Puberty, Menstruation, Common Menstrual Disorders

puberty

physical maturation that occurs during adolescence

adolescence

timeframe in human development of physical, cognitive, and psychosocial maturation

what is the age of puberty in males and females?

Females: 11yo (8-13yo)

Males: 12yo (9-14yo)

precocious puberty

early gonadotropin secretion from the pituitary (FSH and LH) results in signs of puberty at an age 2-3 standard deviations below the mean age (physical signs before 8)

precocious pseudopuberty

early signs of puberty from estrogen exposure in females, androgen exposure in males

delayed puberty

absence of signs of puberty at an age 2-3 standard deviations above the mean age

gonadarache

activation of the gonads stimulated by pituitary hormones

what hormones are involved in gonadarache?

follicule stimulating hormone (FSH) and luteinizing hormone (LH)

adrenarche

increase in the adrenal androgens

what hormone is involved in adrenarche?

dehydroepiandrosterone (DHEA)

thelarche

the development of breasts stimulated by ovarian hormones

what hormones are involved in thelarche? what are they each specifically responsible for?

estradiol: growth of ducts

progesterone: growth of lobules and alveoli

pubarche

the development of axillary and pubic hair stimulated by adrenal androgens

menarche

the first menstrual period stimulated by ovarian hormones

what are the 5 tanner stages for hair?

Stage I: no hair

Stage II: sparse growth

Stage III: darker, coarser, more curled hair

Stage IV: adult type hair over a smaller area

Stage V: spread to the medial surface of the thighs

what are the 5 tanner stages for breast development?

Stage I: elevation of papilla only

Stage II: breast bud

Stage III: enlargement of breast and areola

Stage IV: projection of the areola and papilla

Stage V: recession of the areola to the contour of the breast, projection of papilla only

what are the 3 layers of the uterus?

serosa, myometrium, endometrium

serosa

outer connective tissue layer of the uterus

myometrium

the muscular layer of the uterine wall (smooth muscle)

endometrium

mucous membrane lining of the uterus; provides environment for reproduction

what are the 3 layers of the endometrium? what layers build and shed? what layer is the basal layer that is always there?

stratum compactum and

stratum spongiosum (builds and sheds)

stratum basale (basal layer that is always there)

what is the average frequency of a menstrual cycle?

28-35 days

typically how long is the follicular/proliferative phase of the menstrual cycle?

14-21 days

typically how long is the luteal/secretory phase of the menstrual cycle?

14 days

what organs produce estrogen?

ovaries (estradiol), adrenal glands (estrone), and liver (estriol)

what are the functions of estrogen?

Stimulates endometrial growth

Stabilizes the endometrium

Prepares the follicle for the release of an egg

Helps create a "sperm-friendly" environment in the uterus.

what organs produce progesterone?

ovaries and adernal glands

what are the functions of progesterone?

Prepares the uterus for pregnancy

Balances estrogen to prevent over-thickening of the endometrium

Facilitates estrogen-withdrawal bleeding (menses)

what organ produces FSH?

anterior pituitary gland

what are the functions of FSH?

Stimulates follicles to ripen eggs

Stimulates the ovaries to produce estrogen

Acted on by Activin and Inhibin

what organ produces LH?

anterior pituitary gland

what are the functions of LH?

Stimulates ovulation

Stimulates the follicle to change into the corpus luteum

Stimulates secretion of estrogen and progesterone from the corpus luteum

what organ produces GnRH?

hypothalamus

what are the functions of GnRH?

Stimulates the synthesis and release of pituitary gonadotropins (FSH and LH)

Released in a pulsatile fashion

Responds differently depending on timing in the cycle

which organ produces prolactin?

anterior pituitary gland

what is prolactin affect by? what does it cause? and what does it inhbit?

Affected by environmental factors (nipple manipulation, medications and drugs, surgical and emotional stress, etc), hypothalamic regulating hormones (estrogen, progesterone, dopamine, etc.), and pituitary regulating hormones (activin, relaxin, melatonin, etc)

Causes milk secretion from the breasts during lactation

Inhibits the affects of FSH and LH, often resulting in amenorrhea and anovulation

follicular/proliferative phase

Rising FSH stimulates follicle growth; dominant follicle secretes estrogen.

Estrogen promotes the proliferation of the endometrium (thickening and repair after menstruation).

Preparation for ovulation and potential implantation.

what is activin?

a protein hormone produced in the ovaries that stimulates the follicular/proliferative phase by acting on the anterior pituitary to release FSH

what is inhibin?

a protein hormone produced in the ovaries that is stimulate by high estrogen levels during the follicular/proliferative phase that suppresses FSH secretion from the anterior pituitary gland, acting as a negative feedback regulator

what is the LH surge?

peak estrogen levels cause an increase of the frequency of GnRH pulsation which causes a rapid increase of LH which then leads to ovulation

what is the corpus hemorrhagicum?

the ruptured follicle that fills with blood after ovulation

mittelschmerz

pain that occurs in the lower abdomen during ovulation from minor bleeding from the corpus hemorrhagicum

how is the corpus luteum formed and what does it produce?

clotted blood in the follicle degrades and is replaced with luteal cells; progesterone in increasing amounts as well as estrogen in lesser amounts

luteal/secretory phase

Progesterone (from the corpus luteum) stimulates the endometrium to become more glandular and vascular, preparing for implantation of a fertilized egg.

High progesterone and estrogen suppress FSH and LH secretion to prevent new follicle development.

If fertilization occurs: The corpus luteum is maintained by hCG from the developing embryo.

If no fertilization: The corpus luteum degenerates, hormone levels drop, and the endometrial lining sheds (menstruation)

what is the corpus albicans?

fibrous tissue left behind by corpus luteum

what effects does estrogen and progesterone have on the cervix?

Estrogen: Makes the cervical mucous thinner and alkaline, facilitating sperm transport

Progesterone: Thickens cervical mucous

what effects does estrogen and progesterone have on the vagina?

Estrogen: Increases cornified epithelial cells

Progesterone: Promotes proliferation of vaginal epithelium

what effects does estrogen and progesterone have on the breasts?

Estrogen: Causes breast enlargement, pigmentation of the areola, and proliferation of mammary ducts

Progesterone: Causes growth of lobules, alveoli, and areola, supports lactation

what effects does estrogen and progesterone have on the MSK system?

Estrogen: Causes epiphyseal plate closure, decreases bone resorption, influences secondary sexual characteristics

Progesterone: Increases bone formation

what effects does estrogen and progesterone have on neuro?

Estrogen: Increases libido, regulates body temperature, delays memory loss

Progesterone: Enhances cognitive function, decreases anxiety

what effects does estrogen and progesterone have on the endocrine system?

Estrogen: Increases pituitary size, libido, angiotensin, and thyroid binding globulin

Progesterone: Promotes metabolism of fat and thyroid function

what effects does estrogen and progesterone have on parts of the body (other than the ones previously mentioned)?

Estrogen: Inhibits comodones and acne, promotes thrombosis, regulates cholesterol production, reduces abdominal fat

Progesterone: Promotes hair growth, regulates blood pressure and blood sugar, dilates blood vessels, prevents constipation

anovulatory cycles

menstrual cycles without ovulation; common close to menarche and menopause; no corpus luteum

what are 4 ways to predict ovulation?

map cycles, detect change in cervical mucous, ovulation predictor kits, basal body temperature

what is "fertile time"?

~2 days before ovulation through 1-2 days after ovulation

dysmenorrhea

painful menstruation that limits activity and requires OTC or Rx medication

what is primary and secondary dysmenorrhea?

Primary- idiopathic

Secondary- pathological cause

what is the main etiology of dysmenorrhea?

Prostaglandin release from endometrial sloughing

what is the typically clinical presentation including symptoms of dysmenorrhea?

Pain typically occurs with the onset of menses

Nausea, vomiting, diarrhea, headache

what are management options for dysmenorrhea?

Conservative therapies

Antiprostaglandins (NSAIDs, Cox 2 inhibitors)

Combination oral contraceptive pills (cOCPs)

amenorrhea

absence of menstruation

what is primary and secondary amenorrhea?

Primary Amenorrhea: failure of menarche by age 15yo or 13yo with no development

Secondary Amenorrhea: absence of menses for more than three cycles or six months in women who were previously menstruating

Mullerian dysgenesis

(primary amenorrhea) congenital absence of the uterus and the upper vagina

vaginal agenesis

(primary amenorrhea) failure of the vagina to develop; will get signs of period and normal development but no bleeding

transverse vaginal septum

(primary amenorrhea) tissue barrier across the vagina causing a blockage

imperforate hymen

(primary amenorrhea) membrane covering the vaginal opeing

Asherman's syndrome

(secondary amenorrhea) development of scar tissue as a result of surgery, difficult birth, or some type of trauma

name 3 possible causes of amenorrhea from hypothalamic dysfunction

Interference with GnRH transport or GnRH pulse discharge

Congenital absence of GnRH

Kallmans Syndrome Pituitary Dysfunction

what would be an example of primary pituitary dysfunction causing amenorrhea?

Congenital absence of the pituitary (rare and lethal)

name 5 examples of acquired pituitary dysfunction causing amenorrhea

Sheehan's syndrome

Ablation or irradiation of the pituitary

Fe+ deposits in the pituitary

Prolactinoma

Hypothyroidism

Sheehan's syndrome

postpartum pituitary necrosis

what is a sex chromosome disorder that causes amenorrhea and is when the ovaries do not develop or do not fully develop?

Turner's syndrome

what are examples of primary and secondary ovarian failure causing amenorrhea?

primary: premature ovarian failure and ovarian resistance

secondary: PCOS

how do you diagnosis primary amenorrhea?

Laboratory work-up (FSH, testosterone, prolactin, 17-hydroxyprogesterone, ACTH stimulation test, electrolytes)

Pelvic exam

Pelvic ultrasound

Genetic testing/Karyotype

how do you diagnosis secondary amenorrhea?

Laboratory Work-up (HCG, prolactin, testosterone, thyroid stimulating hormone, T3, T4, FSH, LH, estradiol)

Pelvic exam

Pelvic ultrasound

Progestin-challenge test

how do you treat amenorrhea?

treat underlying cause

stimulate menses/protect the endometrium

premenstrual syndrome (PMS)

the cyclical occurrence of symptoms that interfere with certain aspects of daily life, have a predictable relationship with menses

premenstrual dysphoric disorder (PMDD)

PMS with significant interference with daily life and predominantly mood symptoms

the cause of PMS/PMDD is multifactorial like?

Estrogen-progesterone imbalance

Excessive aldosterone

Hypoglycemia

Hyperprolactinemia

Serotonin dysfunction

Physiological ovarian function

name some somatic symptoms of PMS/PMDD

Headache/migraine (with or without aura)

Mastalgia

Pelvic pain

Bloating

Clumsiness

Fatigue

Edema

Sleep changes

Change in appetite

name some affective symptoms of PMS/PMDD

Social withdrawal

Increase in crying

Depression

Irritability

Anxiety

Decreased libido

how is PMS diagnosed?

Patient must exhibit at least 1 somatic symptom and 1 affective symptom occurring during the 5 days before menses in each of the three prior menstrual cycles

how is PMDD diagnosed?

Meeting criteria for PMS with occurrence of more severe affective symptoms

how do you manage PMS/PMDD?

lifestyle modifications, OTC remedies, Rx remedies

cOCPs containing _______ are FDA approved for treatment of PMDD

Drosperinone

abnormal uterine bleeding (AUB)

uterine bleeding in a nonpregnant female that is abnormal in volume, frequency, duration, and/or regularity

what is diagnosed when all possible pathological causes of AUB have been ruled out?

dysfunctional uterine bleeding (DUB)

which of the following is considered AUB?

prolonged uterine bleeding

heavy menstrual bleeding

midcycle bleeding/break through bleeding

all of the above

all of the above

3 multiple choice options

what is the FIBO classification system for AUB?

PALM COEIN

Structural causes -PALM

Polyp

Adenomyosis

Leiomyoma

Malignancy and hyperplasia

Nonstructural causes - COEIN

Coagulopathy

Ovarian dysfunction

Endometrium

Iatrogenic

Not otherwise classified

what is the second most common cause of AUB in adolescence?

blood dycrasias

when does most DUB occur?

in the years around menarche or in perimenopause

DUB is associated with what 90% of the time?

anovulatory or oligoovulatory cycles

DUB only results from a low estrogen state t/f

false, can be low or high

what is the first thing you need to do when diagnosing DUB?

rule out other etiologies, particularly cancer

what are possible medical and surgical treatments for DUB?

Medical: Low dose combination OCPs

Medroxyprogesterone acetate (Provera)

Depo Medroxyprogesterone acetate (Depo Provera or DMPA)

Levonorgestrel IUD

NSAIDS

Antifibrinolytic agent

Surgical: D&C, endometrial abaltion, hysrerectomy

postmenopausal bleeding (PMB)

Uterine bleeding that occurs after a full year of amenorrhea due to menopause