Session 3 - Puberty and Menstrual Dysfunction Flashcards
What is the average age of puberty in males and females?
Females - 8-13 years
Males - 9-14 years
What is the order of events of puberty in females?
Breast bud (thelarche) Pubic hair growth begins (adrenarche) Growth spurt Onset of menstrual cycles (menarche) Pubic hair adult Breast adult
What is the order of events of puberty in males?
Genital development begins Pubic hair growth Spermatogenesis begins Growth spurt Genitalia adult Pubic hair adult
What are the differences in the growth spurt between males and females?
Earlier and shorter in females
Men are generally larger as their growth spurt is longer and slightly faster.
Growth spurt ends when epiphyses fuse.
Describe the hormonal control of puberty:
Onset of puberty is associated with a steady rise in LH and FSH secretion due to an increase in GnRH production. This is initiated by the brain.
The brain controls when puberty occurs, this is mainly dependant on body weight. In girls critical weight is 47kg for menarche. If body weight falls then reproductive cycles may cease.
Pubic and axillary hair is controlled by androgens. Release by adrenals in females.
Breast development is dependant on oestrogen.
Growth spurt depends on growth hormones and steroids in both sexes. Oestrogen close epiphysis earlier in girls.
Genital development in boys depends on testosterone.
Describe the factors that occur in Pre-menopause:
Typically from age c40 years
Changes in the menstrual cycle - follicular phase shortens and ovulation is early or absent.
Less oestrogen secreted
LH and FSH levels rise as there is reduced negative feedback.
Reduced fertility.
Describe the factors that occur in the menopause:
Cessation of menstrual cycles Average age 49/50 but variable No more follicles develop Oestrogen levels fall dramatically FSH and LH levels rise dramatically
Describe the symptoms/signs of the menopause:
Vascular changes - hot flushes affect 80% of people, transient rises in skin temperature and flushing. (can be relieved by oestrogen treatment)
Regression of endometrium and shrinkage of myometrium.
Thinning of cervix
Vaginal rugae lost
Involution of some breast tissue
Changes in skin
Changes in bladder
Bone mass reduction - increased resorption compares to production. Can lead to osteoporosis ( can be reduced by oestrogen therapy)
What are the advantages/disadvantages of Hormone Replacement Therapy?
Relieves symptoms of the menopause
Can improve well-being
Can limit osteoporosis but is not first line treatment for protection against osteoporosis
It is not advised for cardioprotection
Can increase the risk of breast, womb, ovarian cancer and stroke. Also increased risk of DVT and PE.
What is precocious puberty and what causes it?
Puberty before the age of 8.
Can be caused due to early stimulation caused by pineal tumour or meningitis.
Or can be due to uncontrolled gonadotrophin or steroid secretion - may be due to hormone secreting tumours.
Define amenorrhea:
Absence of a period
What is the average blood loss every cycle?
30-45ml
Define menorrhagia:
Heavy periods >80ml or prolonged >7 days
Define dysmenorrhea:
Painful periods
Define oligomenorrhea:
Uterine bleeding occurring at intervals between 35 days and 6 months.
Define dysfunctional uterine bleeding:
Abnormal bleeding which is excessively heavy, prolonged or frequent of uterine origin. No obvious organic cause usually anovulatory. Diagnosis of exclusion. Usually occurs at extremes of reproductive life in patents with PCOS.
Define primary amenorrhea:
Absence of a period by the age of 14 with absence of secondary sexual characteristics. Or 16 in presence of sexual characteristics.
Define secondary amenorrhea:
Where established menstruation has ceased for more than three months in women with regular periods or nine months in women with irregular periods. This usually happens in women aged 40-55 during menopause.
Describe the general causes of amenorrhea:
Hypothalmic/Pituitary Problems
Ovarian Problem
Outflow Tract issues
Describe the causes of outflow tract amenorrhea:
FSH levels normal
Primary
Uterine: Mullerain agenesis (second most common cause, 15% of primary amenorrhea)
Vagina: Vaginal atresia, cryptomenorrhea (menses occurs but is not visible) imperforate hymen.
Secondary
Intrauterine adhesions - Asherman’s syndrome - pregnancy causes, miscarriages, c-sections, abortions.
Describe the general cause of gonadal/end-organ disorders:
The ovary does not respond to pituitary stimulation. Low oestrogen levels are seen in these patients. These usually are associated with high FSH levels (in menopause range)
What are some of the causes of gonadal/end organ disorders causing primary amenorrhea:
Gonadal dysgenesis e.g. Turners Syndrome
Androgen insensitivity syndrome
Receptor abnormalities for hormones FSH and LH
Specific forms of congenital hyperplasia - excess androgen production - progesterone plus oestrogen means no menses.
What are some of the causes of gonadal/end organ disorders causing secondary amenorrhea:
Pregnancy Anovulation Menopause Pre-mature menopause Polycystic ovarian syndrome Drug-induced
What is the general cause of pituitary and hypothalmic/central regulatory disorders?
Inadaquate levels of FSH lead to inadequately stimulated ovaries which fail to produce enough oestrogen to stimulate the endometrium. Hence amenorrhea.
What are some of the pituitary/hypothalamic central regulatory disorders causing primary amenorrhea?
Hypothalamic causes - Kallmann Syndrome - cells which produce GnRH fail to migrate to hypothalamus in development - this is also associated with loss or reduced sense of smell.
What are some of the pituitary/hypothalamic central regulatory disorders causing secondary amenorrhea?
Hypothalamic - exercise amenorrhea, stress amenorrhea, eating disorders and weight loss (obesity, anorexia nervosa or bulimia)
Pituitary Sheehan Syndrome - vascular necrosis of pituitary, hyperprolactinaemia, hematochromatosis.
Hypo/Hyperthyroidism.
What questions would you need to ask in the history of a women presenting with secondary amenorrhea?
Menstrual history - regular/irregular Contraception Pregnancy Surgery Medication Weight Change Chronic disease/stress/diet Family history - age of menopause in female relatives, thyroid dysfunction, diabetes, cancer.
What would you want to examine in a women presenting with secondary amenorrhea?
BMI Hair distribution (PCO/Turners) Thyroid Visual fields Breast discharge? Abdomen mass? Tenderness?
Describe the pathophysiology of DUB:
Disturbance of the HPO axis that leads to changes in length of the menstrual cycle. No progesterone withdrawal from an oestrogen primed endometrium. Endometrium builds up with erratic bleeding as it breaks down.
How would you investigate DUB?
HCG/TSH ? Coagulation workup Ensure smear if appropriate >35 or Cancer risk factors, tamoxifen use Sample endometrium
How would you manage DUB?
IV/IM conjugated oestrogen therapy
Usually followed by OCP or progesterone.
Describe some of the causes of menorrhagia:
Usually secondary to distortion of uterine cavity - e.g. fibroids - benign growth in the uterus leads to increased SA so greater area to bleed from. The uterus is unable to contract down on open venous sinuses in the zona basalis.
Organic/Endocrinolgic/hemostatic/Iatrogenic.
Usually ovulatory.
Describe the investigation into menorrhagia:
Physical exam, USS if abnormal.
Check for:
anaemia, obesity, androgen excess, acne, ecchymosis/purpura, thyroid, galactorrhoea, liver/spleen, Pelvic - uterine, cervical and adnexal.
Describe the management of menorrhagia:
Levonorgesterol releasing IUS OR
Tranexamic acid - antifibrinolytic plus OCP OR
Norethisterone.
