Week 2 pt 1 Flashcards by Morgan Evans

1) Define menstrual cycle
2) How long does it last?

1) Cyclic & predictable sequence of ovulation followed by menstrual bleeding (if pregnancy does not occur)
2) ~30 yrs of cycles (ages 15-45)

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What are some reasons for interruptions in the menstrual cycle?

Pregnancy, lactation, illness, GYN & endocrine disorders, & exogenous factors (hormone-based contraceptives & some medications)

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1) What is the duration of the menstrual cycle?
2) What is the duration of menstruation?

1) 28 days (+/- 7 days) from day 1 of one cycle to day 1 of next cycle
2) 3-7 days

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List and describe the 3 phases of the menstrual cycle

1) Follicular (menstruation) phase (~14 days duration but can vary): Begins with onset of menses; ends with LH surge
2) Ovulation: Occurs within 30-36hrs of LH surge
-Mittelschmerz
3) Luteal phase (~14 days duration): Begins on day of LH surge; ends with the 1st day of menses

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Which phase is more likely to vary, follicular or luteal?

Follicular

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What regulates the cycle by interactions between hormones?
(GnRH, LH, FSH, & ovarian sex hormones: estrogen and progesterone)

Hypothalamic-pituitary-gonadal axis

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What are the 2 sources of follicular androgens and estrogens?

Granulosa cells produce estrogens (estrone and estradiol)
Theca cells produce androgens (androstenedione and testosterone)

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Define ovulation

progesterone-secreting ovarian cyst (corpus luteum)

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1) How many follicles are at birth? What happens during childhood?
2) What happens during the follicular phase?

1) 1-2 million primordial follicles at birth; childhood follicular atresia (leaving ~300-500K follicles at menarche)
2) Preparation of egg for ovulation

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Luteal phase:
1) What occurs?
2) What happens if fertilization doesn’t happen?
2) What if it does happen?

1) Corpus luteum produces estrogen and progesterone  endometrium prepares for implantation
2) corpus luteum degenerates, progesterone levels fall, the endometrium is not maintained menstruation occurs.
3) hCG is produced by early embryo tissue to help support the endometrium then is produced by the placenta beginning at 8-10wks gestation

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Describe the endometrial cycle

1) Proliferative and secretory phases
2) Entire endometrium expelled during menstruation (except basal layer)
3) Aided by prostaglandin-associated uterine contractions

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Endometrial cycle:
1) What hormone changes happen in the follicular phase?
2) What hormonal shift happens during ovulation?

1) Rise in estrogen levels stimulates endometrial cell growth and healing
2) Shift from estrogen to progesterone

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Menstrual cycle:
1) What converts from proliferative to secretory phase?
2) Withdrawal of _________________ (end of luteal phase) results in endometrial breakdown & sloughing
3) If no ovulation, endometrium continues to thicken, _______________ production continues, & it outgrows its blood supply and sloughing intermittently (abnormal uterine bleeding AUB

1) Progesterone
2) progesterone
3) estrogen

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1) What type of process is puberty?
2) Define puberty
3) Is it a short or long process?

1) Puberty = endocrine process
2) Physical, emotional, and sexual transition from childhood to adulthood
3) Gradual process: well-defined events and milestones

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Hypothalamic-pituitary-gonadal axis:
1) When does it begin functioning? When is it suppressed?
2) What is part of puberty is it involved in? Explain.
3) What hormones does it trigger?

1) Begins functioning as fetus; suppressed at a few weeks old (estrogen)
2) Initial endocrine changes associated with puberty
10-11yo: Androgens (DHEA, DHEA-S, androstenedione) rise leading to adrenarche
3) Axis reactivates during puberty triggering GnRH production (from hypothalamus) leading to pulses of LH and FSH

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What are the 5 stages of sexual maturation?

1) Growth acceleration (often missed as the first step)
2) Thelarche (breast development)
3) Pubarche (pubic hair development)
4) Maximum growth rate
5) Menarche

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1) Breast development & pubic hair quantified by what?
2) During which stage does not a lot happen?

1) Tanner Staging
2) Stages 1-2

1) There is _____________ puberty with mild (BMI 30-34.99)-to-moderate (BMI 35-39.99) obesity
2) Are there any ethnic differences?

1) earlier
2) Yes

Precocious Puberty:
1) Define this term
2) What are the 2 causes?

1) Onset of secondary sexual characteristics prior to age 6 in African-American girls & age 7 in Caucasian girls
2) a) GnRH-dependent sex hormone production = true (central) precocious puberty
b) GnRH-independent sex hormone production = precocious pseudopuberty (peripheral)

What should a workup for precocious puberty include? (tests)

LH
FSH
Estradiol
DHEA-S
17-hydroxyprogesterone (can indicate adrenal iss.)
TSH, FT4
Bone age
If central, MRI of brain and pituitary
If peripheral gonadal tumor, tumor markers (a-fetoprotein, hCG, CEA)

Describe GnRH-dependent (central) precocious puberty

1) More common than GnRH-independent
2) Early activation of HPG axis: Idiopathic cause most common
3) Early maturation
4) Elevated estrogen: Lead to short stature in adulthood
5) May promote psychosocial problems and should be addressed carefully

Describe GnRH independent (peripheral) precious puberty

1) Sex hormone production (androgens or estrogens) independent of HP stimulation
2) Exam may reveal a palpable pelvic mass  further evaluation/imaging

1) What are the 2 main goals for precocious puberty Tx?
2) How do you Tx GnRH-dependent?
2) What abt GnRH-independent?

1) Arrest and diminish sexual maturation until normal pubertal age
Maximize adult height
2) GnRH agonist
3) Suppress gonadal steroidogenesis (based on cause)

Evaluation for primary amenorrhea considered in what 3 scenarios?

1) Menarche not reached by age 15 or
2) Menarche not reached within 3 years of thelarche or
3) Lack of thelarche by age 13

What should you evaluate when considering delayed puberty?

Past general health Height Dietary habits Exercise patterns Sibling & parent puberty details Pubertal development absent or stalled?

Hypergonadotropic hypogonadism: 1) Define this 2) Most common cause of delayed puberty with an elevated FSH is what?

1) Primary ovarian insufficiency results in low levels of estradiol but elevated levels of gonadotropins (LH, FSH) 2) Turner syndrome (45 XO; gonadal dysgenesis); FSH >30

How should you Tx Hypergonadotropic hypogonadism?

1) Growth hormone & estrogen -GH very early; before estrogen, to normalize adult height -Estrogen: at “normal time” of puberty, careful dosing 2) Progestin at Tanner stage IV

Hypogonadotropic hypogonadism: 1) Define this 2) What is the most common cause? Describe it 3) Describe Kallmann syndrome 4) How would you find a Craniopharyngioma (pituitary) tumor causing delayed puberty?

1) Dysfunction of hypothalamus causes no LH or FSH secretion (FSH + LH <10) > ovaries not stimulated > no estradiol secreted > delayed secondary sexual maturation 2) Constitutional (physiologic) delay (20%): Usually familial; delayed secondary sexual maturation & short stature (aka just "late bloomers") 3) Hypoplastic olfactory tracts & no GnRH secretion Anosmia & no breast development 4) MRI to locate calcified cyst

Müllerian Agenesis (Paramesonephric agenesis): 1) What is it? 2) What does the normal ovarian function assoc. with this lead to? 3) What are other abnormalities assoc. with this? 4) What is the Tx?

1) Congenital absence of vagina (uterus & fallopian tubes usually absent as well) 2) Secondary sexual characteristics of puberty appear at appropriate time 3) Renal & skeletal abnormalities 4) Creation of artificial vagina with dilators & pressure or surgical treatment construction

Imperforate hymen: 1) Define this 2) How can this seem like delayed puberty? 3) S/Sx? 4) Tx?

1) Incomplete genital plate canalization so hymen is closed 2) Menarche occurs at appropriate time but not apparent since outlet is blocked 3) Presents with pain in area of uterus & bulging, bluish-appearing vaginal introitus 4) Hymenotomy

Premenstrual syndrome (PMS): 1) Define 2) When does it occur? 3) When does it resolve? 4) How severe is it? 5) How many women does it affect?

1) Group of physical, mood-related, & behavioral changes Occur in regular, cyclic relationship to luteal phase of menstrual cycle AND interferes with some aspect of patient’s life Occur in most cycles Resolve with onset of menses (OR by cessation of menses) Varying in degrees of severity AND disruption of work, home, & leisure life Affects 75-85% women (mild PMS) Significant disruption of daily life in 5-10% women (moderate PMS)

What are the core Sx of PMDD?

depressed mood, anxiety or tension, irritability, or anhedonia

Premenstrual dysphoric disorder (PMDD): 1) What is it? 2) What are the DSM-5 criteria? 3) When does it occur?

1) More severe form of PMS (3-5% of women) 2) Specific set of at least 5 of 11 possible symptoms (of PMS) with at least 1 core symptom (depressed mood, anxiety or tension, irritability, or anhedonia) 2) During luteal phase

PMS & PMDD: What 3 things do both have in common?

1) Pathophysiology for both not well established 2) Both occur during luteal phase of menstrual cycle 3) Both should not be confused w. with molimina (normal cyclic ovulatory symptoms not interfering with daily routine)

1) How do you Dx PMS? 2) What does PMDD Dx require? 3) When do both begin?

1) Based on either mood OR physical symptoms 2) Mood-related symptoms 3) With menarche or later in life

Describe how to Dx PMS

**>1 of the following symptoms during the 5 days before menses in each of 3 menstrual cycles** (and relieved within 4 days of onset of menses): 1) Behavioral Sx: Mood lability, Depression, Angry outbursts, Irritability, Anxiety, Confusion, Social withdrawal 2) Somatic Sx: Abdominal bloating, Fatigue, Breast tenderness, Headache, Swelling of extremities

PMS & PMDD: 1) Are there exam or lab markers for diagnosis? 2) What does Dx rely on? What can help? 3) Are there specific physical findings diagnostic of PMDD? 4) What 2 labs are reasonable to order? 5) What 2 things are common in young menstruating women but not more common in patients with PMS or PMDD?

1) No exam or lab markers for diagnosis 2) Diagnosis relies on relationship of symptoms to luteal phase Menstrual diary in 2 or more cycles 3) No specific physical findings are diagnostic of PMDD 4) CBC & TSH reasonable to order 5) Anemia & hypothyroidism

Give examples of Nonpharmacologic Treatment for PMS/ PMDD

1) Daily record & diagnosis may be therapeutic (“not going crazy”) 2) Continue record to monitor effectiveness & guide therapy 3) Dietary discretion (fresh instead of processed foods) 4) Aerobic exercise (instead of static/weight-lifting) 5) Calcium carbonate & magnesium supplementation

Pharmacologic Tx for PMS: 1) What are effective for dysmenorrhea, breast pain, & leg edema? 2) What only decreases bloating?

1) NSAIDs effective for dysmenorrhea, breast pain, & leg edema 2) Spironolactone OCPs help some patients with PMS (*1st step if also requires contraception) Drospirenone/ethinyl estradiol only in PMDD

SSRIs are gold standard for PMDD, but: 1) When are they effective? 2) Which 3 are FDA approved? 3) What are the side effects?

1) When dosed continuously or intermittently 2) Fluoxetine, sertraline, paroxetine 3) GI upset, insomnia, sexual dysfunction, weight gain, anxiety, hot flushes, nervousness

Describe Danazol & GnRH agonists for PMDD

Effective in short-term studies Long-term effects not evaluated Significant (often prohibitive) side effects Possible use as trial before oophorectomy

________________ should only be performed for severe PMDD & failure of meds (other than GnRH agonists)

Oophorectomy