Women's Health: Sexual Health and Development

Menopause

Cessation of menses > 1 year due to loss of ovarian function, leading to decreased estrogen and progesterone production

-Average age is 52 years

-Presentation: hot flashes, night sweats, sleep disturbances, mood changes, osteoporosis, dyspareunia, vaginal atrophy

-Dx: absence of menses x 1 year after 40, FSH is most sensitive

-Tx: hormone replacement therapy

Estrogen + Progesterone

What type of hormone replacement therapy can be given to women with an intact uterus?

-Increased risk of MI, stroke, DVT, and breast cancer

-Decreased risk of colorectal cancer and fractures

Estrogen

What type of hormone replacement therapy should be given to women without an intact uterus?

-Increased risk of stroke, DVT, and endometrial cancer

-Decreased risk of fractures

Bisphosphonates

What class of medications should be prescribed for osteoporosis?

Topical vaginal estrogens

What is the most effective treatment for vaginal atrophy?

-ADRs: vaginal bleeding, breast pain, nausea, thromboembolism, endometrial cancer

Perimenopause

Transition between reproductive capability and menopause, where the hallmark symptom is irregular menses (lasts 3-5 years)

Premature Ovarian Failure

Menopause before age 40

Dyspareunia

Pain during sexual intercourse

-Etiologies: anatomic, infectious, hormonal, trauma, inflammatory conditions, neoplastic disorders, neurologic issues, psychosocial, relationship issues, and idiopathic

-Dx: H&P, rule out causes

GnRH

Produced by the hypothalamus and secreted in a pulsatile manner, which stimulates the anterior pituitary to secrete FSH/LH which act on theca cells and granulosa cells

LH

Produced by the anterior pituitary, which stimulates theca cells of the ovaries to produce progesterone and androstenedione

FSH

Produced by the anterior pituitary, which stimulates follicles and egg maturation

Estrogen

Produced by the granulosa cells in the ovaries

-Works during the follicular phase to stimulate the proliferation of the endometrial lining

Progesterone

Produced by the theca cells of the ovaries

-Responsible for uterine ripening to allow proper implantation of a fertillized ovum

Follicular Phase

Days 1-14 of the ovarian cycle, where estrogen dominantes

-Pulsatile GnRH → increase LH/FSH → stimulates ovaries

-FSH release leads to secretion of estradiol and production of a dominant follicle

-Rise in estrogen production causes negative feedback on the hypothalamus, which inhibits GnRH and production of new follicles

Ovulation

Occurs at day 14 of the ovarian cycle

-Increased estrogen being released from the mature follicle switches from negative to positive feedback on GnRH, which increases FSH/LH and estrogen

-Sudden LH surge leads to ovulation, causing the dominant follicle to rupture and release egg

Corpus Luteum

The follicle that ruptures during ovulation creates the what?

Luteal Phase

Days 14-28 of the ovarian cycle, where progesterone dominates

-Corpus luteum secretes progesterone and estrogen to maintain the endometrial lining, then switches back to negative feedback

-Ovum travels through fallopian tube to the uterus. If it is not fertilized, the corpus luteum inovulates (corpus albicans) and the cycle starts over

Menstrual Phase

Egg is not fertilized

-Corpus luteum deteriorates → decline in estrogen and progesterone → endometrium sloughs off leading to menstruation

-Causes constriction of the spiral arteries which feed the endometrial tissue → ischemia → cramps

Proliferative Phase

Tissue regeneration after menses, where the endometrial glands get bigger

-Ovaries are producing estrogen, leading to endometrial thickening

-As the endometrium thickens, FSH declines and LH emerges

Secretory Phase

Days 14-28 of the uterine cycle

-Endometrium begins to proliferate under the influence of progesterone

-Glands and arteries become closely related and connective tissue keeps the lining stable

20-23

What days of the uterine cycle are considered the implantation window?

Differences of Sexual Development

Conditions present from birth where the chromosomes, gonads, and the external genitalia don’t all line up the usual way

-Presentation: ambiguous genitalia in a newborn, primary amenorrhea in a teenager

Congenital Adrenal Hyperplasia

A full term newborn noted at delivery to have ambiguous genitalia, an enlarged clitoris with partially fused labioscrotal folds and no palpable gonads. On day 3-4 of life, the infant develops poor feeding, vomiting, dehydration, and lethargy.

-Labs show low sodium, high potassium, and low glucose

-Karyotype reveals 46, XX and the 17-hydroxyprogesterone is markedly elevated

21-hydroxylase deficiency congenital adrenal hyperplasia

What is the #1 cause of ambiguous genitalia?

Androgen Insensitivity Syndrome

Body makes testosterone but can’t respond to it, so a genetic male (46, XY) develops a female body with testes and no uterus

-Classic presentation: a teen with normal breasts, a short or absent vagina, no periods, and little to no pubic/underarm hair

5a-reductase deficiency

Patient looks female at birth then virilizes at puberty, often presenting with a penis by the age 12

Turner Syndrome

45, X

-Short stature, nonfunctional “streak” ovaries, and no periods

Klinefelter Syndrome

47, XX&

-Tall male with small, firm testes and gynecomastia

-Infertile

Karyotype

In addition to a pelvic ultrasound, what is the diagnostic of choice for differences in sexual development?

Cortisol + Fludrocortisone

What is the treatment of choice for congenital adrenal hyperplasia?

Entry Pain

What type of pain is associated with these causes of dyspareunia?

-Atrophic vaginitis (MC), vulvodynia/vestibulodynia/vaginismus, inadequate lubrication, vulvar dermatoses, infection, or scarring

Deep Pain

What type of pain is associated with these causes of dyspareunia?

-Endometriosis, PID, adhesions, uterine fibroids, adenomyosis, ovarian pathology, or interstitial cystitis

Pap Smear

A 26 y/o transgender male who has been on testosterone for 2 years and comes in to establish primary care. He has not had genital surgery and still has a cervix and uterus, and he asks what cancer screenings he still needs. What is indicated at this time?

Hematocrit

What should be monitored in patients on testosterone?

VTE

What is the biggest risk associated with feminizing gender affirming hormone therapy, which is made up of estrogen + spironolactone?

Erythrocytosis

What is the biggest risk associated with masculinizing GAHT, which is testosterone?

GnRH agonists

What class of medication can be prescribed for transgender adolescents seeking to undergo gender-affirming hormone therapy?

Prostate Cancer

What must transgender female patients be screened for when they reach the appropriate age?

Excitement, plateau, orgasm, resolution

What are the four phases of the Masters & Johnson cycle of human sexuality?

SSRI

What is the most common reversible cause of decreased libido or sexual dysfunction?

CVD

New onset erectile dysfunction can be an early marker of what?

Hyperprolactinemia

What hormonal imbalance due to a pituitary tumor can cause decreased libido?

SSRI

What class of medication can be used to treat premature ejaculation?

Elevated triglycerides, DVT history

In addition to undiagnosed vaginal bleeding, endometrial cancer, history of breast cancer, and CVD history, what are two contraindications to HRT?

Thelarche

Development of breast buds, which is the first sign of puberty

Pubic hair, growth spurt

What are the two stages of puberty between thelarche and menarche?

2 years

How long after the development of breast buds does menarche occur?

Testicular growth

What is the first sign of puberty in males?

Precocious Puberty

Puberty before age 8 in girls/9 in boys

-Work up with bone age x-ray and hormone levels

-Pause with GnRH agonist

Delayed Puberty

No breast development by 13 in girls or testicular growth by 14 in boys

-Usually caused by a constitutional delay

46 XY

What is the chromosomal pattern for complete androgen insensitivity syndrome?

-Patient Presentation: female external genitalia, absent uterus, blind-ending vagina, and primary amenorrhea due to nonfunctional androgen receptors

Hyponatremia, shock from cortisol and aldosterone deficiency

What two things make congenital adrenal hyperplasia a neonatal emergency?

17-hydroxyprogesterone

What lab finding, if elevated, confirms 21-hydroxylase deficiency congenital adrenal hyperplasia?

5-Alpha-Reductase Deficiency

Inability to convert testosterone to DHT causes ambiguous or female-appearing genitalia at birth with virilization at puberty

Superficial

Dyspareunia with entry

Deep

Dyspareunia with deep penetration

Vaginismus

What is the most common cause of superficial dyspareunia?

Endometriosis

What is the most common cause of deep dyspareunia?

Gender Dysphoria

Clinically significant distress arising from incongruence between one’s experienced gender and assigned sex

Elevated FSH

What hormonal changes confirm menopause?

Osteoporosis

What is a major long-term health consequence of estrogen deficiency after menopause?

LH

What hormone surge triggers ovulation?

Progesterone

What hormone dominates the luteal phase?

Estrogen

What hormone drives endometrial proliferation in the first half of the cycle?

SRY gene

What determines male sexual differentiation in utero?

-Triggers testis formation, testosterone and anti-Mullerian hormone