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50 Cards in this Set
- Front
- Back
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What is 1st hormonal sign of puberty?
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Increase in LH pulsatility at night
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What is the 2nd hormonal sign of puberty?
What does this lead to? |
LH and FSH pulses occurring thruout the day
This leads to increasing estrogen levels from the growing ovarian follicle → positive feedback from E2 finally initiates LH surge and ovulation → elevated progesterone levels + luteal phase |
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Why do many teens have irregular periods?
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Because ovulation is often inconsistent 1-2 yrs after menarche
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If teenagers continue to have irregular periods >2yrs after menarche, what might this indicate?
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A reproductive disorder
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What non-androgen hormone does estrogen stimulate?
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Growth hormone → IGF-I → increased somatic growth
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What non-androgen hormone does estrogen stimulate?
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Growth hormone → IGF-I → increased somatic growth
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What is adrenarche?
What is produced? At what age does it occur? |
1) Increased androgen production by the adrenal glands. It is NOT essential for normal ovarian function, and gonadal function is NOT essential for proper adrenal function.
2)The adrenals produce increased quantities of DHEA, DHEAS, and androstenedione 3) 6-8 yrs old |
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What effect does estrogen have on bone?
What is the difference between estrogen and growth hormone on bones? |
1) Increases bone growth (esp axial skeleton); promotes epiphyseal plate fusion (precocious puberty = grow early, but are short)
2) Growth hormone has more effect on long bones |
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What is the body type of a hypogondal pt?
Of a GH-deficient pt? |
1) Short trunk + long arms/legs
2) Long trunk + short arms/legs |
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What factors determine when puberty begins?
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Family history
Race (African American = earlier) Altitude (lower = earlier) Distance to equator (closer = earlier) Urban vs rural (urban = earlier) Obese or blind = earlier |
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What are factors that can lead to delayed puberty?
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Diabetes
Extreme obesity Poor nutrition Excessive stress Over-exercise |
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What is Frisch's critical body fat theory?
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Pt needs 17-22& body fat to initiate puberty (good for anorexic or obese teens)
But, this does not explain all teens |
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At what age is the HPG axis functional?
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20 WEEKS of life (prenatal)
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When do LH and FSH levels first peak?
When do they first flare? |
20wks gestational age
First 1-2 years of life |
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What is the accepted age range for onset of puberty?
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8-14 yrs
African American girls may start before 8 (this is normal) |
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What two ages are markers for delayed puberty needing workup?
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No secondary sexual characteristics by 14
Secondary sexual characteristics but no menarche by 16 |
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Should we workup isolated breast or pubic hair development in absence of other puberty signs?
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Usually warrants observation to exclude precocious puberty
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What is premature adrenarche thought to be an early sign of?
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PCOS later in life
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Which gender more commonly gets precocious puberty? (ratio?)
Delayed puberty? |
Girls (5:1)
Boys |
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How long (average) does puberty take in girls vs boys?
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Girls: 3yrs
Boys: 5yrs |
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Isosexual vs heterosexual precocious puberty?
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Iso: Premature puberty compatible with individual's genetic sex
Iso is way more common type!! Hetero: premature puberty with changes OPPOSITE of individual's genetic sex In girls this means xs androgen production from adrenals or ovaries |
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GnRH-dependent vs GnRH-independent precocious puberty?
Please give 3 alternate terms for each name |
Dependent: Premature re-activation of HPG axis → the hypothalamic pulse generator starts up too early
AKA: True, Complete, Central Indie: Early sex steroid production NOT from HPG axis AKA: Pseudo-puberty, Incomplete, Partial |
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What is “mixed picture” GnRH precocious puberty?
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Peripheral hormone production leading to HPG activation
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What percent of precocious puberty is idiopathic in girls?
In boys? |
Girls: 75%
Boys: 40% More MRI use might help find subtle changes that reduce these figures!! |
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What causes GnRH dependent precocious puberty? (2)
How to treat each? |
Idiopathic; tx w/ GnRH agonists (leuprilide acetate)
Tumors (hamartomas = MC); tx w/ surgery, rads, GnRH agonists |
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What causes GnRH independent precocious puberty? (7)
How to treat each? |
1) Functional ovarian cyst; surgery(?)
2) Granulosa cell tumor; surgery 3) Adrenal steroid producing tumor; surgery 4) McCune-Albright (aka polyostotic fibrous dysplasia) 5) Genetic mutation in gonadotropin-R, causing autonomous ovarian estrogen production (constitutional activation); tx = testolactone (inhibits aromatase) 6) Hypothyroidism; hormone replacement 7) Exogenous drug ingestion; stop taking drug! |
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In female, what is order of puberty? (4)
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Thelarche (breast bud)
Pubarche (pubes) Max growth velocity Menarche |
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What is only form of precocious puberty in which bone growth is delayed rather than advanced?
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Primary hypothyroidism
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What should you ask in H&P of pt w/ precocious puberty?
5 H, 6P |
H: Growth & puberty milestones
Family history (reproductive anomalies?) Any exogenous drug ingestion? Symptoms of thyroid disease? Neuro symptoms or hx of CNS insults? PEx: Ht, wt, %tle for age Tanner staging Neuro + thyroid exam Skin (cafe au lait spots?) Abdominal exam Pelvic & rectal exam (masses?) |
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What labs and rads for precocious puberty w/u?
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Serum E2, LH, FSH, TSH, hCG
Hetero: Add DHEAS, 17-OH progesterone, testosterone Left wrist bone age Pelvic US or CT (ovarian or adrenal masses?) Head MRI (tumors?) Skull XR (cystic lesions of McCune-Albright?) |
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What is McCune-Albright syndrome characterized by?
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Multiple cystic bone lesions
cafe-au-lait spots precocious puberty |
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What is w/u & ddx of pt w/ delayed puberty and primary amenorrhea?
Pt has NO breasts, YES uterus, High FSH |
High FSH? Hypergonadotropic hypogonadism
Get karyotype 45 XY = Swyer's 45X = Turner's syndrome or mosaicism 46XX = Many things (see other card) |
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No breasts, yes uterus, high FSH, 46XX pt differential? (6)
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1) Pure gonadal dysgenesis
2) 17-OHase deficiency 3) X chromosome deletion 4) FSH-R defect 5) Ovarian destruction: rads/chemo, viral, autoimmune (schmidt's), galactosemia 6) Myotonic dystrophy or Kennedy's disease. |
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What is w/u and ddx of pt w/ delayed puberty and primary amenorrhea?
Pt has NO breasts, YES uterus, Low/Normal FSH |
Low FSH? Hypogonadotropic hypogonadism
Image CNS Tumor: Pituitary or hypothalamic (craniopharyngioma) No tumor: Many things (see other card) |
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No breasts, yes uterus, low FSH, CNS image shows no tumor differential? (7)
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1) Kallman's
2) Gonadotropin deficiency 3) Constitutional: anorexia, xs exercise, systemic disease 4) GnRH-R defect 5) Histiocytosis X 6) Pituitary insufficiency 7) Hypothyroidism |
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What is w/u & ddx of pt w/ delayed puberty and primary amenorrhea?
Pt has NO uterus, YES breasts |
Take karyotype + Testosterone levels
XY: Androgen insensitivity XX: Uterovaginal agenesis |
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What are MC causes of primary amenorrhea AND delayed puberty?
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1) Gonadal dysgenesis (usually Turner's)
2) Uterovaginal agenesis 3) Androgen insensitivtity 4) Anorexia nervosa or extreme exercise |
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What is the incidence of primary amenorrhea?
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<1%
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What is secondary amenorrhea?
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No menses >6m
No menses for a total of 3 previous cycle intervals |
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What is the incidence of secondary amenorrhea?
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~0.7%
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What questions to ask in H&P of amenorrhea?
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History of coitus?
Nature and sequence of other pubertal events (primary) Hx of severe systemic illness or stress? Changes in sleep, thirst, appetite, smell? Headaches? Vomiting? Visual field defects? Fatigue? Galactorrhea? Pt on meds or chemo/rads? Ht? Wt? Pulse? BP? Evidence of low estrogen or hirsuitism? See normal reproductive tract on PEx? |
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What initial blood tests should be performed for pt w/ amenorrhea?
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Thyroid fxn tests
PRL level |
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Pt w/ galactorrhea and amenorrhea should have which test?
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Head MRI or thin-section coronal CT w/ contrast
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What is a progesterone challenge test?
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200mg IM progesterone in oil OR 300mg PO micronized progesterone OR 10mg PO medroxyprogesterone acetate for 5 d
Positive test = bleeding or spotting w/in 2-7 days of test. |
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What does a positive progesterone challenge test indicate? (4)
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Serum estrogen level > 40pg/mL
The anterior pituitary is making LH and FSH Endometrium and outflow tract are fxning If Thyroid fxn tests and PRL are normal, pt is anovulatory |
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What does a negative progesterone challenge test indicate? (7)
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1) Outflow tract defect, e.g.
Asherman's fibrosis 2/2 severe endometriosis cervical stenosis uterine agenesis imperforate hymen transverse vaginal septum 2) Hypoestrogen state |
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Pt has amenorrhea, normal TH/PRL, NO withdrawal bleeding on progesterone challenge – what tests and what do they indicate?
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LH & FSH
Low FSH = hypothalamic causes of amenorrhea High FSH = ovarian failure |
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What are MC causes of primary amenorrhea?
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1) Gonadal failure: Turner's; gonadal agenesis (1/3 of all cases)
2) Mullerian anomalies: Uterovaginal agenesis (1/5 of all cases) |
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What condition occurs in Mayer-Rokitansky-Kuster-Hauser syndrome?
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Uterovaginal agenesis
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Primary amenorrhea WITH breasts and WITH uterus? (5)
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Hyperandrogenic amenorrhea (PCOS)
Hypothalamic dysfunction Hypothyroid Hyperprolactinemia Obstruction (imperforate hymen os transverse vaginal septum) |
