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R2F > Puberty and Menstrual Disorders 1 > Flashcards

Puberty and Menstrual Disorders 1 Flashcards

1
Q

Hypothalamic-pituitary axis

A
  • GnRH (from hypothalamus)
  • stim LH and FSH (from ant pit- stored in gonadotrophs)
  • stim estrogen and progesterone (from ovarian follicle)
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2
Q

Ovarian Cycle- phases

A
  • Follicular phase- onset of menstruation to surge of LH

- Luteal phase- LH surge to first day of menses

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3
Q

dec estradiol and progesterone from the regressing corpus luteum- initiates

A

-inc in FSH- stim follicular growth and estradiol secretion

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4
Q

2 cell theory of ovarian follicular development

A
  • LH stim Theca cells- produce androgens (androstenedione and T)
  • FSH stim Granulosa cells- convert androgens into estrogens
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5
Q

Luteal phase

A
  • LH and FSH are suppressed (neg feedback of elevated estradiol and progesterone)
  • if conception doesnt occur- progesterone and estradiol dec due to corpus luteal regression- FSH rises!- follicular growth
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6
Q

GnRH

A
  • stim syn and release of LH and FSH (from ant pit)

- estradiol enhances hypothalamic release of GnRH to induce the midcycle LH surge

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7
Q

ovarian cycle- estrogen

A
  • early follicular development- estradiol is low
  • 1 wk before ovulation- estradiol starts to inc- reaches a maximum 1 day b/f LH peak
  • after LH peak- estradiol falls
  • luteal phase- estradiol rises for 5-7 days after ovulation and then returns to baseline b/f menstruation
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8
Q

ovarian cycle- progestins

A
  • follicular development- ovary secretes small amt of progesterone
  • prior to ovulation, the grafian follicle begins to produce progesterone
  • secretion of progesterone by corpus luteum reaches a max 5-7 days after ovulation- returns to baseline b/f menstruation
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9
Q

ovarian cycle- follicular development

A
  • primordial follicles mature into a graafian follicle
  • follicle ruptures- releases an ovum
  • luteinization of ruptured follicle= corpus luteum
  • 8-10 wks of fetal development- oocyte-granulosa cell complex= primordial follicle
  • adult- graafian follicle
  • granulosa cells adhere to ovum- cumulus oophorus- antrum forms along the granulosa cells- innermost layer forms corona radiata- corona radiata and oocyte is released at ovulation
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10
Q

ovarian cycle- ovulation

A
  • LH surge causes ovulation

- stigma forms- ruptures the follicular basement membrane- oocyte is expelled

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11
Q

ovarian cycle- luteinization and corpus luteum fxn

A
  • after ovulation- granulosa cells of rupture follicle undergo luteinization= forms corpus luteum
  • corpus luteum produces progesterone!!
  • if pregnancy doesnt occur, corpus luteum is replaced by a scar (corpus albicans)
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12
Q

overall cycle

A
  • corpus luteum dies- E and P fall
  • inc FSH
  • follicles grow, secrete E
  • E neg feedback on FSH
  • dec FSH levels- causes selection of dominant follicle- produces high levels of E
  • high E- positive feedback on LH
  • LH surge- ovulation- corpus luteum produces high P
  • high P, E- neg feedback on LH and FSH
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13
Q

Endometrium-2 zones

A
  • outer portion (functionalis)- sloughed off at menstruation, contains spiral a’s
  • inner portion (Basalis)- remains unchanged, basal a’s
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14
Q

Endometrial cycle- 3 stages

A
  • menstrual
  • proliferative (estrogenic)
  • secretory (progestational)
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15
Q

Menstrual phase

A
  • 1st day of menstruation- day 1

- sloughing of functionalis layer, compression of basalis layer

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16
Q

Proliferative phase

A
  • endometrial growth due to estrogenic stim

- inc in spiral a’s, mitoses

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17
Q

Secretory phase

A
  • after ovulation- progesterone secretion by corpus luteum stim glandular cells to secrete mucus, glycogen
  • glands become tortuous and lumens dilated
  • stroma is edematous
  • spiral a’s
  • endometrial lining- maximal thickness
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18
Q

Secretory phase- if no conception

A
  • corpus luteum regress- dec progesterone- endometrium undergoes involution
  • constriction of spiral a’s- ischemia of endometrium- necrosis- sloughing of endometrium
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19
Q

Secretory phase- coag pathway is necessary

A
  • menstruation disrupts BVs- normal hemostasis allows for the to rapidly repair
  • warfarin, aspirin, clopidogrel- heavy bleeding
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20
Q

Menarche- median age

A
  • 12.43 yrs

- 2-3 yrs after thelarche, at Tanner stage IV

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21
Q

Primary amenorrhea

A

-no menstruation by 13 W/O secondary sexual development
OR
-age of 15 W/ secondary sexual development

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22
Q

normal cycle length

A
  • 21-35 days long in adults

- irregular thruout adolescents

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23
Q

excessive menstrual flow

A
  • mean blood loss= 30 cc (change pad 3-6x/day)

- > 80 cc= anemia (change pad 1-2 hrs)

24
Q

puberty- occurs when?

A

10-16 yo (mean is 12.4)

  • genetic factors
  • geographic location
  • nutritional status
25
Q

Fetal/newborn and childhood period

A
  • HPO axis is suppressed b/w 4-10 yo
  • low levels of gonadotropins and sex steroids:
  • gonadostat sensitivity to neg feedback of low estradiol
  • CNS inhibition of GnRH secretion
26
Q

late childhood

A
  • ages 8-11- inc in DHEA, DHEA-S, and androstenedione
  • androgen prod- diff of zona reticularis- initial endocrine changes!!!
  • rise in adrenal androgens- pubarche/adrenarche (axillary/pubic hair)
27
Q

Onset of puberty

A
  • 11 yo- intrinsic loss of CNS inhibition of GnRH release, dec sensitivity of the gonatostat to neg sex steroid feedback
  • sleep-assoc inc in GnRH secretion
  • inc GnRH- ovarian follicular maturation and sex steroid production- secondary sex characteristics
  • positive-feedback mech of estradiol on LH release
28
Q

Stages of Normal Pubertal Development

A

TAG ME

  • Thelarche (breast development)- requires estrogen
  • Adrenarche/pubarche (pubic/axillary hair)- requires androgens
  • Growth spurt (1 yr before onset of menses)
  • Menarche- requires pulsatile GnRH
29
Q

Breast development- Tanner Staging

A
  • 1- preadolescent- papilla elevation
  • 2- breast bud stage- small mound
  • 3- enlargement of breast and areola w/o separation of contours
  • 4- projection of areola and papilla- form secondary mound
  • 5- mature- projection of papilla only- recession of areola to general contour of breast
30
Q

Pubic hair- Tanner Staging

A
  • 1- preadolescent- absence of pubic hair
  • 2- sparse hair along labia, slight pigment
  • 3- sparsely spread, darker and coarser
  • 4 adult-type hair
  • 5- spread to medial thighs
31
Q

precocious puberty

A
  • secondary sexual characteristics prior to an age 2.5 standard deviations early than expected
  • 8 yo- girls
  • 9 yo- boys
  • 75% idiopathic
  • need to evaluate to eliminate a serious dz
32
Q

2 groups of precocious puberty

A
  • Heterosexual (opp gender characteristics)- virilizing neoplasms, CAD, exogenous androgens
  • Isosexual (same gender)- constitutional, brain dz
33
Q

Heterosexual precocity

A
  • virilizing neoplasms, CAD, exogenous androgens

- androgen secreting neoplasms- Sertoli-leydig cell

34
Q

CAD

A
  • def of 21-hydroxylase
  • excessive androgen prod
  • classical- ambiguous genitalia at birth- if untreated, progressive virilization and short adult status
  • Nonclassical (late onset)- premature pubarche
  • salt wasting
35
Q

Isosexual Precocity

A
  • True- premature act of HPO axis

- Pseudo-isosexual- exposure of estrogens indep of HPO axis (tumors)

36
Q

True Isosexual Precocious Puberty

A
  • 75% constitutional or idiopathic
  • dx- admin exogenous GnRH- resultant rise in LH
  • 10% caused by CNS disorder
  • dx with MRI of head
  • tx- GnRH agonist (leuprolide acetate)- suppresses release of FSH and LH- decline of gonadotropins
  • if untreated- 50% will < 5 ft height
37
Q

Pseudoisosexual precocity

A

(w/o act of HPO axis!!)

  • ovarian tumor
  • exogenous estrogen
  • McCune-Albright syndrome
  • Peutz-Jeghers Syndrome
38
Q

McCune-Albright Syndrome

A

(polyostotic fibrous dysplasia)

  • somatic mutation during embryogenesis- fxn indep of their normal stim H’s
  • mult cystic bone defects, cafe au lait spots
39
Q

Peutz-Jeghers syndrome

A
  • sex cord tumor- secretes estrogen

- GI polyposis, mucocutaneous pigmentation

40
Q

Delayed puberty

A
  • secondary sex characteristics not appeared by age 13
  • no thelarche by 14
  • no menarche by 15-16
  • menses hasnt begun 5 yrs after onset of thelarche
41
Q

Delayed puberty- causes

A
  • Hypergonadotropic Hypogonadism (FSH, LH inc)
  • Hypogonadotropic Hypogonadism (FSH, LH dec)
  • Anatomic causes
42
Q

Amenorrhea- types

A

(absence of menses)

  • primary- no menses by age 13 W/O secondary sex characteristics; or no menses by age 13 W/ secondary sex characteristics
  • secondary- prior menses, but has absent menses for 6 months
43
Q

Primary amenorrhea- then do what?

A
  • if NO sex characteristics- measure FSH and LH

- if sex characteristics- do US of uterus

44
Q

primary amenorrhea- no secondary sex characteristics- measure what?

A
  • FSH and LH!!
  • if low- hypogonadotropic hypogonadism
  • if high- hypergonadotropic hypogonadism- do karyotype analysis!!- 46,XX (premature ovarian failure) or 45X (turner’s syndrome)
45
Q

Hypogonadotropic Hypogonadism

A
  • low FSH and LH
  • MRI
  • exercise
  • physiologic delay- most comon cause!!- hereditary- dx of exclusion
  • Kallman syndrome
46
Q

Kallman syndrome

A
  • mutation of KAL gene on X chrom- prevents migration of GnRH neurons into hypothlamus
  • anosmia!!!
47
Q

Hypergonadotropic hypogonadism

A
  • inc FSH and LH
  • chromosomal or injury to ovaries by surgery, chemotherapy, radiation tx)
  • 46,XX- premature ovarian failure
  • 45X- turner’s syndrome
48
Q

Turner’s syndrome

A

(45 X karyotype)

  • most common form of female gonadal dysgenesis
  • no signs of secondary sex characteristics
  • mosaicism in 25%
  • webbing of neck, broad flat chest, widely spaced nipples, short stature, streaked ovaries, absent puberty, coarctation of aorta
49
Q

Primary amenorrhea + secondary sex characteristics- do what

A

US of uterus!!!

  • absent or abnormal- Karyotype analysis: 46X,Y (androgen insensitivty syndrome); 46XX (mullerian agenesis)
  • uterus present- outflow obstruction- imperforate hymen or transverse vaginal setpum
50
Q

Primary amenorrhea + secondary sex characteristics- uterus abnormal

A
  • AIS (androgen insensitivity syndrome)

- Mullerian agenesis

51
Q

AIS (androgen insensitivity syndrome)

A
  • 46,XY
  • male levels ot T
  • defect in androgen R
  • testes are in abd wall- secrete antimullerian H’s- no uterus is formed
  • external female genitalia, absent pubic hair
  • small breasts
  • tx- gonadectomy after puberty to avoid neolasm
52
Q

Mullerian Dysgenesis

A

(karyotype 46,XX)

  • mullerian defects that cause obstruction of vaginal canal- imperforate hymen or transverse
  • MRKH syndrome- absence of uterus- failure of mullerian ducts to fuse distally; renal abnormalities
53
Q

MRKH syndrome

A

(Mullerian Agenesis)

  • normal secondary development and external female genitalia
  • normal female range of T
  • absent uterus and upper vagina
  • 46,XX
  • renal anomalies
  • most common cause of primary amenorrhea in women with normal breast development!!
54
Q

Primary amenorrhea + Secondary characteristics + uterus present- then what?

A

check of outflow obstruction!!

  • no- evaluate for secondary amenorrhea
  • yes- imperforate hymen or transverse vaginal septum
55
Q

Outflow obstruction

A
  • normal uterus on US
  • imperforate hymen- monthly dysmenorrhea w/o bleeding- vaginal bulge- tx with hymenectomy
  • transverse vagnal septum- no bulge- dx on MRI

R2F (18 decks)

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