Puberty And Menstrual Disorders - Dr. Moulton Flashcards
hormones stimulated during menstruation
GnRH (hypo) —–> LH + FSH (AP) —-> Estrogen + Progesterone (Ovarian Follicle)
Follicular Phase and Luteal phase
Follicular = start of bleeding to ovulation (proliferative) Luteal = ovulation to start of next bleed (secretory)
regressing corpus luteum does what
decrease in E and P secreted = increase in FSH = increases estrogen
LH role
FSH role
- LH : stimulate theca cells = produce androgens (androstenedione + testosterone)
- FSH : stimulates granulosa cells = converts the androgens into estrogens E1 + E2
no pregnancy after ovulation effects what H to start next cycle
FSH increases as p and e decrease = makes new follicle mature
what causes LH surge
rise in Estrogen to a certain point (E induces GnRH
P levels peak when
5-7 days after ovulation form corpus luteum
Primordial Follicle
after 8-10weeks the fetus makes oocytes surrounded by granulosa cells
cumulus oophorus
cuboidal layer of cell around the adult graafian follicle = becomes corona radiata when oocyte released during ovulation with the corona radiate around it
corpus luteum is made up of what cells + life length
granulosa cells, theca cells, capillaries, CT + 9-10 days
if pt is not menstruating order
FSH and LH
proliferative phase what histo things happen
endometrial growth from E strimulation increase length of spiral arteries + mitoses seen
Secretory phase what happens and histo
- P from corpus luteum = mucus and glycogen secretion (glands become full) + stroma = edematous
- Spiral arteries continue to extend into superficial layer become convoluted
- endometrium reaches maximum thickness
1 day prior to ovulation what happens
constriction of spiral As = ischemia of endometrium, WBC infiltration + RBC extravasation = necrosis to slough away
when does conception need to happen before Corpus luteum regresses
by day 23
what medications can cause heavy bleeding
Warfarin , Aspirin, Clopidogrel
when does menstruation happen
2-3 years after Thelarche (breast budding) at tanner stage 4, (rare to start before Tanner stage 3)
Primary amenorrhea definition
- no menstruation by 13yo + no secondary sexual characteristics
- no menstruation by 15yo + secondary sexual characteristics present
first menses is described how + optimal weight
- medium flow
- 30cc blood loss (3-6 times pad change)
- 21-45days
- 48kgs (106lb) leptin increases E to start
anemia can be caused from how much blood loss
80cc (1-2 hours per pad, longer then 7 days)
gonadostat
regulates the release of GnRH and the HPAxis (CNS does also inhibit HPAxis during prepuberty)
initial puberty changes that happen at 8yo-11yo
zona reticularis or adrenal cortex makes adrenal androgen production (DHEA and androstedione)
= pubit hair and axillary hair
secondary sex characterisitics caused by
lowered sensitivity to gondadostat = GnRH increase + follicular maturation
Thelarchy
breast development
= 1st sign of puberty (can develop unilaterally first 6mos)
= needs E
= peak height and growth 1 year before menses
order of puberty
TAGME
- Thelarche
- Adrenarche
- Peak height
- Menarche
- sexual hair and breasts mature fully
Precocious puberty is what
puberty before 8 women and 9 men (2.5 years SD before normal)
Heterosexual precocious puberty
development o secondary sexual characterisitics opposite of sex type
= virulizing neoplasms
= congenital adrenal hyperplasia
= Androgen exposure
Isosexual precocious puberty
premature * sexual maturation appropriate for sex
= constitutional and organic brain disease (tumor, infection, trauma)
Androgen secreting neoplasms
usually ovariam (Sertoli-Leydic cells) or adrenal tumor
Congenital adrenal hyperplasia (CAD)
most common from 21-hydroxylase defect* = excessive androgen made = high androgens + low cortisol
- female with ambigous genitalia, virilization (classic)
- premature pubarche and adult disorder looking like PCOS (nonclassic), late onset adrenal hyperplasia
Isosexual Precocity
- true
- pseudoisosexual
- true = premature activation of H-P-O axis
2. pseudoisosexual = estrogen exposure (tumor)
how to dx true isosexual precocious puberty
- administer GnRH and see riase in LH system that occurs in older normal women with HPO axis activiated
- MRI of head : tumors, granulomatous disease, hydrocephalus, infection, neurofibromatpsis, trauma
True isosexual precocious puberty tx and what happens if you don tx
GnRH agonist (Leuprolide acetate) = suppress FSH and LH , arresting gonadal sex steroid secretion
- not treated = women do not reach 5ft
pseudoisosexual precocity happens how + examples
- tumor increasing E WITHOUT activiating the HPO axis
2. McCune Albright (cafe au lait) + Peutz Jeghers syndorme (GI polyps + mucocutaneous pigmentation on lips)
McCune Albright
cafe au lait, cystic bone defects, adrenal hypercortisolism
Peutz Jeghers syndrome
sex cord tumor association = secreting E, GI polyps and mucocutaneous pigmentation
delayed puberty 4 ways to dx
2nd sex char not by 13yo, thelarche not by 14yo, menarche not by 15-16yo, mneses not begun 5 years after thelarche
turner syndrome is what type of delayed puberty
and what happens
- Hypergonadotrophic Hypogonadism (FSH over 30mlU, high LH)
- Gonadal dysgenesis
Kallman Syndrome
- type of delay
- what happens
- factor
- Hypogonadotropic Hypodonadism
- anosmia (cant smell) and hyposmia (lower smell)
- KAL mutation on X chr = prevents GnRH neurons into hypothalamus
XY Hypogonadotrophic hypogonadism what should you do
remove gonads due to risk of neoplastic transformation
Turners syndrome
45XO, gonadal dygenesis
= webbing of neck(pterygium colli), broad flat chest, short, low development/puberty, coarctation of aorta
2 reasons for primary amenorrhea WITH breast development
- Androgen insensitivity syndrome (AIS) = male level testosterone, testes in abd secrete antimullerian = no uterus, external Female features , XY
- Mullerian agenesis = XX, MRKUS, often associated with renal abnormalities , no uterus
Androgen insensitivity syndrome (AIS)
normal female breasts, genetalia external, no uterus or upper vagina = XY = male level testosterone = testes in abd = remove gonads to prevent neoplasia
MRKHS mullerian agenesis associated with
renal abnormalities + primary amenorrhea with normal female breast development
- imperforated hymen
- transverse vaginal septum
DX how + TX how
- vaginal bulge with blood inside , tx with hymenectomy
2. MRI, tx with surgery
mild hypothyroidism can cause
hypermenorrhea (heavy bleeding), oligomenorrhea (infrequent periods)
abnormal prolactin levels can cause and what imaging should you do
galactorrhea (over 100ng/mL), secondary amenorrhea
= do head MRI (empty sella syndrome, pituitary adenoma)
Microadenomas are what and do what, tx, macroadenoma is what and tx
- <10mm on MRI, increase prolactin
- rare malignant
- DA agonist (Bromocriptine, parlodel, cabergoline, dostinex)
- over 10mm, DA agonist or transphenoidal resection or craniotomy = to prevent optic chiasm compression leading to bitemporal hemianopia
What to do if someone does not bleed , 2ndary amenorrhea
- TSH and prolactin test
- If both normal do Progesterone challenge test
- If - progesterone challenge do estrogen /progesterone challenge
- If + E/P challenge = check FSH and LH levels
- High LH/FSH = ovary problem
Normal or low LH/FSH = HPO problem order MRI
Progesterone challenge test
- Bleeding occurs with progesterone given = Normogonadotropic Hypogonadism (PCOS)
- No bleeding with Progesterone given = low E or outflow problem
Estrogen/Progesterone challenge
- Bleeding occurs when given P and E = HPO axis problem or ovaries (high FSH + LH = hypergonadotropic Hypogonadism, ovary problem) ( normal or low FSH +LH = hypodonadotropic Hypogonadism , HPO axis problem)
- No bleeding = out flow problem
PCOS reason you dont bleed
You have a bunch of follicles that are made and never ovulate = low Progesterone levels
Asherman syndrome
- DX
- What
- D&C can cause this
2. Scar tissue inside uterus preventing menstruation from coming out
Cervical Stenosis
- How
- What
- Elderly , low E , or cervical lacerations
2. Narrowing of cervix blood cant come out
Nonclassic Conenital Adrenal Hyperplasia
Elevated 17-hydroxyprogesterone
= hirsutism, acne, menstrual irregularities
Adrenal Androgen secreting tumor
DHEA - S over 7000 so high
PCOS can be caused by what tumor
Sertoli-Leydig Tumor secreating Testosterone
PCOS
- SX
- Associated with
- DX
- Leading cause of anovulatory infertility, acne, obesity, hair, sleep probs
- Insulin insensitivity, high insulin + high androgens = low sex hormone binding globulins (SHBG) = higher circulating testosterone **
- 2/3 needed : no/ or not as frequent bleeding, sx of hyperandrogenism (LH 2 : 1 FSH),
US many small cysts
PCOS reason for anovulation
High LH causing tromp and theca cells stimulation = androgen excess stimulating adipose tissue to secrete E = increases LH
PCOS high labs + risk of
- High insulin, LH, testosterone
2. Endometrial cancer
PCOS TX
- OCP, lower LH/FSH = increase SHGB
- Weight low 10lb
- Induce ovulation = clomiphene citrate
- Laser burn stroma
- Spironoactone = competitive binding on Testosterone Rs, lower T
High FSH and high LH at 51 yo and 40yo
Hypergonadotropic Hypogonadism
- Menopause average age 51yo = postmenopausal ovarian failure
- 40yo = premature ovarian failure
- Can happen to people who have had mumps
LOW FSH And LH what do you do and what can be cause
Hypogonadotropic Hypogonadism
- MRI of head to check HPO axis
- Normal MRI = anorexia, chronic illness (DM, IBD, depression, renal deficiency), Sheehan’s syndrome destruction of Pituitary
Hirsutism vs virilization
- H = hair patterns growing like male on female , usually from T —> DIEA more potent
- V : genitals and body is male like in female, excessive androgen
Hyperandrogenism labs you get
- 17-hydroxyprogesterone (CAD high)
- urine cortisol (Cushing)
- Prolactin + TSH
- Glucose, lipid,
- Testosterone (ovarian androgen making tumor)+ DHEA levels (adrenal androgen making tumor)
- Polymenorrhea
- Oligomenorrhea
- Menorrhagia
- Metrorrhagia
- Menometrorrhagia
- Intermittent bleeding
- Polymenorrhea : less then 21 day cycles
- Oligomenorrhea : more then 35 day cycles, less then 6 months
- Menorrhagia : heavy bleeding more then 7 days of 80mL
- Metrorrhagia : irregular uterine bleeding
- Menometrorrhagia : heavy and irregular bleeding
- Intermittent bleeding : some spotting at ovulation for 1-2 days
PALM is what
Structural causes of abnormal bleeding
- P : Polyp
- A : Adenomyosis
- L : Leiomyoma
- M : malignancy or hyperplasia
COEIN is what
Non-structural reasons for abnormal uterine bleeding
- C : Coagulopathy
- O : Ovulatory Dysfunction (PCOS)
- E : Endometrial problem (endometriosis , infection)
- I : Iatrogenic (IUD, IUS ,Hs)
- N : Not yet classified
Imaging done for endometrium
All around thickness = endometrial biopsy
Lesion or polyp to remove = hyperoscopy for visualization
Massive bleeding hat to give
IV Estrogen, Mirena or OCP
