Puberty & Disorders Of Dev And Menstrual Disorders (9) Flashcards
What’s stored in the Post Pituitary?
Oxytocin
Vasopressin (ADH)
What are the phases of the ovarian cycle?
Follicular (estrogen dep)
Luteal (progesterone release)
Decreasing levels of estradiol and progesterone from regressing corpus luteum of preceding cycle does what?
Initiates inc in FSH
- FSH stimulates follicular growth and estradiol secretion
What are the 5 peptides that affect the reproductive cycle?
GnRH -> FSH and LH TRH -> TSH SRIF (somatostatin) inh GH CRF/H -> ACTH PIF (dopamine) inh prolactin release
Where is GnRH synthesized? What does it stimulate? Estradiol usually inh FSH and LH, when doesn’t it?
Arcuate nucleus
Gonadotrophs and FSH/LH synthesis
When high enough levels of estradiol -> LH surge
Where does lots of progesterone present/occur in the menstrual cycle?
Prior to ovulation d/t unreuptured luteinizing graafian follicle, Corpus luteum (max 5-7 days after ovulation)
Describe follicular development:
Primordial follicles dev, differentiate, and mature > graafian follicle > graafian follicle ruptures releasing ovum > ruptured follicle produces corpus luteum
Preovulatory surge of LH causes what?
Biochemical and structural changes resulting in ovulation
What undergoes luteinization after ovulation?
Granulosa cells of ruptured follicle -> corpus luteum (produces lots of progesterone and some estradiol)
Normal functioning life span of corpus luteum is what? What’s it replaced by?
9-10 days
Corpus albicans
What zones is the endometrium divided into? What are some features of these zones?
Outer portion: functionalis
- undergoes cyclic changes during menstrual cycle
- sloughed off at menstruation
- contains spiral aa
Inner portion: basalis
- remains relatively unchanged during each cycle
- houses stem cells to renew functionalis
- basal aa
What are the stages of the histo-phys changes of the endometrium?
- Menstrual phase
- Proliferative/estrogenic phase
- Secretory/progestational phase
Describe the menstrual phase:
Only portion of cycle visualized externally
First day of menstruation is known as cycle day 1
During this phase: disintegration of endometrial glands and stroma, sloughing of functionalis layer, compression of basalis layer
What does one see histologically in the proliferative/estrogenic stage of the endometrium cycle?
Inc length o spiral aa + numerous mitoses
Endometrial growth
What does one see histologically in the secretory/progestational stage of the endometrium cycle?
Progesterone -> Mucous/glycogen secretion
Stroma is edematous
Mitoses are rare
Endometrial lining reaches max thickness
What day does the corpus luteum begin to regress?
Day 23 if conception doesn’t occur
What is imperative in regulating menstruation?
Intact coagulation pathway
Allows inured vessels to be repaired rapidly after menstruation
What’s the median age of menarche? Occurs how many years after thelarche/breast budding? How many females should have menarche by 15?
12.43
3 years
98%
Define primary amenorrhea:
No menstruation by 13 w/o secondary sex dev
No menstruation by 15 with secondary sexual dev
Can cycles be irregular during their first year or so?
Yes, often are, 21-45 days
By third year they’re normalized (21-35 days), 28+/- 7 days
What’s the average mean blood loss per menstrual period? How often are pads changed? What amount is associated w/ anemia?
30cc
3-6 times
80cc, pad change every 1-2h
Do obese kids have earlier onsets of puberty? Malnourished?
Yes
No, later onset
What hormone may stimulate puberty in females?
Leptin around 106 lbs
What’s the peak number of oocytes and when is it reached?
6-7 million
16-20w during gestation
What’s the hypothalamic-pituitary system regulating gonadotropin release called?
Gonadostat
What changes from 8-11 are associated w/ puberty from a biochemical standpoint? 11 onward?
Inc serum DHEA and androsenedione
- zona reticularis begins producing andregens (adrenarch)
- axillary and pubic hair (pubarche)
Gonadostat loses sensitivity
- sleep induces GnRH secretions
- GnRH -> sex steroid production
What does thelarche mean? Why is it significant? What are some features?
Breast dev
First physical sign of puberty
Requires estrogen
Unilateral dev in first 6 months not uncommon
What does axially and pubic hair growth require?
Androgens
What does menarche require?
Pulsatile GnRH > FSH and LH > estrogen and progesterone
What’s the order of things in puberty? (TAPMM)
Thelarche Adrenarche Peak height velocity Menarche Mature sexual hair and breasts
What’s Tanner staging used for?
Staging normal female pubertal dev
What is precocious puberty?
Early dev of sex characteristics
- 8yo for girls
- 9yo for boys
More likely in girls
75% of cases idiopathyic
Leads to premature fusion of long bones of the epephyses
What are the 2 subgroups of precocious puberty?
Heterosexual and isosexual
Heterosexual is the dev of secondary sex characteristics opposite expected
- virulizing neoplasms, congenital adrenal hyperplasia, expsure to exogenous androgens
Isosexual: sex characteristic dev that’s appropriate for individuals phenotype
- 10% organic brain dx, dg w/ MRI of head, pt p/w neurologic sxs
- 75% idiopathic or constitutional, dg w/ administration of exogenous GnRH looking from LH rise
What’s the common androgen secreting neoplasm of childhood?
Sertoli-Leydig cell tumor
What’s the most common defect in Congenital adrenal hyperplasia? What’s the most severe form of CAH? What’s a late onset form?
21-hydroxylase causing excessive androgen production
Classical: females born w/ ambiguous genitalia
Non-classical: premature pubarche, PCOS-like disorder
What’s the tx for isosexual precocious puberty?
GnRH agonist (leuprolide acetate) - suppresses FSH and LH release
What is psuedoisosexul precocity?
Inc estrogen levels w/ sexual characteristic maturation w/o activation of the HPO axis (d/t an estrogen-excreting tumor)
- McCune-Albright syndrome (polyostotic fibrous dysplasia): cafe au lait spots, adrenal hypercortisolism, bone defects
- Peutz-Jeghers: sx cord tumor that secretes estrogen, GI polyposis and pigmentation
What causes hypergonadotropic hypogonadism?
Gonadal dysgenesis (Turner syndrome)
Difference between primary and secondary amenorrhea?
Primary: no menstruation by 15 w/ dev sexual characteristics or 13 w/ no dev of sec sex characteristics
Secondary: pt w/ prior menses as absent menses for > 6 months
What’s the most common cause of primary amenorrhea?
Extreme exercise, constitutional (physiologic delay) is the most common
Kallman syndrome is?
KAL gene mutation prevents migration of GnRH neurons into hypothalamus
Turner’s syndrome is what? What are some signs?
Most common form of female gonadal dysgenesis, majority will show no signs of sec sex char
Webbing o the neck (pterygium colli), broad flat chest, short stature, streaked ovaries (functionless tissue), coarctation of the atorta
Mullerian dysgenesis/agenesis is also associated w/ what anatomical findings? What’s the karyotype? What the abnormally high hormone?
Renal abnormalities/urinary system
No sexual hair
Absent uterus and upper vagina (mullerian dysgenesis/agenesis)
46XY, testosterone
Whats Maryer-RKH syndrome?
Absent uterus and upper vagina
Normal external features
Normal testosterone
Karyotype, 46XX
What’s a normal prolactin level? What causes hyperprolactinoma < 100 ng/mL? Hyperprolactinoma > 100 ng/mL?
< 20 ng/mL
Ectopic production (renal cell carcinoma), breast feeding or stimulation, excessive exercise, hypothyroidism, meds (OCs)
Pituitary adenoma, Empty sella syndrome
What’s the size of a macroadenoma vs microadenoma? Tx?
Micro < 10mm
Macro > 10mm
Bromocriptine/Parlodel
Amenorrhea w/ normal TSH and prolactin, what’s done next? How are results determined? What’s done after?
Progesterone challenge test
Positive = positive bleeding, PCOS most common etiology Negative = no bleeding, inadequate estrogenization or outflow abnormality
Estrogen/progesterone challenge test (neg = outflow tract obstruction, postive = estrogen prob)
Asherman syndrome causes? Due to?
Amenorrhea d/t scar tissue in the uterus from ablation procedures or a spontaneous abortion
What are the positive PCT: normogonadotropic amenorrhea w/ hyperandrogenism issues associated w/?
Adrenal disorders: non-classic congenital adrenal hyperplasia, Cushings, Adrenal androgen secreting tumor (DHEA > 7000 ng)
Ovarian disorders: PCOS, androgen-secreting tumor (sertoli-leydig tumor)
Exogenous
What’s the leading cause of female anovulatory infertility? What 3 criteria are involved in its diagnosis? What’re other common findings associated w/ this?
PCOS
Oligomenorrhea (less) or amenorrhea, biochemical or clinical signs of hyperandrogenism (LH to FSH is 2:1), ultrasound positive or small cysts on cortex of ovary
Insulin sensitivity is decreased -> insulin hypersecretion, reduced hepatic production of sex hormone binding globulins (SHBG) -> inc circulating testosterone
What’s secreted in excess in PCOS? What’s not?
Estrogen
Progesterone
What are some features of PCOS?
Anovulation, hyperandrognism, hirsuitism, acne, menstrual dysfunction, hyperinsulinemia, LH hypersecretion, elevated testosterone, obesity, sleep disorders, acanthosis nigricans, chronic anovulation (inc risk for endometrial CA)
“Ring of pearls” on US associated w/?
PCOS
Tx for PCOS?
Wt loss (10% wt loss can re-stimulate cycles) OCs Clomiphene citrate Spironolactone Metformin
What do you test for to confirm CAH?
17-hydroxyprogesterone levels (which builds up d/t lack of 21-hydroxylase enzyme)
Define primary amenorrhea.
No menstruation by 13 yo w/o sec sexual characteristics OR no menstruation by 15 WITH sec sexual characteristics
Define secondary amenorrhea.
Absence of menses for 6 months or more
Define polymenorrhea.
Abnormally freq menses at intervals < 21 days
Define monorrhagia (hypermenorrhea).
Excessive and/or prolonged bleeding (> 80mL and > 7 days) occurring at normal intervals
Define metrorrhagia.
Irregular episodes of uterine bleeding
Define menometrorrhagia.
Heavy and irregular uterine bleeding
Deine Intermenstrual bleeding.
Scant bleeding at ovulation or 1 or 2 days
Define Oligomenorrhea.
Menstrual cycles occurring > 35 days but less then 6 months
DUB (dysfunctional uterine bleeding) is caused by what? When does it occur?
Aberrations in the HPO axis causing anovulation
Around years of menarche (11-1) or perimenopause (45-50)
What’s the PALM (structural causes)-COEIN (non-structural causes) classification system for abnormal bleeding in reproductive-aged women?
P: polyp (AUB-P)
A: adenomyosis (AUB-A), boggy uterus
L: leiomyoma (AUB-L), subserosal, interstitial, submucosal
M: malignancy and hyperplasia (AUB-M)
C: coagulopathy (AUB-C), vWD
O: ovulatory dysfunction (AUB-O), unpredictable menses
E: endometrial (AUB-E), inection
I: iatrogenic (AUB-I), IUD/S, exogenous hormones
N: not yet classified (AUB-N)
