Gyn- Intro & Menstrual Physiology

The study of women and diseases that affect them is known as _____

gynecology

The management of women during pregnancy, childbirth, and the puerperium is known as ______

obstetrics

What bones form the border of the true pelvis?

3 innominate bones of hip (ilium, ischium, pubis), sacrum, and coccyx

What is between the vestibule and the anus?

perineum

the muscular tube that is a potential space (not sitting open, collapsed) and extremely distensible is the _____

vagina

What regions is the area surrounding the uterine cervix divided into?

anterior fornix, posterior fornix, 2 lateral fornices

The area where fallopian tubes enter the uterus is known as the _____

cornu

The major divisions of the uterus, body and cervix, is separated by the ____

isthmus

How does the uterus normally appear?

pear shaped, thick walled, muscular organ

What are the layers of the uterine wall?

serial layer → outer

myometrium → firm, thick, intermediate coat of smooth muscle

endometrium → inner mucosal lining

The uterus is supported by ______

ligaments

The neck of the uterus, aka the lower, narrow portion of the uterus where it joins w/ the top end of the vagina (fusion of mullerian ducts); and is cylindrical/conical in shape and protrudes through the upper anterior vaginal wall is known as the _____

cervix / cervix uteri

The purpose of which organ is egg transport and site of fertilization to form a zygote?

fallopian tubes

The purpose of which organ is gametogenesis- egg/ova/gamete production?

ovary

what type of cervical os?

nonparous / nulliparous

what kind of cervical os?

parous / multiparous or instrumentation

when would the ovaries be palpable?

reproductive years 50/50- based on timing in menstrual cycle (less often if on BCPS)

postmenopausal - variable; enlargement = alarm

The fallopian tubes, uterus, cervix, and upper 2/3s of the vagina develop from ______

2 paired mullerian ducts

What is derived from germ cells?

ovaries

What arises from the sinovaginal bulb?

lower vagina

Mullerian defects are often discovered due to _____

infertility

What kind of abnormalities commonly accompany Müllerian duct defects due to the close proximity of development?

renal

When one or both Müllerian ducts don’t develop fully, producing abnormalities such as uterine agenesis or hypoplasia (b/l) or unicornuate uterus (u/l), this is known as ______

organogenesis

The process during which the lower segments of paired Müllerian ducts fuse to form the uterus, cervix, and upper vagina, this is known as _____

lateral fusion

Fusion of the ascending sinovaginal bulb with the descending mullerian system, resulting in a patent vagina, is referred to as ____

vertical fusion

incomplete vertical fusion results in _____

imperforate hymen

failure of lateral fusion results in _____

bicornuate or didelphys uterus

After the lower Müllerian ducts fuse, a central septum is present, referred to as _____

septal reportion

failure of septal resorption results in ____

septate uterus

What are the 3 phases of development of complete formation and differentiation of the mullerian defects?

organogenesis, fusion, septal resorption

What class mullerian defect is this?

• hypoplasia / agenesis → no reproductive potential aside from IVF of harvested ova and implantation in a host

class I

What class mullerian defect is this?

• unicornuate uterus → result of complete/almost complete arrest of development of 1 Müllerian duct

  • incomplete arrest (MC) → rudimentary horn w/ or w/o functioning endometrium

  • if horn obstructed, may need surgery, enlarging pelvic mass

• if contralateral healthy horn is almost fully developed, a full term pregnancy is believed to be possible

class II

What class mullerian defect is this?

• didelphys uterus → results from complete confusion of both ducts

• individual horns are fully developed and almost normal in size

• 2 cervices inevitably present

• longitudinal or transverse vaginal septum possible

• consider metroplasty (removing septum & fusing both)

• can carry pregnancy to full term since each horn is almost a fully developed uterus

class III

What class mullerian defect?

• bicornuate uterus → results from partial confusion of ducts

• demonstrates some degree of fusion b/t the 2 horns

• horns not fully developed, typically smaller

• some pts are candidates for metroplasty

class IV

What class mullerian defect?

• septate uterus → results from failure of resorption of septum b/t 2 uterine horns

• septum can be partial or complete

• uterine fundus is typically convex but may be flat or slightly concave

• highest incidence of reproductive complications

• treated by using transvaginal hysteroscopic resection of septum

class V

What class mullerian defect?

• arcuate uterus → variant of normal, no adverse impact on fertility and pregnancy outcomes

• has slight midline septum w/ minimal and often broad fundal cavity indentation

• variously classified as septate, bicornuate, or normal variant

class VI

What class mullerian defect?

• diethylstilbestrol (DES) related anomaly → synthetic form of estrogen prescribe to pregnant women to prevent pregnancy complications from 1945-1971

• seen in female offspring in 15% women exposed to DES during pregnancy

• variety of abnormal findings- uterine hypoplasia and t shaped uterine cavity; inc risk vaginal clear cell carcinoma

class VII

When an individual is physiologically capable of reproduction, this is known as _____

puberty

The development of breasts is _____

thelarche

The development of hair in the axilla and on the pubis is _____

pubarche

The first menstrual period is ______

menarche

An increase of adrenal androgens, early in sexual maturation and precursor to puberty, is ______

adrenarche

The stages of physical and sexual development in children, adolescents, and adults based on external primary and secondary sex characteristics is referred to as _____

sexual maturity rating (SMR) - tanner stages

Which Tanner Stage?

• prepubertal

• height inc at basal rate; 5-6 cm/yr

• breast → papilla elevation only

• pubic hair → villus hair only, no coarse pigmented hair

Tanner Stage 1

Which Tanner Stage?

• height increases at accelerated rate: 7-8 cm/yr

• breast → buds palpable and areolae enlarge; ~ age 10.9 (8.9-12.9)

• pubic hair → minimal coarse pigmented hair mainly on labia; ~ age 11.2 (9-13.4)

• modifications based on increasingly earlier puberty

  • white: may appear 1 year earlier

  • black: may appear 2 years earlier

Tanner Stage 2

Which Tanner Stage?

• height increases at peak rate: 8cm/yr (age 12.5)

• breast → elevation of contour, areolae enlarge; ~ age 11.9 (9.9-13.9)

• pubic hair → dark, coarse, curly hair spreads over mons pubis; ~ age 11.9 (9.6-14.1)

• axillary hair develops (13.1)

• acne vulgaris develops (13.2)

Tanner Stage 3

Which Tanner Stage?

• height increases 7 cm/yr

• breast → areolae forms secondary mound on the breast; ~ age 12.9 (10.5-15.3)

• pubic hair → hair of adult quality, no spread to junction of medial thigh w/ perineum; ~ age 12.6 (10.4-14.8)

Tanner Stage 4

Which Tanner Stage?

• no further height increases after age 16

• breast → adult contour, areola recesses to general contour of breast

• pubic hair → adult distribution of hair, spreads to medial thigh, does not extend up linea alba

Tanner Stage 5

The onset of secondary sexual development before the age of 8 in girls and 9 in boys is referred to as _____

precocious puberty

What are the signs of precocious puberty in girls?

breast development and/or pubic hair→ white before age 7, black before age 6

menarche before age 10

**refer if 2 signs under 8 years old

What might suggest a pathological cause of precocious puberty?

premature puberty in very young children, contrasexual development, peripheral cause (asynchronous development), visual field deficit suggesting pituitary mass

What kind of precocious puberty?

• caused by early maturation of hypothalamic pituitary-gonadal -axis

• sequential maturation of breasts and pubic hair in girls, and testicular enlargement and pubic hair in boys

• sex characteristics appropriate for gender (isosexual)

• idiopathic in most cases

gonadotropin-dependent (GDPP) / central / true precocious puberty

What kind of precocious puberty?

• caused by excess secretion of estrogens/androgens (derived from adrenal glands or gonads), exogenous sources of sex steroids, or ectopic production of gonadotropin from GCT

• may be appropriate for child’s gender (isosexual) or inappropriate (contrasexual)

gonadotropin-independent (GIPP) precocious puberty / peripheral precocity / pseudo-precocious puberty

What kind of precocious puberty?

• isolated breast development in girls (premature thelarche) or

• isolated male hormone mediated sex characteristics in boys or girls that result from inc adrenal androgen production (premature adrenarche)

• can be variant of normal puberty

• should be monitored bc may progress to precocious puberty

• tx: GnRH agonists

incomplete precocious puberty

Most cases of premature thelarche are ____

idiopathic and present around age 2 with serum estradiol in prepubertal range

What are the key features of premature thelarche?

• isolated breast development; either u/l or b/l

• absence of other secondary sex characteristics

• normal linear growth & bone age

Premature thelarche occurs in what two peaks?

first 2 years of life & 6-8 years of age

When would a consultation with an endocrinologist be warrnet for premature thelarche?

progressive secondary sexual development, increasing growth velocity, or accelerated bone maturation present

What population is premature adrenarche most common in?

girls (black > white) & individuals w/ obesity and insulin resistance

Premature adrenarche is a risk factor for ______

PCOS

What is the diagnosis of premature adrenarche best supported by?

• elevated DHEA-sulfate concentration in pubic hair stage

• 17-hydroxyprogesterone and testosterone levels in age appropriate normal ranges

Initial periods are usually ______

anovulatory (regular ovulation begins ab 1 yr later

The USA average age of menarche (12.5) has _____

decreased

What is the normal length of a menstrual cycle?

28 days +/- 7

What is the normal duration of menses?

5 days +/- 2

What Is the average blood loss per day in normal menses?

8 or fewer soaked pads / 35-150 ml (usually no more than 2 heavy days)

What is the average loss of iron in normal menses?

13 mg

What are the 3 primary components of the menstrual cycle?

HPA axis (hypothalamus, pituitary gland, & anterior pituitary )

______ secretes LH and FSH to stimulate ovarian function.

anterior pituitary

Which cycle?

• follicular phase

• ovulation

• luteal phase; pregnancy

ovarian

Which cycle?

• proliferative phase

• secretory phse

• menses

uterine

What is the control center that responds to hormones and neurotransmitters and secretes GnRH every 90 minutes, pulsatile to the anterior pituitary via portal circulation?

hypothalamus

What hormones does the anterior pituitary produce?

FSH & LH → ovary

prolactin → breast

What hormone?

• produced in gonads, pituitary gland, placenta, etc

• increases FSH binding and FSH induced aromatization in the ovarian follicle

• participates in androgen synthesis enhancing LH action in the ovary

activin

Which hormone?

• inhibits FSH production

• produced in gonads, pituitary gland, placenta, corpus luteum, etc

• secretion from the granulose cells of ovarian follicles is stimulated by FSH

• secretion is diminished by GnRH and enhanced by IGF-1

inhibin

What phase of the ovarian cycle?

• initiated by lack of estrogen at end of menses

• FSH from ant pit stimulates follicle to grow & produce estrogen

• Graafian follicle chosen by day 7

• as estrogen inc, it inhibits release of FSH

• LH from ant pit in small amounts prior to ovulation, surges mid cycle in response to peak amounts of estrogen from mature follicle, stimulates ovary to produce progesterone after ovulation

• 10-14 days

follicular / phase I

Which phase of the ovarian cycle?

• estrogen peaks at 200-300 pg/ml

• GnRH inhibited by high estrogen & amt of FSH being secreted drops off

• ant pit releases LH surge ahead of ovulation

• one egg released 36-42 hours from onset of surge

• corpus luteum formed at site of follicle that hs matured and released ovum

  • secretes progesterone to ready uterus for pregnancy

  • if not fertilized, becomes inactive after 10-14 days, involutes and becomes corpus albicans (fibrous scar tissue) and menstruation occurs

ovulatory / phase II

what phase of the ovarian cycle?

• progesterone dominant (secreted by corpus luteum)

• relatively constant in length (12-14 days)

• progesterone increases and peaks (day 20 of the cycle - 6 days post ovulation)

• estrogen levels off

• corpus luteum involutes after 14 days, resulting in drop of progesterone levels

  • if implantation, progesterone levels stay up due to production of hCG, progesterone would then further inhibit FSH and new follicular recruitment

luteal / phase III

What phase of the uterine cycle?

• roughly corresponds with follicular phase of ovarian cycle

• influenced by estrogen

• thickness of endometrium rapidly increases by the drawing out of the uterine glands

• dont consulte or secrete in this phase

proliferative phase

What phase of the uterine cycle?

• roughly corresponds with luteal phase of ovarian cycle

• progesterone influence from corpus luteum

• lining becomes highly vascularized, slightly edematous, glands become coiled and tortuous and begin to secrete clear fluid

secretory phase

What process occurs when the corpus luteum involutes, progesterone & estrogen dec,, PG inc & smooth muscle contraction, & endometrium loses its blood supply and sloughs its functional layer?

menstruation

The stage of a woman’s reproductive life that begins up to 10 years before menopause (~40s) when the ovaries gradually begin to produce less estrogen in known as _____

perimenopause

What is the average length of perimenopause?

4 years; ends after 12 consecutive months w/p a menstrual cycle (menopause)

The following symptoms are associated with what condition?

• change in periods - shorter or longer, lighter or heavier, more/less time in between

• hot flashes, night sweats, trouble sleeping

• vaginal dryness

• mood swings, trouble focusing

• less hair on head, more on face and breasts

Perimenopause

What marks the permanent end of fertility with reduced functionaling of the ovaries, confirmed with the absence of menses for 12 consecutive months?

menopause

what is the average age of menopause in the US?

52

T/F: ovulation can still sporadically occur during menopause.

true

What condition might happen during menopause due to the increased loss of estrogen?

osteoporosis

what is the most common cause of secondary amenorrhea?

pregnancy

what type of amenorrhea?

• never menstruated

• eti: gonadal failure, congenital absence of vagina, constitutional delay

primary

What kind of amenorrhea?

• menstruated but failed to menstruate again for more than 3 cycles or w/in 6 mos

• eti: chronic anovulation, hypothyroidism/hyperprolactinemia, wt loss/anorexia

secondary

when should a work up be initiated for amenorrhea?

• no period by age 14 w/ absent secondary sex characteristics

• no period by a ge 16 regardless of secondary sex characteristics

• in menstruating women w/o menses for 6 mos

• obvious cases- turners appearance, genital anomalies, etc

What is the treatment for amenorrhea?

must treat to avoid prolonged uterine exposure to unopposed estrogen or anovulation if fertility desired

OC’s are good for younger pts; otherwise regular progesterone withdrawal

ovulation induction for desired conception

HRT or OC’s if perimenopausal

What is the most common Ullrich turner syndrome?

chromosomal monosomy X (45XO)

The following symptoms are associated with what condition?

• characteristic physical abnormalities → short stature, lymphedema, broad chest, low hairline, low set ears, webbed neck

• gonadal dysfunction (amenorrhea & infertility)

• CHD, hypothyroidism, ophthalmologic problems, etc

Ullrich turner syndrome

Severe uterine pain/cramps during menstruation that are severe enough to limit normal activities or require medication is known as _____

dysmenorrhea

Excessively heavy blood loss is known as ____

menorrhagia

what is the treatment for primary dysmenorrhea?

• OCPs- suppress ovulation, lighter/regular flow

• NSAIDS- ibuprofen, mefenamic acid, naproxen sodium

• low level topical heat

When ectopic tissue similar to the lining of the uterus is found elsewhere in the body, this is _____

endometriosis

What is the most common symptom of endometriosis?

pelvic pain