GYN lecture 1-puberty and menstrual cycle

decreased E2 associated with:

-increased risk of CAD -osteopenia and osteoporosis-bone resorption accelerates due to decreased E2

overview of menstrual cycle

1. average adult menstrual cycle last 28-35 days 2. cycle duration-3-7 days 3. volume of menstrual flow: 20-60 mL 4. regularity is predictive of ovulatory cycles 5. hypothalamus, pituitary, ovaries and uterus are all involved 6. divided into two 14-day phases (follicular and luteal phases) 7. proliferative and secretory phases (concurrent changes in the ENDOMETRIUM over the same period of time)

workup for precocious puberty and delayed puberty

1. careful history, physical examination 2. hormone assessment 3. bone age determination

perimenopause

1. cycles shorten 2. ovulation occurs less frequently 3. FSH increases to stimulate follicles 4. variable to high levels of estradiol

the cycle is then divided into 2 phases:

1. follicular 2.luteal

physiology and endocrinology of puberty

1. hypothalamus disinhibition 2. pulsatile GnRH (hypothalamus) 3. FSH/LH (pituitary) 4. estradiol (ovary) 5. breast development, linear growth, menarche, ovulation

Average age of menopause in US

51 years

hormone therapy

ET if patient does not have uterus estrogen-progestin therapy if patients does have a uterus-progestin converts proliferative to secretory endometrium, thereby preventing hyperplasia and cancer

Menopausal symptoms and long-term effects

F-flushes forgetful -Alzheimer's disease S-sweats at night, sad, stroke, skeletal changes, skin changes, sexual dysfunction H-headaches, heart disease I-insomnia U-urinary symptoms, urogenital atrophy L-libido decreases

T/F If you have a period you ALWAYS ovulate

FALSE- menses can be anovulatory

T/F FSH and LH levels decrease during menopause

FALSE-they rise due to diminished E2 production

diagnosis of menopause is confirmed by testing what?

FSH levels

T/F Menarche is often delayed in gymnasts, distance runners and ballet dancers cause of decrease in body fat

TRUE

T/F careful history comes from the parent or guardian when seeing a pediatric patient

TRUE

T/F initial cycles can be irregular and anovulatory

TRUE

T/F menopausal patients are at risk for hip and vertebral fractures, pain, loss of height and immobility

TRUE

T/F menopause is usually proceeded by menstrual irregularity

TRUE

T/F pubarche may proceed thelarche in African American girls

TRUE

good test question ! T/F hypothalamus, pituitary, ovaries and uterus are all involved in menstrual cycle

TRUE

Turner Syndrome

XO cause of premature menopause

luteal phase

a. Days 14-28 (after ovulation to menses) b. also called secretory phase (P4 induces endometrial gland secretion) c. granulosa and theca cells line follicular wall and form corpus luteum corpus luteum under stimulation by LH; CL (secretes E2 and P4)-secretory endometrium

follicular phase

a. days 1-14 (onset of menses until ovulation) b. increase in FSH stimulates growth of ovarian follicles; 1 dominant follicle develops and matures, increased estradiol production c. also called proliferative phase (E2 induces endometrial growth and thickening)

Gonadarche

activation of the gonads by the pituitary hormones follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Begins around age 8 years

Which of the following does not produce progesterone?

adrenal cortex

pubarche

appearance of pubic hair, primarily due to the effects of androgens from the adrenal gland . this term is also applied to first appearance of axillary hair, apocrine body odor and acne

pubarche happens at what age?

around age 11 years

luteal phase

begins on the day of the LH surge and ends at the onset of the next menses

follicular phase

begins with the onset of menses and ends on the day before the luteinizing hormone (LH) surge

1st stage of thelarche

breast bud development

contraindications to hormone therapy

cardio-protective effect preservation of cognitive function prevention of dementia excellent control of monopausal symptoms prevention of vaginal atrophy decreased risk of colorectal cancer protection against osteoporosis

luteal phase-conception

corpus luteum is maintained by HCG until placenta produces P4

physical exam of a patient with menopause

decreased breast size and change in texture vaginal, urethral and cervical atrophy may be seen consistent with decreased estrogen levels

puberty

general term for the transition from sexual immaturity to sexual maturity

thelarche

happens around age 10, estrogenation of the vaginal mucosa and growth of the vagina and uterus. Further breast development continue throughout puberty and adolescence (Tanner stages)

decreased estradiol leads to

hot flashes, mood changes, insomnia, depression, osteoporosis and vaginal atrophy

adrenarche

increase in production of androgens by the adrenal cortex . starts ages 6-8 years

ovulatory phase

increased E2 levels rapid LH surge P4 and prostaglandins (within follicle) - follicular rupture and oocyte release within 30-36 hours

risk of HRT and ERT

increased risk of cardiovascular disease increased risk of DVTs and PEs invasive breast cancer (prolonged use)

luteal phase -no conception

involution of corpus luteum results in decreased P4 endometrial sloughing occurs and bleeding begins

menopause

last menstrual period which can only be confirmed after 1 year of amenorrhea

average age in US is about 12-13 years old

menarche

premature menopause

menopause before age 40 years results from premature ovarian failure idiopathic or autoimmune If it occurs before age 30, chromosomal studies can be ordered to rule out genetic basic

hot flashes

momentary sensation of flushing. perspiration and intense heat with reddening of the face and neck, usually last about 90 seconds -last up to 5 years for most women

the menstrual cycle is divided into what 2 phases when describing the endometrium?

proliferative and secretory phases

usually follows thelarche

pubarche

perimenopause

span typically lasting 6 years or more that begins with onset of menstrual cycle changes and other menopause-related symptoms -extends through menopause to 1 year after menopause

Delayed puberty

the absence of signs of puberty by 12 to 13 years (for breast development)

precocious puberty

the appearance of breast development before the age of eight years in girls

thelarche

the appearance of breast tissue, primarily due to the action of estradiol from the ovaries

menarche

the first menstrual period caused by the effects of estradiol on the endometrial lining

indications/recommendations for HRT

use lowest effective dose for shortest amount of time needed to relieve symptoms -treatment of vaginal atrophy only-vaginal estrogen (cream, ring, tablet)

not classic symptom of menopause

visual changes

early menopause is NOT more common in

women with hypertension

produces sex steriod's , DHEA, DHEAS, androstenedione

zona reticularis of adrenal gland