sexual characteristics at 13 in girls and 16 in boys

36
Q

what causes delayed puberty?

A

hypogonadotrophic hypogonadism - deficiency of GnrH, LH, FSH due to problem with hypothal or pituitary

hypergonadotrophic hypogonadism - problem with gonads (negative feedback so LH/FSH/GnRH are all high)

gynaecology (7 decks)

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