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OB/GYN > Puberty & Menstrual Disorders > Flashcards

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
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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

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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
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4
Q

Order of Puberty*

A
  1. Adrenarche
  2. Gonadarche
  3. Thelarche
  4. Pubarche
  5. Menarche
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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
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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
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7
Q

Thelarche

A

breast development

  • usually 1st phenotypic sign of puberty (breast buds)
  • usually age 9
  • d/t increased estrogen levels
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8
Q

Pubarche

A

pubic and axillary hair development

  • usually age 11
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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)
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10
Q

when is female puberty complete

A

first ovulatory menstrual period - when capable of reproduction

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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)
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12
Q

length of development of

secondary sex characteristics and linear growth

A

4.5 years (range of 1.5-6 years)

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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

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14
Q

2 abnormalities of reproductive tract development

A
  1. androgen insensitivity
    • male genotype but female phenotype
    • testes palpable in labia majora
    • absence of cervix, uterus, and ovaries
  2. abnormal cell migration in mullerian ducts during development
    • uterine abnormalities
    • trouble becoming pregnant or carrying baby to term
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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
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16
Q

2 types of prococious puberty

A
  1. heterosexual
    • something causing hormone surge: virilizing neoplasms, congenital adrenal hyperplasia, or exposure to exogenous androgens
  2. isosexual
    • incomplete, complete, pseudosexual
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17
Q

Complete Isosexual Precocious Puberty

A

full secondary sex characteristics

and increased levels of sex steroids

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18
Q

Incomplete Isosexual Precocious Puberty

A

early appearance of a single secondary sexual characteristic

(thelarche, adrenarche, pubarche)

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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
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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
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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
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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
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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
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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
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25
Q

Cause of Uterine (menstrual) Cycle**

A

cyclic changes in endometrium

d/t fluctuating ovarian hormone levels

26
Q

3 Phases of Uterine (menstrual) Cycle

A
  1. menstrual phase: days 1-5
  2. proliferative (preovulatory) phase: days 6-14
  3. secretory (postovulatory) phase: days 15-28
27
Q

Characteristics of Menstrual Phase

A
  • 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
Q

Characteristics of Proliferative (preovulatory) Phase

A
  • 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
Q

Characteristics of Ssecretory (postovulatory) Phase

A
  • 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
Q

What happens if fertilization does not occur

during secretory (postovulatory) phase

A
  • 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
Q

What regulates events of ovarian cycle

A

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
Q

3 phases of ovarian cycles and characteristics

A
  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
Q

regular bleeding

avg every 28d (range 21-35), lasts 3-5d, avg 30-50mL

A

normal menses

34
Q

heavy bleeding (>80mL) or prolonged bleeding (>7d)

menses at regular intervals

A

menorrhagia

35
Q

light flow (<30mL)

menses at regular intervals

A

hypomenorrhea

36
Q

any bleeding between normal menses

(usually lighter than normal bleeding)

A

metrorrhagia

37
Q

excessive or prolonged bleeding at irregular intervals

A

menometrorrhagia

38
Q

irregular cycles >35d apart

A

oligomenorrhea

39
Q

frequent regular cycles but <21d apart

A

polymenorrhea

40
Q

no menses by age 16 w/ secondary sexual characteristics

or

no menses by age 14 w/ absent secondary sexual characteristics

A

amenorrhea

41
Q

idiopathic heavy and/or irregular bleeding w/ no ID’d cause

(concerning if older)

A

dysfunctional uterine bleeding

42
Q

pain and cramping during menstrual cycle

w/ absence of pain between cycles

A

dysmenorrhea

43
Q

2 types of dysmenorrhea and Tx**

A
  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
Q

when to work up amenorrhea

A

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
Q

MCC oligomenorrhea

A

irregular menstrual cycles >35d apart

  • PCOS
  • chronic anovulation
  • pregnancy
46
Q

Primary vs. Secondary Amenorrhea

A
  • 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
Q

Effect of androgens

A

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
Q

elevated circulating male hormones in women

A

hyperandrogenism

49
Q

increase in terminal hair on face, chest, back, lower abdomen and inner thighs of a woman

A

hirsutism

50
Q

development of male features

(deep voice, frontal balding, incr. muscle, clitoromegaly, breast atrophy, male body habitus

A

virilization

51
Q

2 types of ovarian disorders

A
  • 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
Q

Signs of Polycystic Ovary Syndrome

(need 2 for PCOS)

A
  • 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
Q

Risk with PCOS**

A

3x increased chance of uterine cancer later in life

54
Q

PCOS S/s and Tx

A
  • S/s
    • dysfunctional bleeding or amenorrhea
    • hirsutism
    • acne
    • infertility
  • Tx
    • first line: Metformin
    • combined oral contraceptives, antiandrogens, fertility drugs
    • weight loss
55
Q

excess production of cortisol

A

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
Q

enzyme deficiencies involved in steriodogenesis

(usually shunt intermediates into androgen pathway)

A

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
Q

cyclic physical, psychological (mental/emotional), behavioral changes that impair interpersonal relationships or usual activites

S/s and Tx

A

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
Q

Criteria of PMDD

A

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
Q

Criteria for PMS

A

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
Q

PMS/PMDD work-up

A
  • 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
Q

Conservative / EBR Low-risk Tx for PMS

A
  • 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
Q

Meds for PMDD/refractory PMS

A
  • first line:
    • antidepressants (luteal or continuous)
      • citalopram, clomipramine, fluoxetine, paroxetine, sertraline, venlafaxine
  • second-line:
    • anxiolytics (luteal only)
      • alprazolam, buspirone

OB/GYN (7 decks)

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