Pubery, Menopause and osteoporosis Flashcards
Cause of puberty
Exact mechanism unknown -> thought that multiple factors lead to withdrawal of central GnRH inhibition –> this increases FSH then LH leading to an increase in testosterone/oestrogen levels
Puberty in girls
Starts 9-13 and ends 12-18 –> Menarche occurs late (11-15) and growth starts and finishes earlier than boys
First sign is breast buds and USS can be used to assess ovarian and uterine development
Puberty in boys
Starts 10-14, ends 15-17 –> full spermatogenesis occurs quite late in the process
Testicular volume >5mL indicates start of puberty
Rising serum testosterone is an earlier sign
Definition of Precocious puberty
Development of secondary sexual characteristics (or menarche in girls) before the age of 9 is precocious
Can be idiopathic or secondary to a number of conditions
Idiopathic (true) precocity of puberty
Rare in boys and commoner in girls –> diagnosed when other causes have been excluded –> can be normal and may run in families
Treatment of Precocious puberty
Long acting GnRH analogues (given nasally, SC or implant) cause suppression by down-regulation of the receptor and are moderately effective
Cyproterone Acetate –>antiandrogen with progestational activity can also be used
Causes of precocious puberty
Cerebral –> hypothalamic disease or tumours (always MRI to exclude, especially in boys)
Also: McCune-albright syndrome, Isolated premature thelarche, Isolated premature adrenarche
Isolated premature adrenarche
Early development of pubic hair without any other changes –> usually after 5yrs and more commonly girls (particularly obese girls)
In boys the risk of androgen secreting testicular tumour should be investigated if androgens are high and LH is suppressed
Isolated premature thelarche
Early, isolated breast development (age 2-4) – may regress or persist until puberty
No early follicular development
McCune-albright syndrome
Usually girls
Presents with precocity, polyostotic fibrous dysplasia and skin pigmentation (cate-au-lait spots)
Delayed puberty
95% of children with show some sign of puberty by 14yrs
Investigate at 15yrs –> mostly constitutional delay
Basal LH/FSH may indicate the site of defect and GnRH can indicate the stage of puberty reached
Constitutional puberty delay
Very rare in women but occurs in boys –> May be family history and puberty, stature and bone age will all be in line
Treatment of delayed puberty
If the delay is significant and this is causing problems then low dose, short term sex hormone therapy is used
Menopause
Cessation of periods - 45-55yrs - FSH then LH rises over the 40s and oestogren drops causing cycle disruption
leading to scanty periods, amenorrhoea or menohagia
Uk average 50yrs 9mo
Post-menopausal hormones
Grossly elevated LH (>50) and FSH (>25) with low estradiol
Raised FSH is the most reliable sign of being post-menopausal
Premature menopause
Can occur from surgical removal of ovaries or radiation damage
Most commonly due to premature ovarian failure –> can be autoimmune or familial/genetic (occasionally linked to fragile X)
Must be diagnosed on repeat LH/FSH levels. Occurs in <1% women under 40
Clinical features of the menopause
Most women will experience hot flushes (80%) –> can be disabling (20%). lasts average 4yrs, up to 12
Breast atrophy and vaginal dryness + non-specific loss of libido, self esteem, anxiety/depression/irritability, rashes & pains
Osteoporosis develops rapidly over 10yrs and increased risk of IHD
Hormone Replacement Therapy (HRT)
Was widely used but increasing awareness of the risk has moved this to limited use if the symptoms are severe enough – not given universal to prevent osteoporosis –> selective oestrogen receptor modulators (SERMs) will likely be used in the future
Risks of HRT
26% increased in risk of breast cancer but no risk in mortality (may be easier to treat) + Sig. increased risk of Uterine cancer
30% increased IHD and 40% increased stroke risk
Withdrawal bleeds unless the continuous oestogrens and progesterone is used
Benefits of HRT
Symptomatic improvement – specific oestrogen deficiency symptoms respond very well and more general symptoms usually improve
Protection from osteoporosis but this is no longer sufficient indication for therapy
1/3 reduction in bowel cancer risk
Treatment of premature ovarian failure
Almost always give HRT because the risk of oestrogen deficiency outweighs risk of HRT at the younger age
Aging in males
There is a non-specific drop in sexual function and testicular volume decreases (SHBG and gonadotropin levels rise) – if premature hypogonadism occurs testosterone replacement should be used to protect from osteoporosis
Androgen inhibition is also used to combat prostatic hypertrophy
Management options for hot flushes or night sweats
Lifestyle factors are first line, HRT is most effective. Tibolone is usable if more than 12months since last period, Clonidine use is often limited by side effects (dry mouth, dizziness & nausea)
Oestrogen production in the body
The ovaries produce 17B-oestrodiol which is converted into estradiol. After the menopause the majority of the estrogen is produced by peripheral fat as estrone, before the menopause estrone is produced from androgens in the adrenal cortex (70%) and the ovaries (30%). Obese women have more.
Causes of Menorrhagia and dysmenorrhoea in the peri-menopausal period
Lack of progesterone causes the endometrium to break down causing bleeding and pain
Indications for HRT
Most commonly it is for control of vasomotor symptoms.
Can also be if menopause is premature but no longer given standardly to prevent osteoporosis. Give oestrogen plus progestogen if they have a uterus.
Contra-indications for HRT
Pregnancy or breast feeding Undiagnosed abnormal vaginal bleeding Active or recent angina or MI Suspected, current or past Breast, Endometrial or other oestrogen dependant Ca Active liver disease with abnormal LFTs Uncontrolled HTN
Use of cyclic vs continuous HRT
Cyclic - If the last period was less than one year ago.
Continuous - if been on cyclic for 1yr OR >1yr since last period OR 2yrs since last period if menopause was premature
