Here are the key considerations for this patient: - She is postmenopausal based on her age - With an intact uterus, estrogen-only hormone therapy would put her at increased risk for endometrial cancer - As she is asymptomatic, hormone therapy may not be needed - Screening for osteoporosis, cardiovascular risk, and breast cancer should be discussed based on risk factors - Lifestyle modifications like calcium/vitamin D, exercise, not smoking can help prevent diseases of menopause - Close monitoring without hormone therapy is a reasonable option given her age and lack of bothersome symptoms The priorities would be assessing risk factors, discussing screening recommendations, and supporting lifestyle changes to promote health during men

1. Precocious Puberty
College of Mount Saint Vincent
Carmen Saunders
Nur 652

2. Precocious Puberty
• Defined as sexual development occurring before
age 8 yrs in females and age 9 yrs in males
• Occurs more often in females
• It involves not only early physical changes of
puberty, but also linear growth acceleration and
acceleration of bone maturation, which leads to
early epipheseal fusion and short adult height.
• Two types- 1) central precocious puberty (more
common) or GnRH dependent puberty 2) GnRH
independent precious puberty ( Ferri, 2009).

3. Differential Diagnosis
• Most common diagnoses to consider:
• Premature thelarche-breast development without pubic hair growth,
without accelerated bone maturation, and with a normal height
outcome. No treatment required and resolves spontaneously
• Premature adenarche- involves only pubic hair manifestations with no
other manifestations of puberty.No treatment is required however
increased incidence with CNS abnormalities
• GnRH dependent- idiopathic, CNS tumors, hypothalamic hamartomas,
nuerofibromatosis,hydrocephalus, and CNS infections
• GnRH independent- congenital adrenal hyperplasia, adrenocortical
tumors, McCune-Albright syndrome,gonadal tumors, severe
hypothyroidism, exposure to exogenous sex steroids ( Dor, 2009).

4. Workup
• Growth, development, order of appearance
of secondary sex characteristics, pubertal
development in family members,
medications, neurological symptoms,
Tanner staging, abdominal and nuero exam
• Breast and genital examination for pubertal
development

5. Laboratory tests
• GnRH testing to determine if dependent or
independent cause
• Sex hormone studies: lutenizing hormone, follicle
stimulating hormone, hCG, testosterone (males),
estrogen (females). Levels of sex steroids should
be determined in the morning with use of assays
that have detection limits adapted to pediatric
values. In girls, serum estradiol levels are highly
variable and have a low sensitivity for the
diagnosis for precocious puberty.
• T4 thyroid-stimulating hormone

6. Imaging studies
• CT scan or MRI of the brain or pituitary
gland to evaluate for CNS pathology
• Pelvic ultrasound to evaluate for cysts or
tumors
• Abdominal imaging with CT scan if
intrabdominal pathology is suspected.
• Radiograph of the left wrist to estimate
physiologic age with chronological age

7. Treatment
• Depends on the etiology of the precocious puberty
• GnRH agonists for treatment of gonadotropin dependent precious
puberty (leuprorelin, leuprolide, triptorelin, etc)
• For CNS lesions depends on location and type of lesion, and overall
prognosis of underlying problem
• For treatment of severe hypothyroidism treatment with thyroid
hormone will result in regression of sexual development and the child
will undergo puberty later in life
• For familial male gonadotropin independent precocious puberty, the
androgen synthesis inhibitor ketoconazole can be used , or a
combination of testolactone and spironlactone can be used

8. Outcome
• For true precocious puberty and some CNS lesions
outcome is usually very good
• When drug therapy is instituted, it is continued until a time
when further pubertal development is appropriate and then
discontinued, allowing the child to progress thorough
puberty
• Refer to an endocrinologist for long term treatment as they
will need long term management and evaluation
• Emotional needs of the child must be tended to and parents
may need referrals to support groups or therapy

9. Menopause
Carmen Saunders
Nur 652

10. Menopause
• The occurrence of no menstrual periods for 1 yr after age
40 yrs or permanent cessation of of ovulation after lost
ovarian activity
• It is a climacteric reproductive stage of life marked by
waxing and waning estrogen levels followed by decreasing
ovarian function. Premature ovarian failure and no
menstrual periods may also occur because of depletion of
ovarian follicles before the age of 40 yrs
• Average age in US is 51
• Age at which menopause occurs is genetically determined
• Perimenopause starts mid 40s to late 40s
• Smokers start menopause 1.5 years earlier than non
smokers (Ferri, 2009)

11. Types of Menopause
• Natural- absence of menses for 1 year. Occurs between the ages of 45-
55
• Induced- bilateral salpingo-oopherectomy(BSO) or chemotherapy
• Premature menopause or premature ovarian failure-natural menopause
occurring before age 40. Genetic or autoimmune cause but often no
explanation.
• Perimenopausal- transitional state when hormone levels are fluctuating
and begin to experience physical changes before the last menstrual
cycle.Usually begins in 40s.Characterized by changes in menstrual
flow,skipped cycles, and length of cycle changes
• Climacteric-the phase a women makes from reproductive to non-
reproductive in her aging process ( Buttaro, 2008).

12. Physical Findings
• Vasomotor- (hot flashes, day sweats, night sweats)
• Insomnia, shorter sleep latency
• Irregular bleeding or bleeding that is heavier or
prolonged
• Atrophic vaginitis which can cause burning
itching, bleeding, and dyspareunia
• Urinary incontinence or urogenital atrophy
• Sexual changes- decreased libido
• Psychological symptoms-anxiety, depression,
nervousness, irritability, insomnia, difficulty
concentrating

13. Diseases Associated with
Postmenopausal women
• Cardiovascular- leading cause of mortality of
women in US. 1 in 3 die of CHD whereas 1 in 25
die of breast cancer
• Osteoporosis-low bone mass causing increased
risk for fractures
• Mammograms every 1 –2 years
• Pap smears 1 –2 years
• Cholesterol checks
• Blood pressure at least every 2 years
• Colorectal screening at age 50 ( Buttaro, 2008).

14. Etiology of menopause
• Most common is physiologic caused by depleted
granulosa and theca cells that fail to react to
endogenous gonadotropins, producing less
estrogen;decreased negative feedback in the
hypothalamic pituitary access, increased FSH and
LH which lead to stromal cells that continue to
produce androgens as a result of the LH
stimulation
• Surgical castration
• Family history of early menopause, cigarette
smoking, blindness, Turners syndrome, and
precocious puberty ( Ferri, 2009).

15. Differential Diagnosis
• Hypothalamic dysfunction
• Hypothyroidism
• Pituitary tumors
• Pregnancy
• Adrenal abnormalities
• Ovarian abnormalities
» Poycystic ovarian syndrome
• Leukemia and other cancer
• Poycystic kidney disease
• Cardiac abnormality
• Ovarian neoplasm
• Tuberculosis of the endometrium

16. Workup
• Height,weight, BP, breast exam, pelvic
exam
• Assess risk for cardiovascular disease,
osteoporosis, cigarette smoking, hx of
breast cancer, liver disease, coagulation
disorders

17. Laboratory test
• FSH/LH/estrogen-menopause when FSH is
consistently above 30 and depressed estrogen level
• CBC-anemia
• Chemistry profile,fasting lipid,BUN,creatinine
• Liver enzymes (esp if considering HT)
• TSH- exclude hypothyroidism
• Pap smear ,endometrial biopsy, or dilation and
cutterage in patients who have had irregular
periods or intermenstrual or postmenopausal
bleeding
• hCG pregnancy test

18. Imaging studies
• Mammogram
• Bone density test
• EKG
• CT scan or MRI of stella of pituitary tumor
is expected

19. Non-pharmacological therapies
• A balanced diet with total fat less than 30%
of calories
• Avoid smoking, caffeine, and excessive
alcohol intake ( can trigger hot flashes)
• 1500 mg of calcium per day
• Vaginal lubricants to help with the
dryness,dypareunia,and atrophy.

20. Treatment
• Estrogen replacement in symptomatic patients can be done in a variety
of forms including oral replacement, patch,creams, and vaginal inserts.
The lowest effective dose should be prescribed
• Before estrogen is prescribed a complete history and physical are
needed. If a patient has an estrogen dependent
malignancy,unexplained abnormal bleeding,history of
thrombophlebitis,or acute liver disease estrogen is contraindicated.
Smoking is not contraindicated but the patient should be counseled on
smoking cessation and try other methods to relive symptoms first.
• In women who have had a hysterectomy it is advised that HT should
be initiated with estrogen alone. In women with a uterus progestin is
usually added to reduce the risk of endometrial cancer

21. Hormone Therapy
Titrate dose depending on symptoms
• Example:conjugated estrogens:start with 0.3 mg qday and increase to
1.25 depending on symptoms
• Estradiol-start with 0.5 mg qday and increase to 2mg qday
• If concerned about hepatic function, inflammatory effects ,or
thrombotic effects, a transdermal should be prescribed
• Statins should be used concurrently when indicated
• Monitor for breast disease, changes in lipid profile, fasting glucose
levels, and unexpected uterine bleeding
• Side effects-increased risk of breast cancer,uterine cancer>10 years,
stroke, and venous thromboembolism
• Benefit-reduced incidence of osteoporosis

22. Types of Hormone Therapy
• Cyclic hormone Therapy-estrogen is used for 25 days each month with
progestin added the last 10-14 days, followed by 3-6 days of no
therapy.80 percent have withdrawal bleeding when the progestin is
stopped.Vasomotor symptoms may occur during therapy-free interval
• Continuous-Cyclic Hormone Therapy (Sequential)-estrogen is used
continuously each day of the month and progestin is added 10-14 days
each month. Uterine bleeding occurs in about 80 percent of women
when progestin is withdrawn but no estrogen free period when
vasomotor symptoms could occur
• Continuous Combined Hormone Therapy-Estrogen and progestin are
taken everyday.80 percent experience no bleeding however when it
does it occur it is unpredictable in timing ( Buttaro, 2009).

23. Treatment
• The 2 most common reasons that women discontinue therapy is fear
of cancer and vaginal bleeding.
• Estrogen therapy side effects include breast tenderness, headaches, and
nausea
• Progestin side effects include withdrawal bleeding,bloating,mood
changes, and rash
• For women whom estrogen is contraindicated or do not want to take
estrogen therapy the following regimens can be used:
-antidepressants- Effexor and Paxil
-Dep-Provera 150 mg IM qmonth
-Clonidine 0.05 to 0.15 mg qday

24. Screening Parameters
• For women using estrogen versus progestin
endometrial evaluation should be considered when
irregular bleeding persists more than 6 months
after beginning therapy,or earlier if other risk
factors are present.
• Persistent vaginal bleeding in a postmenopausal
woman,whether on or off HT, requires evaluation
with and endometrial biopsy or dilation and
curettage, despite transvaginal ultrasound findings.

25. Cardiovascular Disease
Prevention
• Smoking cessation
• Blood pressure control -goal less than 120/80
• Cholesterol management-TC<200,LDL<100,HDL>60
• Weight management-BMI 21-25
• Physical exercise-5 times per week for at least 30 minutes
• Limit alcohol to more than 0.5 ounces of ethanol per day
• Limit sodium intake to less than 2400mg per day
• Reduced intake of saturated fat

26. Osteoporosis
• Characterized by increased bone fragility
and increased susceptibility to fracture
• Also defined as a BMD – 2.5 sd or less
below the young normal mean
• Rate of bone resorption exceeds that of
bone formation

27. Risk factors
• Unmodifiable- advanced age, female gender,
Caucasian or Asian, hx of fx, dementia, history of
fracture in first degree relative
• Modifiable-hypogonadism, cigarette smoking,
excessive alcohol use,, low calcium intake, low
body weight, inactivity, glucocorticoid use,
thyrotoxicosis, recurrent falls,

28. Diagnostics
• Cbc with diff, serum electrolytes, BUN and
creatinine, LFT,serum calcium, serum phosphorus,
25- hydroxyvitamin d,TSH, PTH, 24 hour urine
calcium, bone densitometry
• Primary osteoporosis-includes bone loss arising
from menopausal estrogen deficiency or aging.
• Secondary results from an acquired or inherited
disease that interferes with bone remodeling or
increases bone turnover.

29. Prevention
• Much of the bone loss is irreversible so
prevention should be the major focus of health
care providers
• Adequate calcium – 1000 –1300 mg of calcium a
day and vitamin d 200-600 units daily for adults
• Weight bearing exercise
• Avoiding excessive alcohol intake
• Avoid cigarette smoking

30. Osteoporosis Management
• Estrogens (oral and transdermal) decrease bone loss,
reduce the incidence of fracture, and prevent height loss
• Biphosphinates approved for the treatment of
postmenopausal osteoporosis are: Aldrendronate
(Fosamax), Risedronate ( Actonel), and ibandronate
( Boniva).
• Tamoxifen can promote increased bone density but
vasomotor symptoms are common
• Raloxifene (Evista) is a SERM used for prevention and
treatment of osteoporosis contraindicated in women who
have had a previous thromboembolism

31. Case Study 1
• A 17 year old adolescent female presents with
never having menstrual symptoms but is otherwise
in good health. Her older sister and mother both
experienced menarche at age 13. She denies any
excess eating aversion or excessive exercise. She
is 51 inches tall and weighs 103 lbs. Her neck is
supple without masses. Her breasts appear to be in
Tanner Stage 1 and her pubic pattern also appears
to be in Tanner Stage 1.Abdominal exam reveals
no masses and external genitalia are normal.The
cervix appears normal and on bimanual exam she
has a small uterus with no adnexal masses

32. Answer
• Diagnosis-Delayed Puberty. Most likely gonadal
dysgenesis ( Turner syndrome)
• Tests-FSH level to determine CNS problem versus ovarian
problem (increased inTurner)Estrogen level(decreased)
• Abdominal ultrasound to visualize ovaries(no true ovaries
just bands of fibrous tissue referred to as gonadal streaks
• Giemsa banded karotype to confirm clinical diagnosis
Cardio referral for valvular abnormalities or aortic coarctation
Renal ultrasound

33. Considerations
• Primary ammenorhea
• Breast development should occur by age 14
• Lack of estrogen confirmed due to short stature
lack of breast development
• Absent pubic and axillary hair consistent with
delayed puberty
• Internal and external genitalia will remain normal
but will remain infantile until late in adult life
( Toy, Baker, Ross, & Jennings, 2009).

34. Treatment
• Estrogen replacement therapy early in
adolescence
• Some benefit from recombinant human
growth hormone therapy
• Refer to geneticist, endocrinologist,
cardiologist
• Refer to Turner syndrome support groups.

35. Case Study 2
• A 50 year old woman complaints of irregular
menses over the past 6 months with symptoms of
vaginal dryness, insomnia, hot flashes, and
occasional night sweats. Her BP is 126/78 heart
rate 96 beats per minute, and temp 99.1. Her
thyroid gland is normal to palpation.Breast are
symmetric with no masses or discharge. Cardiac
and lung exams are unremarkable. Examination of
external genitalia does not reveal any masses.

36. Answer
• Dx-Perimenopausal state-Climacteric
• Tests-FSH/LH ( elevated), TSH,chem panel,pap
smear,pelvic US
• Differential dx-pregnancy,hypothyroidism,ovarian
abnormalities,hypothalamic dysfunction,adrenal
abnormality,polycystic ovarian syndrome
• Treatment-hormone replacement therapy ( always
inform of side effects), clonidine,antidepressant,
Depo-Provera shot,prevention of osteoporosis, and
prevention of cardiac complications

37. Case Study 3
• A 57 year old woman has an intact
uterus,no symptoms, and is in the office for
routine care. She is a smoker, has not had a
period in 10 years and is otherwise healthy
with no complaints. She is 5’6” and weighs
130 lbs. She has never received HRT and
has never received any counseling about it

38. Assessment
• Patient’s height has decreased in the last 2 years.
She is 1 inch shorter than her maximum. When
asked about sexuality she reports dyspareunia and
vaginal dryness;she is not happy with these
symptoms. Her mother had a wrist fracture with a
minor fall at age 65. The patient is taking a
multivitamin and some herbal remedies. She has
cut back to 3 cups of coffee a day. In discussing
her own beliefs, she expresses fear of breast
cancer with the use if HRT

39. Management
• What is she at risk for-osteoporosis (family history,loss of height, and
smoking).
• Considerations - ask about DVT in the past, since she is a smoker she
is more at risk for thromboembolism.Pt should be counseled on
smoking cessation but smoking is not totally contraindicated in HRT
• Tests-BMD >2.5 = osteoporosis,biochemical profile to evaluate renal
and hepatic function, primary hypothyroidism, and malnutrition, CBC-
blood count and nutritional status,TSH-hyperthyroidism,24 hour urine
collection for calcium, biochemical markers for bone remodeling
• Treatment-HRT(estrogen or progestin) if patient has agreed to
smoking cessation,biphosphinates ( alendronate or
risedronate),vitamin d (400 u per day) calcium supplement(1500mg
per day)

40. References
• Bramswig, J. & Dubbers, A. ( 2009). Disorders of pubertal
development. Duetsches Arzteblatt Intenational, 106 (17),
295-304.
• Buttaro, T., Tyrybulski, J., Bailey, P., & Sandberg-Cook,
J. (2008). Primary care: A collaborative practice, 3rd
Ed.
St. Louis, MO:Mosby-Elsevier.
• Dor, K., & O’ Connell, T. (2009). Instant workups: A
clinical guide to obstetric and gyneological care.
Philadelphia, PA: Saunders, Elsevier.
• Ferri, Fred (2009). Clinical Adviser. Philadelphia ,
PA:Mosby Elsevier.

41. References
• Toy, E., Baker, B., Ross, P., & Jennings, J.
( 2009). Case files: Obstetrics &
gynecology. Mc-Graw Hill Companies.