Delayed puberty
Secondary sex characteristics have not appeared in
girls by age 13- not breast development, no pubic hair
boys by age 14- Penis enlargement, pubic hair
95% of cases: constitutional delay
5% caused by some type of disruption of the
hypothalamic-pituitary-gonadal axis
--social implications like bullying, low self esteem/ confidence
Avg age for breast development
10.4 Yrs causation
9.5 African American
should have breast development by age 13
Avg age for period beginning
12.6 white, 12.1 AA
Puberty before age 8 prevelance
5% white, 15% AA
-Social limitations, bullying, pedophile attention
Precocious puberty
Sexual maturation before:
age 6 in black girls
age 7 in white girls
age 9 in boys
Dysmenorrhea
painful menstruation. 50% women.
Complain of cramping in lower pelvic/ back/ thighs.
Primary dysmenorrhea
10% (of the 50%) incapacitated for 1-3 days
More common in adolescents
Believed cause of painful periods= 10% more prostaglandin
(myometrial stimulant causes vasoconstriction-> uterine
hypercontractibility-> decreased blood flow to uterus->
increased nerve sensitivity)
Related to the duration and amount of menstrual flow
Secondary dysmenorrhea
Painful menstruation related to pelvic pathology- ex: ovarian cyst,
STD. can be corrected by removing stimulus.
Can occur any time in the menstrual cycle
Primary amenorrhea
Absence of menstruation by age 14 (avg).
Has secondary sex characteristics, but no period 13-14
Has no secondary sex characteristics or period by 15-16
--May be caused by hormonal imbalance or congenital defect. Investigate.
Secondary amenorrhea
Had periods, then they randomly stop for 3+ cycles/ 6months
First thing to rule out: pregnancy
May also be caused by: decreased adipose tissue (anorexia,
athletes), contraceptives, medication side effects, drug use, stress,
disease processes (PCOS)
Where is estrogen stored?
Adipose tissue
Causes of Primary Amenorrhea
-Congenital defects of gonadotropin production
-Genetic disorders- turners syndrome
-Congenital central nervous system defects
-Congenital anatomic malformations
-Acquired CNS lesions
-Pituitary tumor- increase prolactin-> stop period
Causes of Secondary Amenorrhea
Pregnancy
Dramatic weight loss (Malnutrition or excessive exercise)
Hyperprolactinemia- pituitary tumors
Hirsutism- excessive hair growth in female: facial hair, areola
hair, abdomen/ lower back hair. Underlying hormone imbalance
Oligomenorrhea
Only a little bit of bleeding on period
Contraceptives, hormone levels, stress, Athletes, pregnancy
Menorrhagia
excessive amount of bleeding
More than 5-7 days or 70-80mL of flow
Cant really measure. More than a pad/hr
Causes: steroids, changing contraceptive (deproverha over time),
med side effects, hormone levels (after birth), thyroid levels,
disease processes (Endometriosis)
Metorraghia
bleeding between periods`
Menometorrhagia
Heavy menstrual bleeding & bleeding between periods
Polycystic ovarian syndrome (PCOS)
Difficulty becoming pregnant (don�t ovulate), leading cause of infertility
Signs: scant/ no periods. High androgen levels (male
characteristics), ovary full of cysts on ultrasound
Systemic: affects whole body. May cause hyperisulinusm,
hypertension, and high lipid levels
Education on management and health choices: exercise, diet, keeping
levels down
Premenstrual syndrome (PMS)
Cyclic physical, psychological, or behavioral changes that impair
interpersonal relationships or interfere with usual activities
Greater than 200 physical, emotional, and behavioral signs and
symptoms (Every woman is different)
Bloating (pelvic and breast), irritability, mood swings, headaches,
food cravings, fatigue, breast tenderness
Occur week before period starts
Suggestions to decrease PMS
increase B6 Levels: egg yolks, pork, milk, legumes. Believed to
increase serotonin levels and reduce symptoms
Premenstrual dysphoric disorder (PMDD)
3% to 8% of women
Exaggerated PMS. Requires Meds (SSRI, antidepressant). Mood disorder
Pelvic inflammatory disease (PID)
Some part of the female reproductive tract is inflamed (acute, caused
by infection)
Complaints: Pain with intercourse (Positive Cervical Motion
Tenderness:CMT), Spotting after intercourse, abdominal pain, pain with
movement, infection=discharge
STD Screening (STDs are big culprit)
PID Types
Salpingitis- inflammation of fallopian tubes
Oophoritis- inflammation of ovaries
--Polymicrobial infection- caused by a variety of MO�s
Vaginitis
Infection of the vagina, usually caused by bacteria or yeast (fungus)
Sexually transmitted: bacterial vaginosis, and Candida albicans
If not an STD, it may be caused by: Douching, sexual intercourse
(sperm is alkaline), bathing, thongs, tight clothing& sweat,
strong scented soaps
Vaginitis symptoms
Bacterial: milky white vaginal discharge with fishy odor. Requires an antibiotic
Yeast: Cottage cheese discharge. Anti-fungal medications to treat
Vaginitis and pH
Acidic nature of the vagina provides some protection
Best way to avoid: maintain acidic Ph
Cervicitis
Inflammation or infection of the cervix
Most often caused by chlamydia or gonnorhea
Mucopurulent discharge (yellow-green) with red, inflammaed cervix
that bleeds easily
Vulvitis
Inflammation of the female external genitalia (vulva)
Causes of Vulvitis
Irratants, STD (trichimonis), inflammation
Contact with soaps, detergents, lotions, hygienic sprays, shaving,
menstrual pads, perfumed toilet paper, or nonabsorbing or
tight-fitting clothing
Vaginal infections that spread to the labia
Bartholinitis
Inflammation of one or both ducts that lead from the vaginal opening
to the Bartholin glands
Caused by microorganisms that infect the lower female reproductive tract
Not normally palpable. Infection= large and visible. Painful, may
become cystic
Pretty common
Pelvic Relaxation Disorders
muscle (perineal and endopelvic faschia) lose tone with aging
Fails to maintain organs in proper position
More common in females
Pelvic floor muscles relax (childbirth)
Bladder, uterus, rectum
Pelvic Relaxation Disorders: Cystocele
bladder has dropped, prolapse.
Symptoms: Urgency to pee, stress urinary incontinence (sneeze=pee)
Pelvic Relaxation Disorders: Rectocele
weakness between vagina and rectum
Rectum protrudes outwards (prolapsed).
Pt complain about incomplete emptying or manually expel stool by
pushing in vagina
Pelvic Relaxation Disorders: Urethrocele
Urethra comes out through vagina
Pelvic Relaxation Disorders: Vaginal prolapse
vaginal walls collapse.
Pelvic Relaxation Disorders: Uterine prolapse
Uterus protrudes out from vaginal opening.
Main complaint: pressure.
Very common in women who had vaginal births
Benign ovarian cysts
Unilateral
Produced when a follicle or number of follicles are stimulated but
no dominant follicle develops and reaches maturity (it doesnt rupture
and cause a period, it just stays)
Will usually rupture o their own
Follicular cysts
suppress ovulation, Birth control to treat
Corpus luteum cysts-
formed from granulosm cells that are left over after ovulation.
Go away on their own
Dermoid cysts (teratoma)
Contain hair, teeth, nails, muscle fibers, cartilage, bone, and
elements of all 3 germ layers.
May be cancerous in rare instances.
Removed with surgery.
Endometrial polyps
Benign mass of endometrial tissue (in uterus)
Don�t show up on ultrasounds. Cant see with naked eye. Have to find
with scope (hysteroscopy). Most post-menopausal
Symptoms: Intermenstrual bleeding (between periods), sometimes
excessive bleeding, bleeding with or after intercourse.
Leiomyomas (uterine fibroid)
Benign tumors of smooth muscle cells in the myometrium, cause
abnormal uterine bleeding, pain, and symptoms related to pressure on
nearby structures
1:5 women over age 35
Can grow to be very large, can be displaced by full bladder
Hysterectomy if problematic. Do nothing if non problematic.
May complain of: heavier or more painful periods. Usually asymptomatic.
Fed by hormones: bigger during pregnancy, common in menstruating
years, go away after menopause.
Proliferative Conditions: Endometriosis
Uterine tissue and metrin tissue (which should be in uterus) grows
out into peritonesl cavity (bowel, bladder, etc.)
Tissue responds to hormones during period and cramps
Symptoms: alot of pain and discomfort on period, excessive bleeding, infertility
Diagnosis: has to be visualized with scope. May be lasered off.
Pretty common
Possible causes of Endometriosis
Retrograde menstruation
Spread through vascular or lymphatic systems
Stimulation of multipotential epithelial cells on reproductive organs
Depressed Tc cells tolerate ectopic tissue
Genetic predisposition
Female Reproductive Cancer: Cervical cancer`
Cervical dysplasia (CIN): concerning because precancerous.
Moderate to severse dysplasisa: intervention. Remove bad cells
Cervical carcinoma in situ: Mild Dysplaisa
Invasive carcinoma of the cervix
Testing for Cervical Cancer
Screening starts at 21 (papsmear)
Diagnostic test: biposy
Cervical Cancer Risk Factors
***HPV***
HIV
Multiple sexual partners (increased STD risk)
Smokers (weakened immune system)
HPV Types
High risk: cause cancer on cervix, penis, and esophogas
Low risk: don�t kill you. Penile warts
Female Reproductive Cancer: Endometrial cancer
best prognosis if detected early.
Easy to treat (surgery).
#1 problem: post-menopausal bleeding.
At risk: pts with previous history of breast cancer and on meds.
Diagnosis: biopsy to obtain uterine cells. Pts on unopposed
progesterone therapy.
Female Reproductive Cancer:Ovarian cancer
no early symptoms (if there are, theyre vague.)
by the time theyre diagnosed, its spread.
Most lethal female cancer
Misc Female Reproductive Cancers
Vaginal cancer & Vulvar cancer (pic)
Note: Skin lesions, Change, new problems, itchyness
Sexual Dysfunction: Disorders of desire
inhibited sexual desire, decreased libido
women more than men.
No meds to fix
Sexual Dysfunction: Vaginismus
muscles of vagina tighten.
Causes pain and discomfort
Sexual Dysfunction: Anorgasmia
Orgasmic Dysfunction
Can't reach Orgasm, causes sexual frustration
Sexual Dysfunction: Dyspareunia
Painful intercourse
Increases with age because of decreased elasticity.
Recommend lube.
Infertility
Inability to conceive after 1 year of unprotected intercourse with
the same partner
--85% Trying to conceive will conceive within 1 year
Fertility can be impaired by factors in the man, woman, or both
Types of fertility Tests
Structural- egg viability, sperm count,
Hormonal- lab work, thyroid functioning
Benign Breast Lesions: Fibrocystic Breast Changes
Most common benign breast lesion in females.
Cysts in breast.
Cyclic and influenced by hormones. Get worse before period and
better after.
Lumpiness and tenderness.
Diagnosed based on signs and symptoms. Ultrasound to rule out cancer.
Benign Breast Lesions: Fibroadenoma
Solid tumor in breast.
2nd most common breast disorder.
Not cancerous.
More common in adolescents/ young 20�s.
Diagnosed on ultrasound/mammogram -> referred for biopsy
Benign Breast Lesions: Mastitis
Most common in breast feeding women.
Caused by pathogens getting into skin through break in skin.
Acute. Fever, malaise, breast pain and swelling, elevated WBC�s.
Treated with antibiotic
encourage to continue breastfeeding.
Breast Cancer
Most common cancer in American women (1:8 women in lifetime)
Leading cause of death from ages 40 to 44
Second most common killer after lung cancer
Black women more likely to die from it (financial, education,etc)
Risk Factors for breast cancer
Reproductive factors- not having any children
Hormonal factors- exposure time to hormones (early menarchy, late menopause)
Environmental factors and lifestyle
Radiation
Diet- Alcohol. Obesity (adipose tissue=estrogen increases)
Chemicals (xenoestrogens)- Estrogen therapies
Physical activity
Familial factors and tumor-related genes- 1:100 Ashkanazi Jewish
decent, heredity (1 of 2 bracket genes passed onto you)
Manifestations of Breast Cancer
Painless lump
Dimpling of skin
Edema
Blood from nipple
Present for 5 years before palpable
Most diagnosed after age of 55 (Better prognosis as age increases)
Treatment for Breast Cancer
Based on stage of cancer- do most conservative option
Surgery, Radiation, Chemotherapy, Hormone therapy, Biologic therapy,
Bone marrow transplant
Types of Mastectomies: Lumpectomy
Remove only mass and surrounding tissue
Types of Mastectomies: Simple mastectomy
Remove just breast tissue
Types of Mastectomies: Modified radical mastectomy
Remove breast and some lymph nodes
Types of Mastectomies: Radical mastectomy
Remove breast, lymph nodes, and muscle
What is the most common site for re-occurance of cancer
on incision line