Session 3 - Group work Flashcards Preview

Semester 4 - Reproductive System > Session 3 - Group work > Flashcards

Flashcards in Session 3 - Group work Deck (35)

When is thelarche?

8-11 years


When is Adrenarche?

11-12 years


When is growth spurt in the ladies?

10-14 years


When is the menarche?

11-15 years


Precocious puberty is defined as physical signs of sexual maturation before 8 years or
menarche before 10 years old. Why might precocious puberty be stimulated by meningitis?

Irritation and inflammation stimulating early rises in GnRH secretion
True precocious puberty is caused by premature secretion of gonadotrophins - mostly
idiopathic, but can be caused by CNS lesions (hypothalamic tumours, post-encephalitis
neurofibromas etc.). Hence, irritation and inflammation such as meningitis can stimulate early
rises in GnRH secretion.


What are the effects of precocious puberty on a bone growth? Would you expect a girl
to be shorter or taller as an adult because of precocious puberty?

The growth spurt begins earlier and is terminated earlier, so that epiphyses may close at an
earlier stage of growth, making the individual shorter.


Delayed puberty commonly present as primary amenorrhoea, which is failure to
menstruate by the age of 16 years. What possible explanations might you consider if:
(i) plasma LH and FSH levels are in the normal range?

If gonadotrophin levels are normal, then either the ovary is not responding to them so no steroids are produced, or if the tissues are not responding to the steroids that are produced. If no steroids are produced, however FSH & LH levels should be raised. Another possibility is
that menstruation is occurring, but the products are not shed because of a vaginal or cervical problem


Delayed puberty commonly present as primary amenorrhoea, which is failure to
menstruate by the age of 16 years. What possible explanations might you consider if:
plasma LH and FSH levels are very low?
(ii) plasma LH and FSH levels are very low?

If gonadotrophin levels are low, then the problem is likely of pituitary or hypothalamic origin.
Some examples are pituitary tumours. Anorexia nervosa, malnutrition and psychogenic causes
also lead to hypo gonadotropic hypogonadism. Check serum prolactin and consider imaging for
a cranial lesion.


What would you examine to assess the stage of puberty of a boy behind his classmates?

To assess stage of puberty check height, weight, body hair, genitalia, bone age. Also ask
about medical history and medications. Delayed puberty is lack of sexual maturation by age 15 -
majority have constitutional delay - which is quite benign - and which represents normal
variation - often familial. Such boys will eventually undergo a normal puberty and attain normal
height. Constitutional delay is most probable in a healthy boy with delayed growth and bone


Consider that he is 14 years old. What proportion of normal 14 year olds would be
expected not yet to be exhibiting signs of puberty? What factors in his history might
make you feel that he is in this group?

The proportion would be very low (3-5%) since puberty in boys visibly begins between 9 and 14
years with scrotum and testicular development, however, full maturity may not be complete until
early 20's (e.g., facial hair).
If he has good general health and nutrition, also if a brother was a "late developer", you would
suspect constitutional delay of puberty and would give reassurance. Serious systemic illness
(e.g. diabetes, malabsorption can delay puberty).


Explain what is meant by ‘bone age’. How will this help in this boys case?

Accelerated growth is one of the earliest signs of precocious puberty and bone age can be
determined with hand-wrist films and compared with standards for the patient's chronologic age.
If his bone age is inconsistent with (behind) his chronologic age then constitutional delay is


You will want to assess where he is in his pubertal growth spurt. How will you do so?

Growth spurt in boys is approx 10cm/year-so height comparisons over time are useful.


When does the growth spurt occur in relation to the other events of puberty in boys?

The growth spurt starts about 12 months after the first signs of puberty (increase in testicle size
due to FSH induced increase in seminiferous tubules)


Could it be that the boy is starting puberty, but his parents have not noticed it? Why may
they not have noticed the early stages?

Early signs of puberty in boys are the increase size of testes followed by reddening of scrotal
skin and elongation of penis-his parents may not be aware that these changes are occurring.


Might he be producing sperm?

High intra-testicular levels of testosterone are needed for spermatogenesis-so it is doubtful


If he did have a problem of delayed puberty, what test would you use to distinguish
between defects in the gonads and defects primarily in the hypothalamus/pituitary?

If FSH is low, suspect hypothalamic/pituitary.
If testosterone is low, suspect hypogonadism.


What is the lower age limit of normal puberty in boys?

Ten years


How would you assess this boy's stage of puberty?

Height, weight, genitals, body hair, bone age.


What will be the possible consequences of early puberty?

Short stature-premature growth spurt - epiphyseal closure


What are the common causes of early puberty in boys?

True precocious puberty - premature secretion of gonadotrophins - leads to testicular androgen
production and sperm production and virilisation - mostly idiopathic. Can be caused by CNS
lesions, thus evaluation and follow-up is needed. Precocious pseudopuberty results from
secretion of androgens from adrenal glands or testis, virilisation occurs but not sperm
production (most commonly caused by adrenal hyperfunction-congenital adrenal hyperplasia).


What might you do to delay puberty in this case? What other help might he need?

Treatment of underlying condition, e.g. CNS lesion if present. Drugs to inhibit pituitary
gonadotrophin secretion, (medroxyprogesterone or LHRH analogues) or to block androgen
action,( cryproterone ). These drugs do not usually prevent epiphyseal closure. The boy may
also need counselling about social issues related to precocious puberty .


You decide that he has isosexual precocity, which is manifest in males as virilisation, but
no more. What disorders of the adrenal gland may cause these signs?

He may have adrenal hyperfunction - congenital adrenal hyperplasia (from 21-hydroxylase or Il-hydroxylase deficiency)
or an adrenocortical tumour.


How might you differentiate between these possibilities?

Congenital adrenal hyperplasia: Biochemical tests of enzyme levels (patients have elevated
serum 17-hydroxyprogesterone levels).
Adrenal tumours can be seen by imaging studies - sonography, CT, NMR.


There is a gradual depletion of ovarian follicles as a woman proceeds toward the
menopause such that the secretion of oestrogen declines dramatically. What will
happen to plasma levels of the following hormones?

FSH: rises considerably
LH: rises


What will happen to GnRH secretion from the hypothalamus?



Why do these changes occur?

As gonadal steroid production falls there is loss of negative feedback to the pituitary and


Why are the changes in LH and FSH secretion different?

No inhibin from ovary so selective inhibition of FSH no longer occurs and it thus rises
more than LH.


List at least 5 effects of oestrogen depletion that menopausal women may experience.

hot flushes
poor sleep
vaginal/urethral atrophy dysparunia/dysuria
breast atrophy
mood change/depression
osteoporosis/posture & height change/increased fracture risk
changing cholesterol/lipid profile & possible increased risk of CHD


What treatments or preventive measures might you consider for menopause problems?

Oestrogen HRT Calcium

(HRT is comprised usually of a mixture of oestrogens and progesterone, which are either
synthetic or extracted from pregnant mares’ urine.)


What possible disadvantages are there to HRT?

Increased risk of thromboembolism, breast cancer


Why are oestrogen only preparations not given to women who have not had a

Unopposed oestrogens cause proliferation of uterine lining with a risk of endometrial
cancer. Progesterone inhibits this.


How are fibroids diagnosed?

Most fibroids are asymptomatic.
The most common symptom is abnormal bleeding, typically menorrhagia and the women is
usually in her 40s.
Large fibroids may be palpable on bimanual examination (irregularly shaped uterus)
examination by anaesthesia and curettage or by laparoscopy.
ultrasound may show the presence of a mass but may not distinguish other ovarian tumours.


How would you assess whether menstrual blood loss is sufficiently great to have
adverse effects?

Menorrhagia is usually defined as menstrual loss greater than 80ml which will produce
anaemia. Assess by pad and tampon counts and measuring haemoglobin/haematocrit levels.


What options are there for treating this condition (i) in a woman under 35, (ii) in a woman
nearing the menopause?

Treatment options< 35-depends on size/symptoms/desire for fertility
Wait and see with serial exams and monitoring of blood loss
Non-surgical options with GnRH agonist
Surgery with endoscopic resection or abdominal myomectomy or hysterectomy.
Peri-menopausal patients will often benefit from spontaneous shrinkage with age


1 It is common for women in their forties to have a hysterectomy, which usually involves
removal of both uterus and ovaries. What might be the advantages and disadvantages
of removing the ovaries as well as the uterus? What evidence bases would you quote in
helping a woman to decide whether to have her ovaries removed?

Strictly speaking a hysterectomy is the removal of the uterus.
Women in their forties may be counselled on the risks and benefits of bilateral oophorectomy in
conjunction with hysterectomy.
Potential benefits include, avoidance of ovarian pathology in the future(although some ovarian
type tumours can arise from the peritoneum de novo)
Potential disadvantage, sudden onset of menopause as the albeit aging ovary is removed and
loss of ovarian androgen