Session 3 - Puberty and Menstrual Dysfunction

Question 1

What is the average age of puberty in males and females?

Answer 1

Females - 8-13 years

Males - 9-14 years

Question 2

What is the order of events of puberty in females?

Answer 2

Breast bud (thelarche)
Pubic hair growth begins (adrenarche)
Growth spurt
Onset of menstrual cycles (menarche) 
Pubic hair adult 
Breast adult

Question 3

What is the order of events of puberty in males?

Answer 3

Genital development begins 
Pubic hair growth 
Spermatogenesis begins 
Growth spurt 
Genitalia adult 
Pubic hair adult

Question 4

What are the differences in the growth spurt between males and females?

Answer 4

Earlier and shorter in females
Men are generally larger as their growth spurt is longer and slightly faster.
Growth spurt ends when epiphyses fuse.

Question 5

Describe the hormonal control of puberty:

Answer 5

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.

Question 6

Describe the factors that occur in Pre-menopause:

Answer 6

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.

Question 7

Describe the factors that occur in the menopause:

Answer 7

Cessation of menstrual cycles 
Average age 49/50 but variable 
No more follicles develop
Oestrogen levels fall dramatically 
FSH and LH levels rise dramatically

Question 8

Describe the symptoms/signs of the menopause:

Answer 8

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)

Question 9

What are the advantages/disadvantages of Hormone Replacement Therapy?

Answer 9

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.

Question 10

What is precocious puberty and what causes it?

Answer 10

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.

Question 11

Define amenorrhea:

Answer 11

Absence of a period

Question 12

What is the average blood loss every cycle?

Answer 12

30-45ml

Question 13

Define menorrhagia:

Answer 13

Heavy periods >80ml or prolonged >7 days

Question 14

Define dysmenorrhea:

Answer 14

Painful periods

Question 15

Define oligomenorrhea:

Answer 15

Uterine bleeding occurring at intervals between 35 days and 6 months.

Question 16

Define dysfunctional uterine bleeding:

Answer 16

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.

Question 17

Define primary amenorrhea:

Answer 17

Absence of a period by the age of 14 with absence of secondary sexual characteristics. Or 16 in presence of sexual characteristics.

Question 18

Define secondary amenorrhea:

Answer 18

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.

Question 19

Describe the general causes of amenorrhea:

Answer 19

Hypothalmic/Pituitary Problems
Ovarian Problem
Outflow Tract issues

Question 20

Describe the causes of outflow tract amenorrhea:

Answer 20

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.

Question 21

Describe the general cause of gonadal/end-organ disorders:

Answer 21

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)

Question 22

What are some of the causes of gonadal/end organ disorders causing primary amenorrhea:

Answer 22

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.

Question 23

What are some of the causes of gonadal/end organ disorders causing secondary amenorrhea:

Answer 23

Pregnancy 
Anovulation 
Menopause
Pre-mature menopause
Polycystic ovarian syndrome 
Drug-induced

Question 24

What is the general cause of pituitary and hypothalmic/central regulatory disorders?

Answer 24

Inadaquate levels of FSH lead to inadequately stimulated ovaries which fail to produce enough oestrogen to stimulate the endometrium. Hence amenorrhea.

Question 25

What are some of the pituitary/hypothalamic central regulatory disorders causing primary amenorrhea?

Answer 25

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.

Question 26

What are some of the pituitary/hypothalamic central regulatory disorders causing secondary amenorrhea?

Answer 26

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.

Question 27

What questions would you need to ask in the history of a women presenting with secondary amenorrhea?

Answer 27

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.

Question 28

What would you want to examine in a women presenting with secondary amenorrhea?

Answer 28

BMI
Hair distribution (PCO/Turners)
Thyroid 
Visual fields
Breast discharge?
Abdomen mass? 
Tenderness?

Question 29

Describe the pathophysiology of DUB:

Answer 29

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.

Question 30

How would you investigate DUB?

Answer 30

HCG/TSH
? Coagulation workup
Ensure smear if appropriate 
>35 or Cancer risk factors, tamoxifen use
Sample endometrium

Question 31

How would you manage DUB?

Answer 31

IV/IM conjugated oestrogen therapy

Usually followed by OCP or progesterone.

Question 32

Describe some of the causes of menorrhagia:

Answer 32

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.

Question 33

Describe the investigation into menorrhagia:

Answer 33

Physical exam, USS if abnormal.
Check for:
anaemia, obesity, androgen excess, acne, ecchymosis/purpura, thyroid, galactorrhoea, liver/spleen, Pelvic - uterine, cervical and adnexal.

Question 34

Describe the management of menorrhagia:

Answer 34

Levonorgesterol releasing IUS OR
Tranexamic acid - antifibrinolytic plus OCP OR
Norethisterone.