Puberty, menstrual cycle, menopause Flashcards
Order of puberty
- Adrenarche/gonadarche (age 6-8/8)- adrenarche is when the adrenal gland starts regenerating its zona reticularis for sex hormone synth
- Accelerated growth (age 9-10)
- Thelarche (age 10)- breast development
- Pubarche (age 11)
- Menarche (age 12-13 OR 2.5 years after the development of breast buds)
*Thelarche often comes after pubarche in AA girls
First phenotypic sign of puberty
Breat buds aka thelarche
What causes accelerated growth?
- Sex steroids DIRECTLY affect epiphyseal growth
- Sex steroids CAUSE the release of growth hormone
What causes breast development?
inc levels of circulating ESTROGEN
What causes pubic/axillary hair development?
Androgens
Precocious puberty
Before 6 in caucasian girls
Before 7 in AA girls
Delayed puberty
Absence of incomplete breast development by age 12
Initial workup for precocious AND delayed puberty?
H & P, hormone assessment, bone age determination
What happens during the follicular phase?
FSH inc stims the growth of 5-15 primordial follicles, 1 becomes the dominant follicle which produces ESTROGEN (and will eventually be released during ovulation).
How is estrogen produced by the follicle?
LH causes theca interna cells make androstenedione
FSH stims the granulosa cells to convert the androstenedione to estradiol
What does the LH surge do?
Triggers the resumption of meiosis in the oocyte.
Induces production of progesterone and prostaglandins in the follicle.
Causes the RUPTURE of the follicular wall with release of ovum.
What makes HCG in the first 8 weeks of gestation?
The trophoblast. It maintains the corpus luteum so that IT can produce E&P to support the endometrial growth.
What makes HCG after 8-10 weeks of gestation?
The placenta
Normal range for menstrual cycle?
24 days up to 35 days
What happens to hormones during menstrual cycle?
FSH gradually rises again
E&P levels drop
When can perimenopause start?
2-8 years before menopause
Pathyophysiology of menopause?
Low number of follicles left, so there aren’t many to secrete inhibin B which normally downregulates FSH. FSH levels RISE, progesterone levels low.
Menopause is defined as
12 months without a period
Average age of menopause in USA
51 yrs
Premature ovarian insufficiency?
Menopause before age 40
Risk factors for early menopause
- Smoking
- Short menstrual cycles
- Nulliparity
- TYPE 1 DIABETES
- Family hx of early meno
Slightly earlier in tubal ligation & hysterectomy pts
Symptoms of menopause
Hot flashes, NIGHT SWEATS, mood swings, vaginal dryness (vaginal, urethral, cervical atrophy), dyspareunia, dysuria, urinary symptoms, headaches, dec libido
Test to confirm menopause
FSH > 40 IU/L (blood test)
When do symptoms generally disappear
1-2 years after onset (some can take 5 yrs)
What are 2 major systemic affects that a drop in estrogen during menopause can result in?
- Estrogen normally inc HDL and dec LDL so it’s cardioprotective
- Also regulates osteoclastic activity thereby preventing osteoporosis
What is HRT
it’s E&P menopausal therapy for women who STILL HAVE UTERUS
What is ERT
Estrogen only for women who had a hysterectomy and therefore no inc risk of endometrial cancer with estrogen only
Benefits of HRT?
Dec risk of colorectal cancer
Benefits of HRT and ERT?
Prevents osteoporosis, improves vasomotor flushing, atrophy, improves muscle tone, skin
Risks of HRT?
Coronary artery events, DVTs/PEs, risk of invasive breast cancer
Risks of ERT?
Stroke (age-independent), DVTs. NO IMPACT ON HEART ATTACKS.
General rule with hormone replacement therapy?
Shortest dose for shortest amount of time. Basically only 1-5 years.
Contraindications to HRT?
Chronic liver disease Pregnancy Known estrogen-dependent neoplasm Hx of thromboembolic disease Undiagnosed vaginal bleeding
Nonhormonal rx of vasomotor symptoms (hot flashes/night sweats)
Clonidine, SSRIs like Paroxetine, SNRIs like venlafaxine
Gabapentin low-dose
Osteoporosis rx
Vit D and Calcium Bisphosphonates, Calcitonin Raloxifen/tamoxifen Weight bearing exercise
What medications predispose to bone loss?
Levothyroxine, steroids, heparin.
Scan these ladies earlier.
Primary dysmenorrhea
No obvious cause. Possibly from inc levels of endometrial prostaglandin production.
Rx of primary dysmenorrhea
NSAIDs. OCPs second line. Progestin-only ok too.
Secondary dysmenorrhea
Cervical stenosis Pelvic adhesions Adenomyosis Endometriosis Fibroids
Rx of cervical stenosis
Surgical dilation or laminaria.
Delivering vaginally often leads to permanent cure (duh).
Rx of pelvic adhesions
Laparoscopy for dx and rx.
Key to remember about adhesions
NOT VISIBLE on imaging like MRI, CT, U/S.
PMS possible etiology
Serotonin and cyclic change sin ovarian steroids.
They have normal levels of estrogen and progesterone but may have an ABNORMAL RESPONSE to them.
Rx of PMDD
SSRIs, SNRI venlafaxine, the benzo alprazolam (Xanax)
Yaz- has drospirenone, a spironolactone
Exercise and relaxation
Vitamin supplementation
Carb-rich beverages
Definition of abnormal uterine bleeding
Too much or too little
Normal menstrual cycle
21-35 days, 3-5 days long, 30-50mL blood loss
Dysfunctional uterine bleeding
Idiopathic heavy and/or irregular bleeding
Menorrhagia?
MCCs?
Excessive flow- either TOO LONG or TOO MUCH.
Often described as “flooding” or “gushing”.
Fibroids, adenomyosis, endometrial polyps. Evaluate for bleeding disorders as well.
Hypomenorrhea
Regular timing of menses but LIGHT FLOW.
Could be from OCPs, Depo, progestin IUDs
Metrorrhagia
Bleeding BETWEEN menses (usually is lighter)
Menometrorrhagia
Abnormal intervals AND excessive or prolonged bleeding
Oligomenorrhea
MCCs?
Cycles more than 35 days apart.
PCOS, chronic anovulation, pregnancy, thyroid disease
Polymenorrhea?
Less than 21 day cycles.
Tests to do for light or skipped cycles?
Pregnancy test, TSH, PRL, FSH
Tests to do for heavy, frequent, or prolonged cycles?
Pregnancy test, TSH, CBC
Who should get an endometrial biopsy?
Patients over 45 with abnormal uterine bleeding (excessive OR insufficient)
Obese patients with prolonged oligomenorrhea, even if younger than 45.
When is MRI useful in these situations?
To differentiate between fibroids and adenomyosis.
Rx of endometrial hyperplasia?
No atypia: progestin
With atypic: D&C/hysterectomy
In acute hemorrhage from DUB, give what?
IV estrogen
For hemodynamically stable, give high-dose oral estrogens. Or, OCP taper to stabilize endometrium (High to low).
Causes of postmenopauseal bleeding in descending order?
- Vaginal/endometrial atrophy, exogenous estrogens
2. Endometrial cancer, endometrial polyps, endometrial hyperplasia, other
Tests for postmenopausal bleeding
pap smear, high-risk HPV screen, CBC, TSH, prolactin, FSH levels
Pelvic u/s, sonohysterogram, MRI
