Elias Vouzounis C7

BRAIN & BEHAVIOUR/HUMAN DEVELOPMENT

PBL WRITE-UP
HUMAN DEVELOPMENT PBL 1: PUBERTY, FERTILITY AND THE MENOPAUSE
Scenario:
Jacky, aged 48, was feeling miserable as she returned home to an empty house after taking her 18
year old son to university. The 14 year old twins, Emma and Jo, had gone on a week long school trip
to France and her partner, Colin, was away on business.
She felt overwhelmed with anxieties. Although, Jo had recently shot up in height and his voice had
deepened, she was worried about Emma who had not started her periods yet. Jacky was certain she
had started her periods by that age. She made a note to make an appointment for Emma to see their
GP when she got back from her trip. She would also make an appointment for herself as her periods
had become erratic and she couldnt sleep at night due to the excessive sweating. Jacky was also
pre-occupied with Colins change in behaviour and why he was spending so much time away from
home.
Meanwhile, Colin had his own problems. Three weeks ago, he had a one night stand with his firms
new 37 year old director, Sarah, and she had called him to say her period was late and she was
feeling unwell in the mornings. Since then he had been busy looking up the menstrual cycle on the
internet trying to work out the timings and whether he could be the father which he doubted as he
had used condoms. He did discover that many factors can cause a period to be irregular and that
contraception isnt always effective.
Sarah had bought a pregnancy test kit and was plucking up the courage to do it. If she was pregnant
what was she going to do? She had just been appointed to this prestigious job but she also wanted
a family and she was aware of her age. When she finds out the test is positive, Sarah makes an
appointment to see her GP, Dr Rahman. He recommends pregnancy vitamins and gives her some
life-style advice.
Sarah decides to continue with the pregnancy and an appointment is made for her at the antenatal
clinic when shell be about 12 weeks pregnant. At the booking clinic she is given a lot of information,
has blood taken for a variety of tests and is sent for an ultrasound scan. Whilst waiting in the clinic,
Sarah meets KT and her partner Roxanne who talk about how KT got pregnant using donor
insemination and the difficult decisions they had to make before starting a family.

The learning objectives we had as a group were the following:
- Understand the hypothalamus-pituitary-gonadal axis.
- Describe the features and stages of normal puberty.
- Define the different pubertal events culminating in menarche and the normal age ranges for these
events.
- Describe the factors other than pregnancy that affect the regularity of the menstrual cycle.
- Describe the methods of contraception, including emergency contraception.
- Understand the physiological changes that take place at the menopause and describe the
symptoms that occur.
- Recognise the signs and symptoms of pregnancy, understand the interpretation of pregnancy
tests and explain how the expected date of delivery is calculated.
- Outline the different methods of assisted conception - intrauterine insemination (IUI), in vitro
fertilisation (IVF) and intracytoplasmic sperm injection (ICSI).
Elias Vouzounis C7
Understand the hypothalamus-pituitary-gonadal axis:
The hypothalamus-pituitary-gonadal axis is the hormonal system that becomes synchronized during
fetal life and leads to the production of testosterone in males and oestrogen in females when puberty
hits. Testosterone leads to the production of sperm in males, and oestrogen leads to the
development of a rhythmic menstrual cycle in females. Both testosterone and oestrogen lead to the
development of secondary sexual characteristics in both males and females (Guyton and Hall 2006).
The diagrams below show how the hypothalamus-pituitary-gonadal axis works in both males and
females.












































Diagrams showing the hypothalamus-pituitary-gonadal axis in males and females (Guyton
and Hall 2006).


Elias Vouzounis C7
Define the features and normal stages of puberty:
There are 5 different stages of puberty for both girls and boys, with a range of ages for each stage
that are considered normal for each of the different sexual characteristics to develop. The two tables
below show the range of ages that each stage should occur in both males and females, and the
characteristics that develop at each stage.

STAGES MALES (AGE RANGE) FEMALES (AGE RANGE)
1 9-12 8-11
2 12-13 11-12
3 13-14 12-13
4 14-15 13-14
5 14-18 14-17

Table above showing the different stages of puberty and the age ranges for each stage for
both males and females (healthychildren.org 2014).

STAGES MALES FEMALES
1 Testicles begin to mature;
growth of scrotum and
pubic hair begins
(pubarche). Initial growth
spurt may occur,
individual may experience
occasional erections
Ovaries start reacting to
Follicle Stimulating
Hormone (FSH) and
Luteinising Hormone (LH)
and start producing
Oestrogen
2 Growth of height 2-3
inches per year, pubic
hair starts to take some
colour, erections become
more frequent and boy
starts to take a leaner,
masculine shape
Breasts start to bud
(thelarche), growth spurt
will occur and pubic hair
starts to grow (pubarche)
3 Pubic hair grows fuller,
length of penis starts to
grow, erections become
daily, theres an increase
in height of >3 inches per
year and voice begins to
break
Growth of breasts
continues; armpit hair
starts to grow. By this
stage, 70% of all girls will
have undergone
menarche. Vagina starts
to grow in size
4 Hair growth in armpits and
face begins, penis
thickens and continues to
lengthen, voice deepens
further and acne starts to
develop
Growth spurt slows down,
body fat increases,
menstrual cycle reaches
its own rhythm
5 Male gains most of his
height, shoulders broaden
and muscles fully
develop, pubic hair
spreads to inner thighs
and lower abdomen,
gonads have fully grown
By this stage, woman has
reached her maximum
height; breasts have
reached full size and
periods and ovulation
occur regularly

Table above showing the development of different sexual characteristics for males and
females (healthychildren.org 2014).

Elias Vouzounis C7

Define the different pubertal events culminating in menarche and the normal age limits for
these events:
Menarche is defined as the first occurrence of menstruation (merriam-webster 2014). The range of
ages in which a girl may have her first period (bleeding due to shedding of the lining of her uterus)
may range from 9 to 15 years of age; if a girl has not had menarche by the time shes 15, its a
cause for medical attention. Usually, secondary sexual characteristics in females should have
started developing by the age of 14, and menarche usually spontaneously occurs within two years of
starting to develop secondary sexual characteristics (WebMD 2014).
The different pubertal events that lead up to menarche include an attainment of sufficient body mass
and an adult level of body fat in a woman (roughly 26% body fat), occurring between the ages of 13-
14. Secretion of oestrogen in response to pituitary hormones happens between the ages of 8-11 and
oestrogen stimulates the growth of the uterus (growth and vascularity of the endometrium), growth of
the breasts and widening of the pelvis (howstuffworks 2014).
Describe factors other than pregnancy that affect the regularity of the menstrual cycle:
The main factor that causes an irregularity in the menstrual cycle of a woman is amenorrhoea, which
is defined as an absence of periods and can be categorized as either primary or secondary. Primary
amenorrhoea is when the menstrual cycle in a female has not yet occurred by the age of 16 or
above, which is very rare in comparison to secondary amenorrhoea which is when the menstrual
cycles of a woman suddenly stop (patient.co.uk 2014).
Causes of primary amenorrhoea include Turners syndrome, where one of the two X chromosomes
of the sex chromosomes has been deleted, or the second X chromosome of the two is defective. It
causes gonadal dysgenesis with streak ovaries (Kumar and Clark 2012). Other causes of primary
amenorrhoea include a problem in the development of the genital tract such as an imperforate
hymen, missing uterus or vagina or a vaginal septum (MedlinePlus 2014). Weight-related
amenorrhoea is also one of the causes of primary amenorrhoea, which can be caused by anorexia
nervosa reduced leptin levels leads to hypothalamic dysfunction, reducing the levels of
gonadotrophins released by the anterior pituitary and deregulating the menstrual cycle (Kumar and
Clark 2012).
The most important cause of secondary amenorrhoea that should be ruled out from the beginning is
pregnancy. Another main cause is due to androgen excess, such as in polycystic ovarian syndrome
multiple cysts within the ovaries that produce an excess of androgens and deregulate the
menstrual cycle (Kumar and Clark 2012). Sheehans syndrome is also another cause, where theres
been an infarction of the pituitary; Ashermans syndrome can lead to secondary amenorrhoea due to
cervical stenosis. Premature ovarian failure can lead to the cessation of ovulation and the menstrual
cycle and can be completely spontaneous. Finally, another cause of secondary amenorrhoea could
be due to the fact that the woman has reached the menopause (Interactive 2014).
Describe methods of contraception, including emergency contraception:
There are various different methods that can be used for contraception. The fist main method is the
barrier method, which prevents the sperm from reaching the ovum and fertilizing it. This can be done
using either male or female condoms (which prevent the sperm from being deposited in the vagina),
cervical caps and diaphragms (which prevent the sperm from entering the uterus), spermicides
(which kill the sperm before they can reach the ovum for fertilization) and finally the method of coitus
interruptus (where the male doesnt ejaculate in the female genital tract).

Other methods include hormonal methods, such as combined oral contraceptive pills (COCPs) that
contain synthetic oestrogens and progestins, or Progestin-only pills (POPs), both of which interfere
with ovulation. Vaginal rings, implantable rods, injectable birth control and contraceptive patches all
contain hormones (synthetic oestrogens and progestins) that, again, interfere with a womans
ovulation.
Elias Vouzounis C7
Another method of contraception is the use of Intrauterine devices (IUDs), which are inserted into
the females uterus by a medical professional and prevent fertilization; Copper IUDs release a small
amount of copper that stimulates an inflammatory reaction and prevents the sperm from reaching
the ovum, whereas hormonal IUDs release progestin that thickens the cervical mucus and again,
inhibit the sperm from reaching the ovum.

Finally, the last method of contraception is sterilization. Tubal ligation is a nonsurgical method for
blocking the fallopian tubes, and a vasectomy is a surgical procedure that cuts the vas deferens. In
both methods, the way that the contraception works is by preventing a sperm from meeting an
ovum, so fertilization doesnt occur (fpa 2014).



On the left is an image of a Copper IUD inserted
into the uterus (Clinics 2014).








When it comes to emergency contraception, a pill can be taken such as ellaOne or Levonelle 1, or
an IUD can be inserted such as a copper IUD. Levonelle 1 contains levonorgestrel (a synthetic
progesterone) and ellaOne contains ulipristal acetate, which stops progesterone from working
normally; both of these pills work by delaying ovulation in a woman, and therefore no fertilization can
occur. These pills should be taken as a single dose at a maximum of 72 hours after unprotected sex
to work. The copper IUD, on the other hand, works by preventing implantation of a fertilized egg and
is effective up to 5 days after having unprotected sex (Choices 2013).


Understand the physiological changes that take place at the menopause and describe the
symptoms that occur:
Menopause occurs when a woman has not had a menstrual period for 12 months, and the average
age for a woman going through menopause in the UK is 51. Usually, periods become lest frequent
and some periods are missed before they stop completely. Over the age of 40, womens follicles
start becoming less responsive to LH and FSH released from the pituitary due to less receptors for
these hormones on the follicles, and as a result oestrogen (17! oestradiol) levels in the blood drop,
which leads to the more frequent missing of periods. Due to the negative feedback loop, theres less
oestrogen to prevent the release of the gonadotrophins (FSH and LH) and therefore these rise, and
will remain at their peak level once a woman goes through menopause.
The decrease of circulating oestrogen has a variety of symptoms, which include osteoporosis
(osteoblasts stimulated to produce bone by oestrogen, hence now osteoclast activity is greater than
that of osteoblasts, reducing bone density). Theres also vaginal dryness, dyspareunia (decreased
sex drive), depression, mood swings and joint/muscle pain. Theres also increased vasodilation,
which explains the hot flushes and night sweats. All these symptoms are due to the decreased
oestrogen being produced by the ovaries (netdoctor.co.uk 2014).
Recognise the signs and symptoms of pregnancy, understand the interpretation of
pregnancy tests and explain how the expected date of delivery is calculated:
The first and most obvious symptom of pregnancy is a woman missing her monthly period
(amenorrhoea). Women may feel sick and nauseous, as well as feeling incredibly tired. Breasts may
feel swollen and tender, and there may be an increased frequency of urination as well as vaginal
discharge (Choices 2014).
Elias Vouzounis C7
There are various pregnancy tests available, but they all work on the same principle. When women
become pregnant, the developing placenta of the fetus produces a hormone called human chorionic
gonadotrophin (hCG) from its syncytiotrophoblast cells. This hormone is a glycoprotein with a "
subunit (the same in hCG, LH and FSH) and a ! subunit (different in hCG, LH and FSH). Since hCG
is only produced by syncytiotrophoblasts, its only produced when a womans pregnant and exists in
the mothers urine. Even though blood tests for hCG are much more accurate, pregnancy tests test
whether the mothers urine contains hCG. If it does, it means shes pregnant. hCG is produced from
7-9 days after implantation, but testing too early can produce a false negative result so its advised
that the pregnancy test is carried out 28 days after the womans last menstrual period
(howstuffworks.com 2014).

Negative pregnancy test. Bar on the
right is a control, indicating that the
pregnancy test is valid
(welcomelittle.com 2014).



There are various methods of calculating the expected date of delivery. The first is Naegles formula,
where you add seven days to the womans last menstrual period, and then add nine months. The
second method is adding 270 days to the day of conception, assuming the mother knows the exact
day of conception and has a regular 28-day menstrual cycle.
Outline the different methods of assisted conception Intrauterine Insemination (IUI), In-
vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI):
Intrauterine insemination is a procedure whereby the sperm is collected from the male and then
inserted into the womans uterus. The sperm is washed and filtered and then placed into the
females uterus using a catheter, and has a 15% chance success rate.
In-vitro fertilization ova are removed from the females ovaries and are fertilized with sperm in a
laboratory. The fertilized egg is then returned to the uterus, and theres a 20-30% chance of the
woman falling pregnant.
The last method is Intracytoplasmic Sperm Injection; this technique is mostly used for male infertility.
The process is pretty much the same as that of IVF, except a single sperm is injected into the egg.
Again, success rate is roughly 20-30% (netdoctor.co.uk 2014).
REFERENCES:
Choices, N. (2013). "Emergency contraception: morning after pill and IUD - Contraception guide - NHS
Choices."

Choices, N. (2014). "Early pregnancy signs and symptoms - Pregnancy and baby guide - NHS Choices."

Clinics, C. R. (2014). "IUD Copper from Birth-Control-Comparison.info." from http://www.birth-control-
comparison.info/iud-copper.

fpa (2014). "Contraception help."

Guyton, A. C. and J. E. Hall (2006). Textbook of medical physiology. Philadelphia, Elsevier Saunders.

Elias Vouzounis C7
healthychildren.org (2014). "Stages of Puberty."

howstuffworks (2014). "HowStuffWorks "How Female Puberty Works"."

howstuffworks.com (2014). "HowStuffWorks "Pregnancy Tests Overview"."

Interactive, H. B. (2014). "The basics - Secondary amenorrhoea | GPonline.com."

Kumar, P. J. and M. L. Clark (2012). Kumar & Clark's clinical medicine. Edinburgh, Saunders Elsevier:
xiii, 1286 p.

MedlinePlus (2014). "Amenorrhea - primary: MedlinePlus Medical Encyclopedia." from
http://www.ncbi.nlm.nih.gov/pubmed/.

merriam-webster (2014). "Menarche - Definition and More from the Free Merriam-Webster Dictionary."
from http://www.merriam-webster.com/dictionary/menarche.

netdoctor.co.uk (2014). "Infertility and assisted conception."
Many couples believe that it is easy to have a child and are often surprised when the woman does not fall
pregnant as soon as they start trying for a baby. Is it common to have difficulties becoming pregnant?

netdoctor.co.uk (2014). "The menopause."

patient.co.uk (2014). "Amenorrhoea | Doctor | Patient.co.uk." from
http://www.patient.co.uk/doctor/amenorrhoea.

WebMD (2014). "Menarche - Topic Overview." from http://www.webmd.com/parenting/tc/menarche-topic-
overview.

welcomelittle.com (2014). "Negative Pregnancy Test and Missed Periods What it may mean? -
Welcome Little."