Flashcards in Female and Male Puberty and Menstrual Cycle: Claudette Jones Shephard Deck (19)
Define normal and abnormal puberty
1) precocious puberty
2) delayed puberty
Normal sexual maturation occurs over 4 yrs and in a predictable sequence:
1) Growth acceleration
2) Thelarche- breast development (estradiol)** First noticed**
3) Pubarche- pubic hair development (androgens)
4) Maximum growth rate
5) Menarche - menstrual cycle begins
1) Onset of secondary sexual development prior to age 6 for African American girls and age 7 for white girls.
2) No secondary sex characteristics by age 13
No evidence of menarche by age 15-16
No menses within 5 years of thelarche
Describe principle causes of abnormal puberty
::Ovarian cysts. MCC follicular cyst. Pts often present after alarming episode of vaginal bleeding.
::Ovarian tumors (granulosa cell tumors, leydig cell tumors,, and gonadoblastoma are rare causes)
::Exogenous estrogen (kid taking mom's BC)
::Adrenal pathology (androgen secreting tumors, CAH)
::McCune-Albright Syndrome - Café-au-lait skin pigmentation characteristic
::Hypergonadotrophic hypogonadism- elevated FSH levels. MMC- Turner Syndrome. Tx w/ estrogen.
::Gonadal dysgenesis (normal or abnormal karyotype)
::Iatrogenic (tx of cancer, surgery)
::Hypogonadotropic hypogonadism- no GnRH secretion from arcuate nucleus.
20% due to constitutional delay (familial- AD).
Kallman syndrome- hypoplastic olfactory tracts, no GnRH from nucleus. Can't smell, delayed puberty.
::Anorexia, exercise, stress.
::hyperprolactinemia (inh. GnRH)
::Craniopharyngioma- most common tumor associated with delayed puberty
Discuss evaluation and tx of abnormal puberty
Eval./Tx. for precocious puberty:
::GnRH-dependent: MRI brain for tumor, Thyroid testing
Tx- GnRH analog, stops HPO axis and delays further development until appropriate time.
::GnRH-independent: pelvic ultrasound for ovarian cyst or tumor. Bone scan.
Tx- remove exposure, tx underlying condition (resect tumor).
::Physical exam: Tanner staging, vaginal patency, estrogen effect, pelvic masses, signs of Turner syndrome.
Tx: Address surgical/medical causes. Induction of puberty using progressive doses of estrogens.
What effect does mild/moderate obesity have on onset of puberty.
A rapid progression of puberty suggests a GnRH-dependent or independent cause?
GnRH independent (such as ovarian tumor)
Estrogen stimulation results in large breasts
Androgen stimulation results in lots of pubic/axillary hair
Discuss two causes of anatomic amenorrhea.
Mullerian agenesis- congenital absence of vagina and/or uterus and fallopian tubes. Normal ovaries.
Imperforate hymen- obstruction of menstrual blood. Pain in uterus and bulging vaginal introitus.
What is gonadarche and what regulates it?
Activation of the ovaries. Occurs when increased pulsatile GnRH secretion leads to increased production of FSH and LH. Begins around age 8. Leads to ovarian production of estrogen. This estrogen release triggers the characteristic physical changes associated with puberty: thelarche, pubarche, growth, menarche.
What is the earliest sign of pubertal development in males and what do you use to measure this?
4cc testicular volume. Measured w/ orchidometer.
1-3 cc prepubertal
List a few chemical factors that inhibit the secretion of GnRH.
Leptin (prolonged excess)
What is kisspeptin?
Signaling molecule that initiates release of GnRH and thus LH and FSH from anterior pituitary by binding to GPR54 receptor on GnRH releasing cells in hypothalamus.
What is minipuberty of infancy?
Describes the initial (in 1 day olds) spike in testosterone levels in infants. This drops down low before end of 1st yr and then resumes its peak during puberty and throughout life, slowly declines.
Describe the Tanner Stages for male puberty.
testicular volume less than 1.5 ml; small penis of 3 cm or less (prepubertal). Villus hair only. 5-6cm/yr growth. Adrenarche. (typically age 9 and younger)
testicular volume between 1.6 and 6 ml; skin on scrotum thins, reddens and enlarges; penis length unchanged . Sparse hair at base of penis. 5-6cm/yr growth. Body fat decreases. (9–11)
testicular volume between 6 and 12 ml; scrotum enlarges further; penis begins grows . Thick, curly hair to mons. 7-8cm/yr growth. Muscle mass increases. (11–12.5)
testicular volume between 12 and 20 ml; scrotum enlarges further and darkens; penis grows . 10cm/yr growth in height. Axillary hair, voice change, acne. (12.5–14)
testicular volume greater than 20 ml; adult scrotum and penis of 15 cm in length. Hair to thigh, facial hair. Growth stopped. (14+)
What is the role of the ovarian hormones estradiol and progesterone in the menstrual cycle?
- Estradiol increases toward and peaks at ovulation; then has another rise during the luteal phase
- Progesterone rises and peaks in the luteal phase
- Both are low during menses
What are the 2 key functions of the ovary?
1. Generation of a fertilizable oocyte with full competence.
2. Secretion of steroid hormones required for preparation of the reproductive tract for fertilization and subsequent establishment of pregnancy.
What are the 2 key functions of the endometrium?
1. Cyclic regeneration and secretion of substances that foster fertilization and implantation.
2. Development of vascular support and immunitary protection for establishment and progression of pregnancy.
What is the length of the menstrual cycle?
And how does it change physiologically?
- 28 to 35 days, with approximately 14 to 21 days in the follicular phase and 14 days in the luteal phase.
- Physiologically (normal changes): cycle length increases with age; it gets longer and longer up until menopause (then it stops)
What factors result in the onset of menses?
- decline in estradiol and progesterone release from corpus luteum
- loss of endometrial blood supply --> endometrial sloughing
- menses occurs approximately 14 days after ovulation
What factors would be considered when evaluating ovulatory dysfunction?
• Menstrual history
• Basal body temperature
• Serum progesterone
• Urinary LH excretion (LHkits)
• Oligo-amenorrhea testing
• Basal FSH