Puberty And Menstrual Disorders Flashcards
The menstrual cycle occurs with the maturation of what?
The HPO axis
What does GnRH stimulate?
FSH and LH from the anterior pituitary which stimulates estrogen and progesterone from the ovarian follicle
What hormones does the anterior pituitary secrete?
FSH, LH, TSH, prolactin, GH and ACTH
FSH and LH are synthesized and stored in which cell type?
Gonadotrophs
Which hormones does the posterior pituitary secrete?
Vasopressin and oxytocin
The normal ovarian cycle can be divided into which two phases?
Follicular and luteal phase
The follicular phase of the ovarian cycle begins with what?
The onset of menstruation and culminates in the pre-ovulatory surge of LH
The luteal phase of the ovarian cycle begins with what?
The onset of preovulatory LH surge and ends with the first day of menses
What do decreasing levels of estradiol and progesterone from the regressing CL of the preceding cycle initiate?
An increase in FSH by a negative feedback mechanism which stimulates follicular growth and estradiol secretion
What is the 2 cell theory of ovarian follicular development and estrogen production?
LH stimulates the theca cells to produce androgens (androstenedione and testosterone); FSH stimulates the granulosa cells to convert these androgens into estrogens
What suppresses LH and FSH levels during the luteal phase?
Negative feedback effect of elevated circulating estradiol and progesterone
If conception doesn’t occur, what happens to estrogen and progesterone levels during the luteal phase?
They decline near the end of the luteal phase as a result of CL regression; FSH will then rise which initiates new follicular growth for the next cycle
Which 5 peptides are secreted from the hypothalamus and affect the reproductive cycle?
GnRH, TRH, somatostatin, CRF, PIF
Estradiol enhances the hypothalamic release of which hormone to induce the mid cycle LH surge?
GnRH
What is the average age for menarche?
12.43 years
When does menarche occur?
Within 2-3 years after thelarche (breast budding) at tanner stage IV (rare before stage III)
What is primary amenorrhea?
No menstruation by 13 yo without secondary sexual characteristics OR by age 15 with secondary sexual characteristics
What is the average blood loss per menstrual period?
30cc (changing pad 3-6 times a day); >80cc has been associated with anemia
What is puberty?
The development of secondary sexual characteristics and the acquisition of reproductive capability
When does puberty usually occur?
Between 10-16 yo (mean is 12.4)
What are the factors that determine the onset of puberty?
Genetic factors including race; geographic location (girls that live in metropolitan areas, at altitudes near sea level begin earlier); nutritional status (obese will have early onset whereas malnourished will have later onset)
When does a female infant acquire the lifetime peak number of oocytes?
By mid gestation (16-20 weeks)
When is the HPO axis suppressed?
Between the ages of 4-10 years old
What is the gonadostat?
The hypothalamic-pituitary system regulating gonadotropin release
At what age is there an increase in DHEA, DHEA-S, and androstenedione?
Between the ages of 8-11
What are the initial endocrine changes associated with puberty?
Adrenal androgen production and differentiation by the zona reticularis of the adrenal cortex
What causes growth of axillary and pubic hair (adrenarche or pubarche)?
Rise in adrenal androgens
At what age is there a gradual loss of sensitivity by the gonadostat to the negative feedback of sex steroids?
Around 11 years of age; in combination with the intrinsic loss of CNS inhibition of hypothalamic GnRH release
When do sleep associated increases in GnRH secretion occur and gradual lay shift into adult type secretory patterns?
Around the onset of puberty
What leads to the development of secondary sexual characteristics at the onset of puberty?
Increase in GnRH promotes ovarian follicular maturation and sex steroid production
What event occurs by mid to late puberty?
The positive feedback mechanism of estradiol on LH release from the anterior pituitary gland is complete and ovulatory cycles are established
What are the stages of normal puberty development?
Thelarche —> adrenarche —> peak height velocity (max growth) —> menarche —> mature sexual hair and breasts
What is thelarche?
Breast development and first physical sign of puberty; unilateral development in first 6 months is not uncommon; requires estrogen
Pubarche and adrenarche require which hormone?
Androgens
When does maximal growth or peak height velocity occur?
Occurs 2 years earlier in girls; occurs about 1 year before onset of menses
What does menarche require?
Pulsatile GnRH from the hypothalamus, FSH and LH from the pituitary, estrogen and progesterone from the ovaries, and a normal outflow tract
What is the tanner staging for breast development?
- Preadolescent elevation of papilla only;
- Breast bud stage; elevation of breast and papilla as a small mound with enlargement of the areolar region;
- Further enlargement of breast and areola without separation of their contours;
- Projection of areola and papilla to form a secondary mound above the level of the breast;
- Mature stage; projection of papilla only resulting from recession of the areola to the general contour of the breast
What is the tanner staging for pubic hair development?
- Preadolescent, absence of pubic hair;
- Sparse hair along the labia; hair downy with slight pigment;
- Hair spreads sparsely over the junction of the pubes; hair is darker and coarser;
- Adult type hair; there is no spread to the medial thigh;
- Adult type hair with spread to the medial thighs assuming an inverted triangle pattern
What is precocious puberty?
Refers to the development of any sign of secondary sexual characteristics prior to an age 2.5 SD earlier than the expected age of pubertal onset; 8 years old for girls and 9 years old for boys
Precocious puberty can lead to what?
Premature fusion of the long bones of the epiphysis
When secondary sexual characteristics have not appeared by the age of 13; if thelarche has not occurred by age 14; no menarche by age 15-16; when menses has not begun 5 years after the onset of thelarche
What is secondary amenorrhea?
Pt with prior menses has absent menses for 6 months or more
What tests can be used to evaluate primary amenorrhea without sexual secondary sexual characteristics?
MRI of the brain, FSH, karyotype, progesterone prolactin; if karyotype comes back with a Y chromosome gonadectomy is recommended to prevent malignant neoplastic transformation
What are some causes of menstrual irregularity?
Pregnancy, endocrine changes, acquired conditions, tumors
What are some endocrine causes of menstrual irregularity?
Poorly controlled DM, PCOS, Cushing’s syndrome, thyroid dysfunction, premature ovarian failure, late onset congenital adrenal hyperplasia
What are some acquired conditions that can cause menstrual irregularity?
Stress related hypothalamic dysfunction, meds, exercise induced amenorrhea, eating disorders (anorexia, bulimia)
Which tumors can cause menstrual irregularities?
Ovarian and adrenal tumors, prolactinomas
What will be seen upon a history and physical in someone with secondary amenorrhea?
Significant changes in wight, strenuous exercise, dietary habits, concomitant illness, abnormal facial hair, galactorrhea, dyspareunia, presence of hot flushes and/or night sweats
Which labs should be performed for secondary amenorrhea?
Urine HCG, TSH, prolactin, FSH
What are microadenomas?
Typically slow growing and rarely malignant; can be monitored with repeat prolactin measurements and imaging; tx should focus on management of infertility, galactorrhea, breast discomfort; consideration for dopamine agonist
How are macroadenomas treated?
With dopamine agonists; transphenoidal resection or craniotomy
What can cause hyperprolactinemia (<100ng)
Ectopic production due to bronchogenic carcinoma, ovarian dermoid cyst, RCC, gonadoblastoma; breast feeding and stimulation, excessive exercise, severe head trauma, hypothyroidism, liver or renal failure, meds (OCPs, antipsychotics, antidepressants, anti-HTN, H2 blockers, opiates, cocaine)
What can cause hyperprolactinemia (>100ng)?
Pituitary adenoma and empty sella syndrome
What is the history for a pt with hyperandrogenism?
PCOS and late onset CAH often appear during puberty and progress slowly; neoplastic disorders can occur at any time and rapid virilization is common
What is seen on PE for a pt with hyperandrogenism?
Degree of hirsutism, acne, alopecia, should be documented; look for evidence of Cushing’s dz; Acanthosis nigricans; bimanual exam to assess for ovarian enlargement
What is virilization?
A masculinization of a female associated with marked increase in circulating testosterone; enlargement of the clitoris, temporal balding, deepening of voice, decreased breast size, loss of female body fat distribution, and hirsutism; results from excessive male hormone production or exogenous hormone use
Which labs should be performed to evaluate a pt with hyperandrogenism?
17-hydroxyprogesterone level to exclude CAH; 24 hr free urinary cortisol or overnight dexamethasone suppression test to r/o Cushings; prolactin and TSH to exclude hyperprolactinemia +/- thyroid dz; glucose and lipid levels; testosterone and DHEA-S
If DHEA-S levels are above 7000 what should be suspected?
Adrenal androgen producing tumor
If total testosterone levels are >200 what should be suspected?
Ovarian androgen producing tumor
What is polymenorrhea?
Abnormally frequent menses at intervals of <21 days
What is menorrhagia (hypermenorrhea)?
Excessive and/or prolonged bleeding (>80mL and >7 days) occurring at normal intervals
What is menorrhagia?
Irregular episodes of uterine bleeding
What is menometrorrhagia?
Heavy and irregular uterine bleeding
What is intermenstrual bleeding?
Scant bleeding at ovulation for 1-2 days
What is oligomenorrhea?
Menstrual cycles occurring >35 days but less than 6 months
What is dysfunctional uterine bleeding?
Defined as abnormal uterine bleeding that cannot be attributed to meds, bloody dyscrasias, systemic dz, trauma and organic conditions
What are the two classifications for abnormal bleeding in reproductive aged women?
PALM (structural causes) and COEIN (non structural causes)
What does PALM stand for?
Polyp, adenomyosis, leiomyoma (submucosal myxoma or other myoma), malignancy and hyperplasia
What does COEIN stand for?
Coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified
How should massive abnormal uterine bleeding be treated?
Hospitalization and transfusions if hemodynamically unstable; 25mg IV conjugated estrogens then hormonal treatment (combination hormonal therapy, Mirena)
How should moderate AUB be treated?
Combination OCP’s, Mirena
How should AUB be treated when the pt is unresponsive to conservative therapy?
D&C, polypectomy, myomectomy, endometrial ablation, hysterectomy
