Puberty, Menstrual Cycle and Menopause

Question 1

What is the order of puberty?

Answer 1

Adrenarche (age 6-8) - adrenal gland secretes sex steroid hormones
Gonadarche (age 8) - pulsatile GnRH production from hypothalamus –> pulsatile LH and FSH secretion from ant pit
Thelarche (age 10) = breast bud development
Pubarche (age 11) = pubic and axillary hair due to circulating androgens
Menarche (age 12-13) = 2.5 years after thelarche. Menstrual cycle typically irregular for first 1-2 years, requires adequate body fat

Question 2

Define precocious puberty

Answer 2

Pubarche or thelarche before age 7 in Caucasians, and age 6 in AA

Question 3

Define delayed puberty

Answer 3

Absent or incomplete breast development by age 12

Question 4

What are the phases of the menstrual cycle?

Answer 4

Follicular and luteal phase (ovary)

Proliferative and secretory phase (endometrium)

Question 5

What occurs during the follicular phase?

Answer 5

Increasing FSH = follicular development (5-15)
Dominant follicule develops and matures, produces estrogen (from theca cells producing androstenedione from LH and granulosa cells making estradiol from FSH),
Rising estrogen feedsback to decrease FSH, but the dominant follicle is protected by upregulating FSH receptors

Question 6

What occurs during ovulation?

Answer 6

Estrogen levels surge, which causes a LH spike

LH triggers meiosis in the oocyte and induces progesterone and prostaglandin production = rupture

Question 7

When must fertilization take place?

Answer 7

24 hours within ovulation or it degenerates

Question 8

What occurs during the luteal phase?

Answer 8

Granulosa and theca interna cells become corpus luteum which secretes estrogen and progesterone to prepare endometrium for implantation

If fertilization occurs, then beta-hcg produced maintains corpus luteum
If not, then corpus luteum degenerates

Question 9

When does ovulation generally occur?

Answer 9

14 days prior to menses (which is the luteal/secretory phase)
The follicular and luteal phases can be variable

Question 10

Why does menses occur?

Answer 10

The decrease in estrogen and progesterone from degenerating corpus luteum
Then FSH begins to rise which restarts the follicular phase

Question 11

What is perimenopause?

Answer 11

The period beginning 2-8 years before menopause where menses becomes irregular

inhibin B secretion from granulosa cells decrease = FSH rises and progesterone decreases

Estradiol is preserved until late perimenopause

Question 12

Define menopause

Answer 12

12 months of amenorrhea after final menstrual period

average age of 51

Question 13

What are the hormonal changes and symptoms during menopause?

Answer 13

Decreases estrogen, increased FSH

hot flashes, night sweats, mood swings, vaginal dryness, osteoporosis

Question 14

What is the mnemonic for menopause?

Answer 14

FSH>40IU/L
Flushes/forgetfulness
Sweats, sadness, stroke, skeletal changes, skin changes, sexual dysfunction
Headaches, heart disease
Insomnia
Urinary symptoms (stress and urge), urogenital atrophy
Libido decreases

Question 15

What are 2 important long-term consequences of menopause?

Answer 15

Increased risk for CAD
Osteoporosis

Estrogen is protective for both

Question 16

How can menopausal symptoms be treated?

What is the danger to that?

Answer 16

Hormone replacement therapy
Estrogen treats the symptoms, but unopposed estrogen can lead to endometrial hyperplasia = need to give progestins too to prevent endometrial cancer

In women without uterus, can just give estrogen

Question 17

HRT can be protective for which cancer?

Answer 17

Colorectal

Question 18

HRT has what adverse events?

Answer 18

increased CAD, DVTs, and PEs

increased risk for invasive breast cancer

Question 19

What are current guidelines for HRT/ERT?

Answer 19

Treatment for menopausal symptoms at the lowest effective dose for the shortest period of time

Question 20

What are the contraindications for HRT?

Answer 20

Chronic liver disease, pregnancy, known estrogen-dependent neoplasm (breast, ovary, uterus), history of thromboembolic events, undiagnosed vaginal bleeding

Question 21

When should post-menopausal women get DEXA scan?

Answer 21

Age 65

Higher risk (thin, caucasian, asian, smoker, fhx, fractures) should get it at 60 or age of menopause

repeat 2-3 years