Puberty & Menstrual Disorders Flashcards
1
Q
Puberty definition
A
onset of sexual maturation
- neuroendocrine and physiologic changes
- includes:
- ability to ovulate and menstruate
- fertility
- growth spurt
- development of secondary sexual characteristics
2
Q
age of onset of puberty in girls
A
ages 8-9 w/ thelarche (breast development)
obese mature earlier d/t leptin hormone and gonadotropin secretion
3
Q
Biological Factors of Puberty
A
HPG axis, CNS, endocrine system
- extrahypothalamic factors- cause hypothalamus to secrete gonadotropin-releasing hormone (GnRH) ->
- GnRH stimulates anterior pituitary to release gonadotropins: FSH and LH ->
- FSH/LH stimulate ovaries to release sex hormones ->
- paracrine (regional/local) sex hormones - inhibin, activin, follistatin - influence +/- feedback loops for HPG axis
4
Q
Order of Puberty*
A
- Adrenarche
- Gonadarche
- Thelarche
- Pubarche
- Menarche
5
Q
Adrenarche
A
increased production of adrenal androgens
- occurs w/ regeneration of zona reticularis in adrenal cortex
- usually age 6-8
- starts process, occurs before visible phenotypic changes
6
Q
Gonadarche
A
gonadal maturation
- activation of H-P-gonadal axis (GnRH secretion stimulating AP production of LH/FSH causing ovaries to produce estrogen)
- around age 8
7
Q
Thelarche
A
breast development
- usually 1st phenotypic sign of puberty (breast buds)
- usually age 9
- d/t increased estrogen levels
8
Q
Pubarche
A
pubic and axillary hair development
- usually age 11
9
Q
Menarche
A
onset of menstruation
- avg. is age 12-13 or 2.5 years after breast bud development
- usually irregular for first 1-2 years (anovulatory cycles)
10
Q
when is female puberty complete
A
first ovulatory menstrual period - when capable of reproduction
11
Q
average age of female growth spurt
A
age 12
- about 9 cm per year
- d/t direct affect of sex steroids on epiphyseal growth and GH secretion from anterior pituitary (to all tissues)
12
Q
length of development of
secondary sex characteristics and linear growth
A
4.5 years (range of 1.5-6 years)
13
Q
Marshall and Tanner
classification of breast and pubic hair development
A
I - prepubertal stage fine vellus hair
II - growth of sparse straight hair along labia
III - increase in hair, darker and curlier
IV - hair resembles adult pubic hair, escutcheon covers smaller area
V - hair increases in volume and speads to medial thigh in characteristic female configuration
14
Q
2 abnormalities of reproductive tract development
A
- androgen insensitivity
- male genotype but female phenotype
- testes palpable in labia majora
- absence of cervix, uterus, and ovaries
- abnormal cell migration in mullerian ducts during development
- uterine abnormalities
- trouble becoming pregnant or carrying baby to term
15
Q
Precocious Puberty
(definition and MCC*)
A
- development of secondary sex characteristics
- before age 8 in girls (9 in boys)
- taller than others as children but shorter as adults d/t premature fusion of long bone epiphyses
- idiopathic MCC
16
Q
2 types of prococious puberty
A
- heterosexual
- something causing hormone surge: virilizing neoplasms, congenital adrenal hyperplasia, or exposure to exogenous androgens
- isosexual
- incomplete, complete, pseudosexual
17
Q
Complete Isosexual Precocious Puberty
A
full secondary sex characteristics
and increased levels of sex steroids
18
Q
Incomplete Isosexual Precocious Puberty
A
early appearance of a single secondary sexual characteristic
(thelarche, adrenarche, pubarche)
19
Q
True Isosexual Precocisous Puberty
A
premature activation of hypothalamic-pituitary-gonadal system
- 75% constitutional, 10% CNS disorder (include MRI)
- Dx:
- GnRH challenge- see rise in LH equivalent to normal girls in puberty
20
Q
Pseudosexual Isosexual Precocious Puberty
A
elevated estrogen levels cause sexual maturation WITHOUT activation of hypothalamic-pituitary axis
(something else creating estrogen)
- GnRH stimulation test does not induce pubertal gonadotropin levels
- examples**
- ovarian or adrenal neoplasm
- exogenous estrogen exposure
- advanced hypothyroidism
- McCune-Albright syndrome
- sexual precocity, cystic bone defects, cafe au laits
- Peutz-Jeghers syndrome
- GI tracts polyps, mucocutaneous pigmentation
21
Q
Causes and Tx of True Isosexual Precocious Puberty
A
75% constitutional or idiopathic
- Tx: GnRH agonist therapy
- need to prevent accelerated epiphysial fusion (or <50% reach 5ft tall)
- final stature determined by chronological age at dx and initiation of tx
- <6 y/o- final height increases by 2-4%
- >6 y/o- final height not affected
22
Q
2 definitions of delayed puberty
(more common than precocious)
A
- secondary sex characteristics have not appeared by age 13 in girls
- no menarche by age 15 or 16
23
Q
Causes of delayed puberty** and Tx
A
- physiologic factors
- normal hormonal or HPG axis maturation delay
- cause 95% of those w/ delayed puberty
- disruption of HPG axis
- 5% of delayed puberty
- Tx: hormonal replacement
24
Q
establishing ovarian cycle
A
- before puberty- ovaries secrete small amounts of estrogen -> inhibits hypothalamic release of GnRH
- as puberty nears- if leptin levels adequate, hypothalamus becomes less estrogen sensitive -> GnRH released -> FSH/LH released by pituitary -> act on ovaries
- events continue until adult cyclic pattern achieved- occurrence of menarche is last step in development
25
Cause of Uterine (menstrual) Cycle\*\*
cyclic changes in _endometrium_
d/t fluctuating ovarian hormone levels
26
3 Phases of Uterine (menstrual) Cycle
1. menstrual phase: days 1-5
2. proliferative (preovulatory) phase: days 6-14
3. secretory (postovulatory) phase: days 15-28
27
Characteristics of Menstrual Phase
* days 1-5
* ovarian hormones at lowest levels
* gonadotropin levels begin to rise
* stratum functionalis detaches from uterine wall and is shed
* menstrual flow of blood and tissue lasts 3-5 days
* by day 5 growing ovarian follicles start to produce more estrogen
28
Characteristics of Proliferative (preovulatory) Phase
* days 6-14
* rising estrogen levels prompt generation of new stratum functionalis layer
* as layer thickens glands enlarge and spiral arteries increase in number
* estrogen also increases synthesis of progesterone receptors in endometrium
* thins out normally thick, sticky cervical mucus - facilitates sperm passage
* ovulation occurs at end of proliferative phase on day 14
29
Characteristics of Ssecretory (postovulatory) Phase
* days 15-28
* **phase is most consistent\*\*** (best phase to use and work backwards for family planning)
* endometrium prepares for embryo to implant
* rising progesterone from **corpus luteum** prompt:
* functional layer to become a secretory mucosa
* endometrial glands to enlarge and secrete nutrients into uterine cavity
* thickened mucus to form cervical mucus plug - blocks entry of more sperm, pathogens, debris
30
What happens if fertilization does not occur
during secretory (postovulatory) phase
* corpus luteum degenerates toward end of secretory phase - progesterone levels fall
* causes spiral arteries to kink and spasm
* endometrial cells die and glands regress
* spiral arteries constrict again then relax and open wide - creates rush of blood into weakened capillary beds
* blood vessels fragment and functional layer sloughs off
- uterine cycle starts all over again on 1st day of menstruation
31
What regulates events of ovarian cycle
fluctuating levels of ovarian hormones
(estrogens and progesterone)
high estrogen levels responsible for pituitary gonadotropins surge:
follicle-stimulating hormone (FSH) and luteininzing hormone (LH)
32
3 phases of ovarian cycles and characteristics
1. menstrual - functional layer of endometrium is shed
2. proliferative - functional layer of endometrium is rebuilt
3. secretory - begins immediately after ovulation, enrichment of blood supply and glandular secretion of nutrients prepare endometrium to receive the embryo
1 and 2 occur before ovulation = follicular phase
3 = luteal phase
33
regular bleeding
avg every 28d (range 21-35), lasts 3-5d, avg 30-50mL
normal menses
34
heavy bleeding (\>80mL) or prolonged bleeding (\>7d)
menses at regular intervals
menorrhagia
35
light flow (\<30mL)
menses at regular intervals
hypomenorrhea
36
any bleeding between normal menses
| (usually lighter than normal bleeding)
metrorrhagia
37
excessive or prolonged bleeding at irregular intervals
menometrorrhagia
38
irregular cycles \>35d apart
oligomenorrhea
39
frequent regular cycles but \<21d apart
polymenorrhea
40
no menses by age 16 w/ secondary sexual characteristics
or
no menses by age 14 w/ absent secondary sexual characteristics
amenorrhea
41
idiopathic heavy and/or irregular bleeding w/ no ID'd cause
(concerning if older)
dysfunctional uterine bleeding
42
pain and cramping during menstrual cycle
w/ absence of pain between cycles
dysmenorrhea
43
2 types of dysmenorrhea and Tx\*\*
1. Primary (50% of adolescents)
* painful menstruation associated w/ prostaglandin release in ovulatory cycles
* no identifiable cause - dx of exclusion
2. Secondary
* painful menstruation related to pelvic pathologic condition any time in menstrual cycle (endometriosis, pelvic inflammation, adenomyosis/fibroid tumors, ovarian cysts, pelvic congestion)
* later in life
* Tx
* first line: NSAIDs taken at onset of menses for 1-3d then PRN
* second line: OCPs - decrease prostaglandin release
* other: exercise, heating pad, ab patches, massage, acupuncture, hypnosis, TENS unit
44
when to work up amenorrhea
failure of menarche and _absence of menstruation_ by age 16
or
within 4 years of thelarche
or
if no thelarche by age 14
(primary vs. secondary - 50% 1' d/t chromosomal disorders)
45
MCC oligomenorrhea
irregular menstrual cycles \>35d apart
* PCOS
* chronic anovulation
* pregnancy
46
Primary vs. Secondary Amenorrhea
* Primary
* Compartments I-IV
* I - disorders of outflow tract or uterine target organ
* II - disorders of ovary
* III - disorders of anterior pituitary
* IV - disorders of CNS or hypothelamic factors
* text
* sexual infantilism
* breast development and Mullerian anomoalies (ductal problems)
* breast development and normal Mullerian structures
* Tx
* correction of underlying factors
* hormone replacement
* Secondary (absence of menstruation 3+ cycles or 6m w/ previous menstruation)
* causes:
* Pregnancy\*\* (MCC)
* anovulation- lack of ovulation
* hyperprolactinemia- overproduction of prolactin by pituititary
* dramatic weight loss
* malnutrition/excessive exercise
* hypothyroidism
* Polycystic ovarian syndrome
* common during adolescence, perimenopause, lactation
* clinical manifestations
* infertility, vasomotor flushes, vaginal atrophy, acne, osteopenia, hirsutism
* Tx
* replace deficient hormones (estrogen, thyroid, glucocoriticoids, gonadotropins)
* correct underlying pathologic condition
47
Effect of androgens
convert vellus hair to terminal hair at puberty
* vellus - soft non-pigmented hair that covers body
* terminal - thick and pigmented covering scalp, axilla, pubic
excess androgens increase terminal hair (or increase in 5-alpha reductase which converts testosterone to dihydrotestosterone)
48
elevated circulating male hormones in women
hyperandrogenism
49
increase in terminal hair on face, chest, back, lower abdomen and inner thighs of a woman
hirsutism
50
development of male features
(deep voice, frontal balding, incr. muscle, clitoromegaly, breast atrophy, male body habitus
virilization
51
2 types of ovarian disorders
* Non-neoplastic
* polycycstic ovarian syndrome- common
* hyperandrogenic insulin resistance/acanthosis nigricans syndrome (HAIR-AN)- uncommon
* thecan lutein cysts (usually during molar pregnancy, multiple pregnancies, or infertility tx)
* Neoplastic
* functional ovarian tumors (produce varying amounts of androgens)
* Sertoli-Leydig cell
* Leydig cell
* Gonadoblasoma
* non-functional ovarian tumors (don't secrete androgens but stimulate adjacent ovarian stroma which can lead to increased andogen production)
* cystic teratomas
* Brenner tumors
* serous cystadenomas
* Krukenberg tumors
52
Signs of Polycystic Ovary Syndrome
| (need 2 for PCOS)
* oligoovulation or anovulation
* elevated levels of androgens
* clinical signs of hyperandrogenism and polycystic ovaries
* multifactoral (leading cause of infertility in US)
* hyperandrogenic state
* hyperinsulinism
* dysfunction of follicle development
* polycystic ovaries DO NOT have to be present / PRESENCE ALONE does not establish diagnosis
53
Risk with PCOS\*\*
3x increased chance of uterine cancer later in life
54
PCOS S/s and Tx
* S/s
* dysfunctional bleeding or amenorrhea
* hirsutism
* acne
* infertility
* Tx
* **first line: Metformin**
* combined oral contraceptives, antiandrogens, fertility drugs
* weight loss
55
excess production of cortisol
Cushing Syndrome (adrenal disorder)
* excess cortisol regardless of cause (Cushing dz refers to pituitary adenoma hypersecreting ACTH)
* obesity, moon faces, HTN, easy bruising, thinning skin, muscle wasting of upper legs/arms, purple abdominal striae, impaired glucose tolerance, risk of osteoporosis
56
enzyme deficiencies involved in steriodogenesis
(usually shunt intermediates into androgen pathway)
congenital adrenal hyperplasia
(adrenal disorder)
* can't synthesize cortisol or mineralcortisol
* salt wasting and adrenal insufficiency at birth
* females w/ ambiguous genitalia d/t androgen excess
* 21-alpha hydroxylase deficiency MC type
* usually diagnosed early in young
57
cyclic physical, psychological (mental/emotional), behavioral changes that impair interpersonal relationships or usual activites
S/s and Tx
Prementrual Syndrome / Premenstrual Dysphoric Disorder
(PMS/PMDD)
* occur in luteal (postovulatory) phase
* depression, anger, irritability, fatigue
* HA, bloating, weight gain, breast tenderness
* 8/10 w/ mild symptoms, 5-10% severe
* Tx
* hormonal cycle regulation
* SSRIs, antidepressants, counseling
58
Criteria of PMDD
At least 5, including 1 of first 4
* Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
* Marked anxiety, tension, feelings of being “keyed up” or “on edge”
* Marked affective lability (eg, feeling suddenly sad or tearful or experiencing increased sensitivity to rejection)
* Persistent and marked anger or irritability or increased interpersonal conflicts
* Decreased interest in usual activities (eg, work, school, friends, and hobbies)
* Subjective sense of difficulty in concentrating
* Lethargy, easy fatigability, or marked lack of energy
* Marked change in appetite, overeating, or specific food cravings
* Hypersomnia or insomnia
* A subjective sense of being overwhelmed or out of control
* Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain
59
Criteria for PMS
Only 1 symptom but limited to luteal phase and ceases at start of menstruation or a couple days later
* psychological symptoms
* weight gain, hand swelling, breast tenderness, poor concentration, aches and pains, change in appetite, sleep disturbance
60
PMS/PMDD work-up
* no specific labs
* r/o other disorders w/ similar symptoms (TSH lab, CBC anemia)
* look for Sx during luteal phase
* worsening disorders: migraine, seizures, asthma, allergies, genital herpes
* psychologic disorders
* depression, anxiety, panic d/o, bulemia, substance abuse, mania, chronic fatigue syndrome, fibromyalgia, IBS
* **must occur 2 months in luteal phase and cease w/ menstruation**
61
Conservative / EBR Low-risk Tx for PMS
* Diet
* reduce/eliminate salt, chocolate, caffeine, alcohol
* small frequent complex carb meals
* vitamins and minerals in moderation
* Moderate regular aerobic activity
* Stress reduction
* Self-help groups or books
* Vit B6, Ca++, Mg+, Optivate, Vit E, Spirolactone, Bromocriptine
62
Meds for PMDD/refractory PMS
* first line:
* antidepressants (luteal or continuous)
* citalopram, clomipramine, fluoxetine, paroxetine, sertraline, venlafaxine
* second-line:
* anxiolytics (luteal only)
* alprazolam, buspirone
