Obgyn 13 - Menarche

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Definition of puberty

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series of events where child matures into adult. Includes development of secondary sex characteristics, the growth spurt and achievement of fertility

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Stages of Puberty

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Adrenarche
Gonadarche
Thelarche
Pubarche
Growth spurt
Menarche

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Adrenarche

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**Occurs around age 8
Secretion of sex steroid hormones like DHEAS, DHEA, androstenedione

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Gonadarche

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Begins around age 8
Leads to stimulation of gonadotropins in anterior pituitary (LH/FSH)

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Thelarche

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10-11 yrs old
Development of breast buds

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Pubarche

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11-12 y.o.
Start growth pubic and axillary hair

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Growth Spurt

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11-12 y.o.
Acceleration due to GH and somatomedin-C

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Menarche

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1st menstrual blood
Usually occurs 2 yrs after thelarche (12.8 yo), typically at breast Tanner stage 4

Avg ht 5'2"
Avg wt 105 lbs

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Average age females have adult pubic hair, breast?

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Adult pubic hair-13.7 y.o.
Adult breast-14.6 y.o.

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True biological marker of puberty.

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Menarche

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Menarche - onset depends on?

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Depends on hypothalamus, pituitary, ovary.
Critical body weight (20% fat)
good nutrition
absence of debilitating disease

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Hormones in Menarche

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Marked increase by age 11 of estrogen, progesterone
FSH peaks at approximately 13 y.o.
Rapid increase in LH just before menarche (approx. 1 year) → onset menarche.

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Connection btw body fat and hormones?

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increased body fat → increased aromatization of androgens → estrogens → positive feedback to hypothalamus and pituitary → LH surge.

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*Effects of Estrogen and Menarche:

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Vaginal secretions increased
Vaginal pH decreased
Vaginal mucosa thickens, rugated
Increase size labia, uterus, ovaries

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Menarche- association with Growth:

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*Increased growth hormone (GH) 3-4 years before menarche → growth spurt.

Growth slows near menarche due to increased estrogen → decreased GH.

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Purpose of the Menstrual Cycle

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Oocyte for fertilization and prepare uterus for pregnancy

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Frequency of menstrual cycle (mean length?)

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28 days (+/- 7 days)

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*When are menstrual cycles most irregular?

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The first 2 years after menarche, and
the 3 years before menopause

anovulation (absent ovulation) is most common.

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menses duration?

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3-5 days

(range 1-8 days)

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Blood loss during menstrual cycle

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Approximately 30-50 ml

range: spotting to 80 ml
> 80 ml is abnormal bleeding

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Amt = abnormal bleeding during menses?

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>80 ml

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Menstrual blood consists of:

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dark red, non-clotting, mostly arterial blood (25% venous)
Contains tissue debris, prostaglandins, large amounts of fibrinolysin from endometrial tissue

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Blood clots in menses?

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**Fibrinolysin lyses clots in menstrual blood unless the bleeds are very heavy.
“Clots” are really tissue

Menstrual blood is NON-CLOTTING

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Early Cycles and Transition to Regular Ovulation:

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1st yr: 50% anovulatory cycles, in regular intervals
1st 2 yrs: 90% cycles in normal ranges (freq, duration)
7th yr: 90% cycles ovulatory

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Menorrhea

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Normal discharge of menses

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*Polymenorrhea:

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Menstrual cycles that occur at short intervals (less than 21 days)

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*Oligomenorrhea:

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Infrequent menstruation.
Menstrual cycles that occur at long intervals (more than 35 days).

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Menorrhagia

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Excess or prolonged uterine bleeding at regular intervals.

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Metrorrhagia

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Uterine bleeding at time other than expected menses;
irregular bleeding.

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Menometrorrhagia:

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Excessive uterine bleeding both during menses and at irregular intervals.

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Menostaxis

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Excessively prolonged menstruation;

aka menorrhagia; hypermenorrhea.

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Menorrhalgia

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Dysmenorrhea
Painful menses

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Menoschesis

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Retention of the menses.

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Menostasia/menostasis

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amenorrhea

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Phases of Menstrual Cycle:

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*Two phases:

Follicular (proliferative ) phase
Luteal (secretory) phase.

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Follicular (Proliferative) Phase: when?

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*1st day of menses to ovulation.

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Follicular (Proliferative) Phase: what?

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Endometrial glands proliferate under the influence of estrogen (mostly estradiol).

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Follicular (Proliferative) Phase: *Features

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1. Variable length
2. Low basal body temp
3. Development ovarian follicles
4. Vascular growth endometrium
5. Secretion estrogen from ovary
6. +/- cramps on days 1-2 with prostaglandins (PGF2 alpha)
7. Vag epithelium thickens, incr transudation --> lubrication from estradiol

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Luteal (Secretory) Phase: when?

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*ovulation to onset of menses

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Luteal (Secretory) Phase: what?

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*Under the influence of progesterone

Endometrial glands develop the secretory status necessary for implantation of embryo.

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Luteal (Secretory) Phase: *Features

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1. Regular duration 12-16 days
2. Elevated basal body temp (>98 F)
3. Formation corpus luteum in ovary, with secretion of progesterone and estrogen.
4. Endometrial changes: tortuous glands, secretion, stromal edema and decidual reaction.
5. Vagina -decrease in secretory changes
6. Decr sex desire, pleasure

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*The menstrual cycle involves the interaction of what hormones?

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GnRh, FSH, LH, and sex steroids (androstenedione, estradiol, estrone, and progesterone)

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GnRH

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*Hypothalamic hormone; controls gonadotropin release.

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Secretion of GnRH:

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*GnRH secreted in a pulsatile manner.
1 pulse/hr typical of follicular phase
1 pulse every 2-3hrs luteal

Secreted into portal circulation --> anterior lobe pituitary

?mechanism; influenced by estradiol, catecholamines.
Amplitude, frequency regulated by feedback of estrogen, progesterone, NTs

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Action GnRH:

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*Stimulates synthesis and release of both FSH and LH from the same cell.

Causes a rapid (30 min) increase FSH and LH , then a slower (90 min) release of LH.
High, prolonged stim --> saturates GnRH receptors --> inhibits FSH and LH secretion

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Gonadotropins

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FSH and LH
Protein hormones secreted by anterior pituitary

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*FSH receptors primarily on

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granulosa cell membrane

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*FSH

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Mainly acts on granulosa cells→ stim follicular growth.
Stimulate formation of LH receptors
Stimulate follicular growth by increasing both FSH and LH receptors in granulosa cells.
Stimulates follicular growth by increasing both FSH and LH receptors in granulosa cells.
Estradiol enhances action.

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*LH receptors on

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theca cells at all stages of cycle, AND

granulosa cells after follicle matures under influence of FSH and estradiol

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*LH

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stimulates androgen synthesis by theca cells.

When enough receptors on granulosa cells, directly causes luteinization (formation of corpus luteum) and production of progesterone.

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Estrogen Production:

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LH → theca cells → produce androgens (androstenedione and testosterone) → androgens transported to granulosa cells

FSH →enzyme aromatase in granulosa cells→ Androgens are aromatized to estrogens (estradiol and estrone)

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Progesterone Production: Depends on

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*Depends on FSH/LH

Production begins approximately 24-hours before ovulation and rises rapidly.
Maximum production is 3-4 days after ovulation and is maintained approximately 11 days. If there is NO fertilization and implantation, → rapid decrease in Progesterone

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Progesterone Production: Needed for

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*Needed for implantation of fertilized oocyte into endometrium and to sustain pregnancy early on in the first trimester. (corpus luteum)

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Progesterone Production: Neg Feedback on

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*Negative feedback on FSH/LH.
Decreased FSH and LH in luteal phase.

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Oogenesis:

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In a cycle, one oocyte matures before ovulation

Multiple oocytes stimulated to partial maturation but undergo atresia
Unknown reason why

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Primordial Follicle:

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Covered by single layer of granulosa cells

Develop into preantral follicles; sometimes even without gonadotropin stim

Process occurs in all cycles (ovulatory and anovulatory)

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Preantral Follicle:

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Increase in number of granulosa cells in primordial follicle by FSH

Increase estradiol → stim preantral follicle growth, reduces follicle atresia, and increases FSH action

Almost all become atretic

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Antral Follicle:

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*Dominant follicle secretes the most estradiol
*Rising estradiol → negative feedback on FSH secretion→ halts development of other follicles
*Rising estradiol→positive feedback on LH secretion

FSH induces appearance of LH receptors on granulosa cells.

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*Follicular rise in estradiol causes positive feedback on LH secretion:

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1. LH levels rise steadily during late follicular phase
2. LH stimulates androgen production in the theca cells
3. Dominant follicle uses the androgen to further accelerate estrogen production.

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Preovulatory Follicle:

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*Estrogens rise rapidly; peak 24-36 hrs before ovulation
LH increases steadily until midcycle, then surge, with lesser surge of FSH.
LH initiates luteinization & progesterone production in granulosa layer.

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midcycle FSH surge caused by:

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Preovulatory rise in progesterone

by enhancing pituitary response to GnRH and facilitating positive feedback action of estrogen.

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*Ovulation occurs when? (hormone-wise)

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approx 10-12 hours after LH peak and 24-36 hours after estradiol peak.

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most reliable indicator of timing of ovulation?

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*The onset of the LH surge (28-32 hrs prior to ovulation)

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Ovulation:
*LH surge stimulates:

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1. Completion of reduction division in oocyte
2. Luteinization of granulosa cells
3. Synthesis of progesterone, prostaglandins within follicle

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What is responsible for the digestion and rupture of the follicle wall?

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*Prostaglandins and proteolytic enzymes rupture wall
(cramping at ovulation)

Mid-cycle rise in FSH (progesterone dependent) frees oocyte from follicle and ensures sufficient LH receptors for adequate luteal phase.

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Corpus Luteum: forms from what?

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from cells that surrounded the oocyte.

2.5 cm diameter, deep yellow in color.

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Corpus Luteum lifespan, if no pregnancy?

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13-14 days

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*Peak levels of progesterone ?

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at 8-9 days after ovulation
(approximates the time of implantation of embryo)

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*A defective luteal phase can contribute to both infertility and early pregnancy loss.

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Good pre-ovulatory follicular development necessary for normal luteal function.
Accumulation of LH receptors during follicular phase has major impact on extent of luteinization and functional capacity of corpus luteum.

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*In early pregnancy, what maintains luteal function?

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hCG maintains luteal function, with secretion of progesterone, until placental steroidogenesis (production of progesterone) is established.

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Menstruation

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*Absence of pregnancy→ decrease in steroid levels
→ spiral arteries of "functional endometrium" constrict
→ischemia and degradation of endometrial tissue
→desquamation/shed →bleed/menses

Within 2 days of onset of menses, surface epithelium begins to regenerate under influence of estrogen and continues while endometrium is shedding.

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Lesbian Health in Primary Care:
some disease topics

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Mental health
Breast and gynecologic cancer
Smoking, obesity, coronary risk
STIs/STDs

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Most common STI in WSW

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*Bacterial vaginosis

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Likely STIs among WSW

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1. BV
2. Trichomonas
3. Genital herpes
4. HPV

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Uncommon STIs among WSW

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syphilis, hepatitis A and HIV

Hepatitis B and HIV more likely if also IVDA

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Not yet documented STIs among WSW

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Sexual transmission of Chlamydia, gonorrhea, hepatitis B and hepatitis C

Risk if also have sex with men, or recent history of sex with men

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hepatitis B and WSW

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offer everyone the vaccine
IVDA --> use own needles, clean with bleach, give vax