20. Puberty Disorders of Development Flashcards
1
Q
Menstrual cycle occurs with the maturation of what _______.
A
Hypothalamic - pituitary - ovarian axis
2
Q
[Arcuate nucleus of the hypothalamus] => __________ => [AP] => ____________ => acts on ________.
A
[Arcuate nucleus of the hypothalamus] => GnRH => [AP] => LH/FSH => acts on theca cells/ granulosa cells .
3
Q
FSH and LH are stored in what cells?
A
Gonadotrophs in the AP.
4
Q
LH => _____ cells => releases _____
A
- LH => theca cells => androgens (androstenedione and testosterone)
5
Q
FSH => ______ cells => releases _____
A
FSH => granulosa cells => converts androgens to estrogens (estrone = E1 and estradiol = E2)
6
Q
Phases of the NL Ovarian Cycle
-What phases of the endometrium do they respond to?-
A
-
Follicular phase: [1st day of menstruation => preovulatory stage of LH surge]
- Corresponds to: menstrual and proliferative phase of endometrium
-
Luteal phase: [preovulatory stage of LH surge => 1st day of menstruation]
- Corresponds to: secretory phase of the endometrium
7
Q
Describe the Ovarian Cycle
A
[1st day of period => pre-ovulatory stage of the LH surge]
- If conception does NOT occur, levels of progesterone/estradiol decrease as the corpus luteum from the previous cycle regresses.
- Initiates increase in FSH to cause follicles to grow: => granulosa cells => increase estrogens (estron/estradiol) => Large # of large antral follicle grows :)
- As follicle grows, increase estrogen negatively feedbacks and tells AP to decrease FSH secretion => all but ONE of the developing follicles will stop growing and die off
- Follicle with most FSH receptors becomes the dominant follicle that will secrete estrogen.
- Increase estrogren from dominant follicle will become more responsive to pulsatile action of GnRH
- Estrogen from dominant follicle become a positive feedback => Increases the amount of FSH/LH (LH surge) release from hypothalamus 1-2 days before ovulation => meitotic maturation, ovulation and luteinization.
- Corpus luteum produces high [progesterone and estradiol]
- High progesterone and estradoil negatively feedback on LH/FSH, to return to baseline levels
- If ovulation does not occur (hCG does not increase), CL will regress.
8
Q
_____ enhances the hypothalamic release of GnRH and induce the midcycle LH surge.
A
Estradiol
9
Q
_____ have an inhibitory effect on GnRH release.
A
Gonadotropins
10
Q
When are estradiol levels low and when do they begin to rise?
A
- Low = early follicular development
- Rise = 1 week before ovulation bc will cause LH surge
11
Q
Course of estrogen: when does it peak, what occurs after and during luteal plase?
A
- Estrogen peaks 1 day before LH surge.
- After peak and before ovulation => marked fall
- During luteal phase => estradiol rises to a max 5-7 days after ovulation d/t release from CL => returns to BL before menstruation.
12
Q
Describe levels of progesterone during the ovarian cycle.
A
- Follicular phase: ovary secretes SMALL amounts. The bulk of it mainly comes from peripheral conversion.
- Before ovulation: Unruptured luteinzing graafian follicle begins to secrete increasing amounts of progresterone
- CL: secretes progesterone, which reaches max 5-7 days AFTER ovulation and returns to BL before menstruation.
13
Q
What is the outcome of a mature graafian follicle (made from primordial follicle) ?
A
- Innermost 3-4 layers of granulosa cells become cuboidal and form cumulus oophorus.
- Fluid filled antrum forms amount granulosa cells => enlarges and pushes primary oocyte to wall.
- Innermost layer of granulosa cells of cumulus oophorus become elongated and form corona radiata.
- Ruptures => releases ovum + corona radiata
- Luteinization produces corpus luteum.
14
Q
How does the LH surge result in ovulation?
A
- Degenerates cells on the wall of the follicle => forming a stigma.
- BM of follicle then bulges through stigma => ruptures => oocyte is expelled => ovulation.
15
Q
What happens to the follicle AFTER ovulation?
A
- Granulosa cells under luteinization => luteinizing granulosa cells, theca cells, CT and capillaries => corpus leutum (lives 9-10 days).
16
Q
What happens to the corpus luteum if pregnancy does NOT occur?
A
Menses happens and CL is replaced by avascular scar (corpus albicans)
17
Q
Zones of the endometrium
A
- Outer portion = functionalis
- Contains spiral arteries and undergoes cyclic changes, sloughing off during menstruation
- Inner portion = basalis
- Contains basal arteries and stem cells to renew endometrium; remains unchanged
18
Q
Phases of the Endometrial Cycle
*which is the only phase seen visually*
A
- Menstrual phase (sloughing) *****
- Proliferative/estrogenic phase (grows)
- Secretory/progestational phase
19
Q
Endometrial lining of a post-menopausal women should be HOW thick?
A
Less than 4mm
20
Q
Describe the menstrual phase of the endometrial cycle
A
-
Begins at Cycle Day 1 = first day of menstruation
- Conception did not occur by day 23 => CL regresses and progesterone/estradoil decline.
- Cycle day 1: Functionalis layer sloughs off and compression of basalis layer: disruption of endometrial glands, stroma, leukocytes infiltrate and RBC extravasation
21
Q
What hormones stimulates the proliferative phase of the endometrial cycle?
A
Estrogen => increase length of spiral arteries and mitosis
22
Q
What hormone stimulates the secretory phase of the endometrial cycle?
How are the glands, stroma and mitosis affected?
A
-
After ovulation, CL releases progesterone => + secretory phase (stimulates glandular cells to secrete mucus, glycogen and substances)
- Glands= tortous
- Stroma = edematous
- Mitosis = rare
- Endometrial lining reaches MAX thickness
23
Q
When must conception occur by, otherwise CL will regress and endometrium will undergo involution?
A
Day 23
24
Q
What occurs in the secretory phase that prepares the endometrium for menstrauation?
A
- Conception did not occur by 23 => endometrium undergoes involution
- 1 day before => spiral arteries are constrictioned => endometrium undergoes ischemia and necrosis
25
What is **IMPORTANT** in regulation menstruation and why?
**Intact coagulation pathway** because with NL hemostasis, injured vesses are repaired quicky.
26
What is responsible for causing atresia of all but 1 follicle during the follicular phase - leading to selection of the dominant follicle; what does the dominant follicle produce?
- **↓ FSH** levels progressively cause atresia of all but 1 follicle
- The dominant follicle produces high levels of estradiol
27
Diagnosis of **menopause** is made by looking at levels of what?
**↑ FSH:** since ovary is no longer receptive to FSH, there is no negative feedback on the AP
Menopause = **↑ FSH bc no (-) feedback**
28
* What is the median age of **menarche (onset of period)?**
* When when does it occur in respect to Thelarche?
* 12.43 years
* 2-3 **AFTER** thelarche (breast budding) at **Tanner stage IV.**
29
Define **primary amernorrhea.**
- No menstruation by **13 y/o** **WITHOUT** secondary sexual development.
OR
- No menstruation by **15 y/o WITH** secondary sexual characteristics
30
What is the **length** of most normal menstrual cycles during the **first gynecologic year** and how does this **change** as more cycles occur?
* Often **irregular** in **adolescents**, most normal cycles range from **21-45 days**
* By the **3rd year after menarche =\>** cycles are **21-35 days**
31
* What is the mean blood loss per menstrual period?
* How much loss is associated with anemia
* What is a normal and abnormal amount of pad changes per day?
- **Mean** blood loss is **30cc;** changing pads/tampons **3-6x per day**
- **Anemia** = **\>80c**c; changing pad **q 1-2 hrs** is considered **excessive**
32
How does **obesity** vs. a **malnourished** adolescent affect the onset of puberty?
- **Obese children** have **earlier** onset of puberty
- **Malnourished, chronically ill** w/ weight loss will have **later** onset
33
What is the **invariant mean weight** an adolescent needs to be or above **to start menarche?**
**48 kg (106 lbs.)**
34
**Low levels of gonadotropin** and **sex steroids** BEFORE puberty are due to what?
1. Low estradiol (-) feedbacks gondastat (relates gonadotropin release)
2. CNS inhibit secretion of GnRH
35
What are the **initial endocrine changes assoc. w/ puberty**?
1. **Production of adrenal androgen/sex steroids** (DHEA, DHEA-S, and androstenedione) production
2. **Differentiation of the zona reticularis** of the adenal cortex
3. ====\> Growth of axillary and pubic hair (adrenarche or pubarche)
36
Once puberty begins, what changes do we see in GnRH release?
Loss of CNS inhibition of GnRH release =\> released in **pulsatile manner**
37
Which hormones are required for **thelarche** (breast development) vs. **pubarche/andrenarche** (pubic/axillary hair developement)?
- **Thelarche** requires **estrogen**
- **Pubarche/adrenarche** requires **androgens**
38
What is the **1st physical sign of puberty** and what is common in first 6 months?
* **Thelarche** = breast development
* **unilateral** breast development "one boob is growing bigger than the other"
39
What 4 factors does **mecharche** require?
1. [Pulsatile GnRH] from hypothalamus
2. [FSH/LH] from AP
3. [Estrogen and progesterone] from ovaries
4. **NL outflow tract**
40
What are the stages of **normal pubertal development** from earliest to latest?
\*\*\* TAG ME \*\*\*
1. **T**helarche
2. **A**drenarche
3. Peak **G**rowth/height velocity
4. **M**enarche
5. **Mature sexual hair and breasts**
\*\*\* TAG ME \*\*\*
41
Briefly describe the **5 Tanner stages** of **breast development.**
**- Stage 1:** preadolescent elevation of **papilla** only
**- Stage 2:** **breast bud** stage; small mound w/ enlargement of areolar region
**- Stage 3:** more enlargement of breast + areola **w/o** separation of their contours
**- Stage 4:** [**secondary mound**] = projection of areola and papilla
**- Stage 5:** mature stage; projection of **papilla only,** **recession** of **areola** to general contour of breast
42
Briefly describe the 5 Tanner stages of **pubic hair** development.
**- Stage 1: NO** pubic hair
**- Stage 2:** **Sparse**, lightly pigmented hair **along labia**
**- Stage 3:** hair **spreads** sparsely over jct. of pubes; hair is **darker + coarser**
**- Stage 4: adult**-**type** hair, there is **no** spread to **medial** thigh
**- Stage 5:** spread to **medial thighs** assuming inverted triangle pattern
43
What is **precious puberty** and who is it more common in?
* Development of secondary sex characteristics at an age **2.5 SD earlier** than expected age of puberty.
* F
44
What are the **2 major subgroups** of precocious puberty?
1. **Heterosexual precious puberty**: development of **OPPOSITE** secondary sex characteristics --\> virilizing neoplasms, CAH, exposure to exogenous androgens
2. **Isosexual**: premature sexual maturation that is **APPROPRIATE** for the phenotype of the affected individual --\> constituional/organic brain disease
45
What is congenital adrenal hyperplasia?
What type of precious puberty can it lead to?
And which type is less severe and occurs later, in adolescents?
* CAH defect in 21-hydroxylase =\> make **excessive androgens**
* **Heterosexual** precocious puberty
* Types
* **Classical** = most severe and causes birth of F w/ ambigous genitalia
* **Nonclassical** (late onset adrenal hyperplasia) =\> premature pubarche and an adult disorder the resembles PCOS
46
Which test can be administered clinically to diagnose **true isosexual precocious** puberty; what are you looking for?
- Give **exogenous GnRH (stimulation test)**
- See if **↑ in LH levels** consistent w/ older girls who are undergoing normal puberty
47
**True isosexual precocity vs Pseudoisosexual** is caused by what?
* **True = Premature activation** of NL pubertal processes that involve HPO axis
* **Pseudo** = Increased estrogen **w/o** activation of HPO axis
48
If a CNS disorder is suspected to be the cause of **true isosexual precocious (75% are idiopathic/ consitutional)** puberty, what is used to diagnose?
**MRI of head**
49
Treatment of **true isosexual precocious puberty**
What is the important of treating this condition?
**GnRH agonist (leuprolide acetate)** ---\> will suppress release of FSH and LH
- Untreated = \<50% of girls will **not** grow over **5' feet tall.**
50
What 2 syndromes can cause **pseudoisosexual precious puberty?**
* 1. **McCune Albright syndrome** (Polyostotic fibrous dysplasia)
* 2. **Peutz-Jeghers syndrome**
51
What is seen in **McCune-Albright syndrome** (Polyostotic fibrous dysplasia)?
1. **Multiple cystic bone defects**
2. **Café au lait spots** (face, neck, shoulder and back)
3. Adrenal **hyper**cortisolism
52
What is seen in **Peutz-Jeghers syndrome?**
1. Sex cord tumor that secretes estrogen
2. Mucocutaneous pigmentation
3. GI polyposis
53
Puberty is considered **delayed** in what 4 situations?
1. No secondary sexual characteristics by 13
2. No thelarche has not occurred by 14
3. No menarche by 15-16
4. When menses has not begun **5 years after** onset of thelarche
54
What are the **3 causes** of delayed puberty?
1. **Hypergonadotropic hypogonadism** = FSH \>30 mIU
1. Primary amenorrhea WO secdonary sex characteristics
2. **Hypogonadotropic hypogonadism** = FSH/LH \<10 mIU
1. Primary amenorrhea WO secdonary sex characteristics
3. **Anatomic causes** (mullerian agenesis; imperforate hymen; transverse vaginal septum)
55
**Hypergonadotropic hypogonadism (FSH \>30 mIU/mL)** is a cause of delayed puberty associated with what disease in females?
**Gonadal dysgenesis (Turner Syndrome)**
56
What is **primary amenorrhea?**
1. No menstruation by **13 W/O** secodnary sex characteristics
2. No menstruation by **15 W** secondary sex charcteristics.
57
What is **secondary amenorrhea?**
No period **6 months after** last.
58
After hx and PE of patient with **primary amenorrhea,** what do you check for next and how does this dictate the rest of your work-up?
1. **Are secondary sex characterstics present**
* Absent =\> measure **FSH/LH**
* Present =\> do a **US** to see if **uterus is present**
59
When would we expect to see **hypogonadotropic hypogonadism?**
* Primary amenorrhea?
* Secondary sex characterstics?
* Follow up?
1. Pt presents with **primary amenorrhea** _WITHOUT_ **secondary sex characteristics**
2. Measure FSH/LH: **\<10 mIU**
60
List 6 underlying etiologies responsible for **hypogonadotropic hypogonadism** (FSH + LH \<10 mIU/mL).
1. **- Constitutional (physiologic) delay = MCC**
2. - Kallmann syndrome
3. - Anorexia/extreme exercise
4. - Pituitary tumors/disorders
5. - Hyperprolactinemia
6. - Drug use
61
What is **Kallman syndrome?**
* Mutations of the **[KAL gene on the XChr]** that prevents GnRH neurons from migrating into hypothalamus, causing h**ypogonadtropic/hypogonadism**, **anosmia** and **hyposmia** (absent or decreased smell).
62
When would we expect to see **hypergonadotropic hypogonadism**?
* Primary amenorrhea?
* Secondary sex characterstics?
* Follow up?
* Pt presents with **primary amenorrhea** _WITHOUT_ **secondary sex characteristics**
* Measure FSH/LH: \> 30 mIU
63
If a pt has primary amenorrhea WO secondary sexual characteristics, FSH/LH are \> 30mIU, what is the dx and what is done NEXT?
* **Hypergonadotropic/hypogonadism**
* **Karyotype analysis** is performed next.
* 46 XX =\> _Premature ovarian failure_
* 45 XO =\> _Tuners syndrome/gonadal dysgenesis_
64
If karyotype of pt with **hypergonadotropic hypogonadism** comes back with a **Y chromosome**, what is the next best step?
**Gonadectomy** to prevent malignant neoplastic transformation
65
What is the most common form of **female gonadal dysgenesis** and what does it cause?
**Turner Syndrome (45 XO)** = hypergonadotropic/hypogonadism = many will show NO signs of secondary sex characterstics.
66
Signs of Turners Syndrome? (6)
1. Web neck (pteryguim colli)
2. Broad-flat chest with widely spaced nipples
3. Short
4. Rudimentary streaked ovaries
5. Absent or incomplete development of puberty
6. Coarctation of aorta
67
If a pt has [primary amenorrhea **with** secondary sexual characteristics], but *US* reveals an **absent or abnormal uterus**, what test is done next and what are you looking for?
1. Karyotype analysis
* **46, XY = Androgen insensitivity syndrome (AIS)**
* **46, XX = Mullerian agenesis**
68
What is the karyotype seen w/ **Androgen Insensitivity Syndrome (AIS)** and what are some characteristics seen in females with this disorder?
- **46 XY =**\> male levels of testosterone
1. _External female genitalia_ w/ absent to sparse pubic hair with _testes in abdominal_ wall that secrete NL antimullerian hormone =\>
2. _NO_ uterus and upper vagina
3. Breast development w/ smaller than normal areola/nipples
69
**Tx** for androgen insensitivity syndrome (46,XY)?
1. **Gonadectomy** after puberty to avoid neoplasm
2. **Can create neovagina** by surgical and non-surgical methods
3. **+HRT**
70
What is the most common cause of primary amenorrhea in women **with** **normal** **breast development?**
**Mayer-Rokitansky-Kuster-Hauser Syndrome (Mullerian agenesis)**
71
What is the karyotype and characteristics of **Mayer-Rokitansky-Kuster-Hauser Syndrome?**
1. **46 XX** ---\> female range of testosterone
2. **NO uterus and upper vagina** bc distal mullerian ducts did not fuse; **renal abnormalities** common
3. **NL** ovaries, secondary development, and external genitalia
72
**Congenital anomalies of the uterus or vagina** are often associated with abnormalities of _________ and should be assessed with \_\_\_\_\_\_.
**Renal** abnormalities
**Intravenous pyelogram =** to assess urinary system
73
**_Patient presents with_**
* Primary amenorrhea + secondary sex characterstics
* US = NL/present uterus
* **What do we assess for next and DDx?**
* **Is an outflow obstruction present?**
* Yes =\> imperforate hyman or transverse vaginal septum
* No =\> Evaluate for secondary amenorrhea.
74
What should you suspect in **adolescents** that present complaining of **monthly dysmenorrhea without vaginal bleeding;** a vaginal bulge and midline cystic mass?
**Imperforate hymen**
75
Although the presentation of sx's will be similar btw imperforate hymen and transverse vaginal septum, what is one difference?
Transverse vaginal septum will **NOT have vaginal bulge**
76
How do we confirm and treat **imperforate hymen?**
* Confirm: **US** and **hematocolpos**
* Treat: **Hymenectomy**
77
How do we dx and treat **transverse vaginal septum?**
* DX = **MRI**
* Treat: **Surgery**
78
List 4 labs that should be ordered for patient with **secondary amenorrhea**?
1. **Urine hCG (ALWAYS!!!)**
2. **TSH**
3. **FSH**
4. **Prolactin**
79
When a patient presents with **[secondary amenorhea = w/o a period for 6 months of last]**, what are the next steps we do?
1. Pregnancy test. If negative,
2. Check **TSH/Prolactin**
1. *NL prolactin, ABNL TSH* =\> hypothyroidism
2. *NL TSH, ABNL prolactin* =\>
1. Prolactin \>100 ng/mL =\> perform MRI to eval prolactinemia
2. Prolactin \< 100 ng/mL =\> look for other causes
3. *Both NL*
1. **Progesterone challenge test**
1. Positive = bleeding occurs =\> normogondatropric hypogonadism (PCOS is MC)
2. Negative = no bleeding occurs =\> means inadequate estrogen or outflow tract abnormality
1. **Estrogen progesterone challenge test** =\> takes 21 tests
1. Negative = outflow tract obstruction
2. Positive = ABNL HPO axis
1. **Check FSH/LH**
1. High =\> hypergonadotropic hypogonadism =\> ABNL ovary
2. NL/low =\> hypogonatropic hypodonadism =\> pituiary or hypothalamic abnormality
1. **MRI**
1. No tumor =\> hypothalamic cause
80
What do you do if prolactin/TSH are both NL?
**Both NL**
* Progesterone challenge test
* Positive = bleeding occurs =\> normogondatropric hypogonadism (PCOS is MC)
* Negative = no bleeding occurs =\> means inadequate estrogen or outflow tract abnormality
* Estrogen progesterone challenge test=\> takes 21 tests
* Negative = outflow tract obstruction
* Positive = ABNL HPO axis Check FSH/LH
* High =\> hypergonadotropic hypogonadism =\> ABNL ovary
* NL/low =\> hypogonatropic hypodonadism =\> pituiary or hypothalamic abnormality
* Conduct MRI
* No tumor =\> hypothalamic cause
81
Which test is done clinically in pt with seconary amenorrhea and normal TSH/prolactin; what is a positive and negative test?
- **Progesterone challenge test (PCT)** ---\> takes 7-10 days
- **Positive PCT = bleeding** --\> normogonadotropic hypogonadism; **most** **commonly** due to **PCOS**
- **Negative PCT** = no withdrawl bleeding; indicates inadequate estrogenization or an outflow tract abnormality
82
If an **estrogen/progesterone challenge tes**t is **(+),** but there is **elevated FSH and LH,** this indicates the abnormality is where?
**Ovarian**
83
What drug is most often used for the **progestin challenge test (PCT)**?
Dose and duration
* **Medroxyprogesterone acetate (Provera)**
* 10 mg po qd
* 7-10 days
84
What drugs are used for **estrogen/progestin challenge test?**
1. Conjugated equine estrogen (premarin)
2. Estradiol (estrace)
Followed by progestin
Takes 21 days
85
**Outflow obstruction** seen in secondary amenorrhea can be due to what?
1. **Asherman syndrome**
2. **Cervical stenosis**
86
What type of menorrhea is **mild hypothyroidism** associated with\>
1. **Hypermenorrhea**
2. **Oligomenorrhea**
3. Treatment reverses
87
What is the most common sx of hyperprolactinemia?
**Galactorrhea** = spontaneous flow of milk from breast
88
What should be done if we have ***REALLY HIGH*** hyperprolactinemia (\>100 ng/mL)?
Common causes?
* **MRI** of the head
1. **Pituitary adenoma**
2. **Empty sella syndrome**
89
What type of pituitary adenomas can we find on MRI?
1. Microadenoma (\<10 mm) on MRI
1. Slow growing and rarely malignany
2. Treat: manage symptoms and DA agonist: Bromocriptine/Parlodel
2. Macroadenoma (\>10 mm)
1. Treat: DA agonists
90
+ progestin challenge test means that our diagnosis is \_\_\_\_\_
* **Normogondotropic hypogonadism**
* 1. Nonclassical congenital adrenal hyperplasia = no genital abnormalities!!!
* 2. Cushings
* 3. Adrenal secreting tumor (DHEA-S \> 7000 ng/mL)
* **4. PCOS = MOST COMMON**
91
What is the leading cause of **female anovulatory infertility?**
**Polycystic ovarian syndrome (PCOS)**
92
60-70% of patients with **PCOS** will have what symptoms?
**Insulin sensitivity** =\> insulin hypersecretion
93
Diagnosis of **PCOS** needs to meet 2 of which 3 criteria?
1. **Oligomenorrhea** or **amenorrhea**
2. Biochemical or clinical signs of hyperandrogenism: **LH to FSH (2:1)**
3. **U/S** revealing **multiple small cysts beneath cortex of the ovary**
94
What is the effect of **elevated insulin** and **androgen levels** in pt's with PCOS?
↓ the liver prod. of sex hormone binding globulins (SHBG) ---\> **↑ in circulating testosterone**
95
Increase LH; decrease FSH in PCOS causes what?
* 1. Decrease follicular maturation and stimulation of stroma and theca cells
* 2. Decrease follicular maturation =\> chronic anovulation
* 3. Stim. of strom and theca cells =\> excess of androgens
* =\> excess of androgens go to adipose tissue =\> extraglandular aromatization that increases estrogen production =\> increase in LH; decrease in FSH
96
Chronic anovulation in PCOS causes what?
=\> unoppsed estrogen =\> **increase risk of endometrial cancer**
97
What are some of the **treatment** options for **PCOS**?
1. **Weight loss!**
2. **Oral contraceptives** --\> suppress FSH and LH --\> ↓ testosterone and estrogen will ↑ SHBG
3. Clomiphene citrate can induce ovulation
4. Ovarian diathermy/laser tx
5. Spironolactone and/or electrolysis
6. Metformin = insulin-sensitizing agent
98
If a **progesterone challenge test (PCT) is (-)** and a **estrogen (PCT) test is (+)**, what levels should be checked next?
**FSH and LH levels**
99
Estrogen PCT is positive =\> check FSH/LH levels. Results tell us what?
* 1. FSH \> 20 IU and LH \> 40 IU =\> hypergonadotropic hypogonadism
* 1. Menopause if over 40 (postmenopausal ovarian failure)
* 2. Premature ovarian failure if before 40
* 2. FSH and LH are \<5
* =\> perform MRI
* Tumor =\> pituiary tumor
* NL =\> hypogonadotropic hypogonadism
100
In evaluating a female pt with **hyperandrogenism** what should be suspected if the **DHEA-S levels are \>7000 ng/mL?**
**Adrenal androgen producing tumor**
101
In evaluating a female pt with **hyperandrogenism** what should be suspected if the **total testosterone is \>200 ng/dL?**
**Ovarian androgen producing tumor**
102
Difference between **hirsutism** and **virilization**?
1. **Hirsutism** =\> excess terminal hair in a male pattern bc hair follicles are exposed to excess androgens.
1. Not always pathological
2. **Virulization** =\> masculinzation of a F associated with marked increase circulating testosterone due to excess M hormones
103
Why is **acanthosis nigricans** a common finding in women with **PCOS**?
Due to the **↑ insulin resistance** and **hyperinsulinemia**
104
Look at levels of ____ to exclude CAH.
17-hydroxyprogesterone level
105
Define **polymenorrhea** and **oligomenorrhea**?
- **Polymenorrhea** = cycles \<21 days causing abnormally frequent menses
- **Oligomenorrhea** = menstrual cycles occuring \>35 days but less than 6 months
106
Define **menorrhagia**, **metrorrhagia**, and **menometrorrhagia**.
1. **Menorrhagia** = heavy and/or prolonged bleeding (\>80 mL and \>7 days) occurring at *_normal_* intervals
2. **Metrorrhagia** = irregular episodes of bleeding
3. **Menometrorrhagia** = heavy and irregular bleeding
107
What is **intermenstrual bleeding?**
**Scant bleeding** at ovulation for 1 or 2 days.
108
What is **DUB** (dysfunctional uterine bleeding)?
* Abnormal uterine bleeding usually due to aberrations in HPO axis, causing anovualation. Cannot be due to:
* Meds, coagulopathies, systemic diseases, trauma, organic
109
When does most **DUB** occur?
1. Around years of menarche (11-14 YO)
2. Perimenopause (45- 50YO)
110
What is the **PALM-COEIN** classification system for abnormal bleeding in **reproductive aged women?**
- **P**olyps (AUB-P) - **C**oagulopathy (AUB- C)
- **A**denomyosis (AUB-A) - **O**vulatory dysfunction (AUB-O)
- **L**eiomyoma (AUB-L) - **E**ndometriosis (AUB-E)
- **M**alignancy and hyperplasia (AUB-M) - **I**atrogenic (AUB-I)
- **N**ot yet classified (AUB-N)
111
1. **AUB- C** is associated with \_\_\_\_\_\_\_.
2. **AUB- O** is associated with \_\_\_\_\_\_\_
1. Heavy flow
2. Unpredictable menses with variable flow (PCOS)
112
What are availble **tissue sampling methods** for abnormal uterine bleeding?
1. **Office endometrial biopsy\*\*\***
2. Hysteroscopy directed endometrial sampling
113
What is the treatment for abnormal **MASSIVE** uterine bleeding?
1. **Hospitalization** and **transfusions** if hemodynamically unstable
2. **25 mg IV conjugated estrogens** then **hormonal** tx (Mirena)
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What is the treatment for abnormal uterine bleeding when moderate amount of blood?
**Combination OCP's, Mirena**
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