1. Amenorrhea and Oligomenorrhea Flashcards
Describe: PRIMARY Absence or Cessation of Menstruation (1)
menstruation that has not started by age 16 in the presence of 2° sexual characteristics or menstruation that has not started by age 14 in the presence of normal 2° sexual characteristics
Describe: SECOND Absence or Cessation of Menstruation (2)
- cessation of previously normal menstruation for > 6 mo
- or no menses for 3 or more normal cycles
What’s the avg age of onset of menarche?
avg. age of onset 12 yr
What’s the avg age of onset of menopause
Name stages of puberty (5)
AGTpM
- Adrenarche
- Gonadarche
- Thelarche
- Pubarche
- Menarche
Define: Adrenarche (1)
↑ secretion of adrenal androgens approximately 2 yr pregonadarche
Define: Gonadarche (1)
↑ secretion of gonadal sex steroids (onset at ~8 yr)
Define: Thelarche (1)
breast development begins at 9 to 11 yr
Describe: Tanner staging for breast development (5)
- None
- Breast bud
- ↑ Size areola and breasts
- 2° mound of areola and papilla
- Areola recessed to contour of breast
Define: Pubarche (1)
pubic and axillary hair development begins at 11 to 12 yr
Desribe: Tanner staging for pubic hair (5)
- None
- Downy hair along labia
- Darker/coarse hair extends over pubis
- Adult-type hair covers smaller areas (no thigh involvement)
- Adult hair in quantity and type, extends over thighs
Define: Menarche (2)
- avg. onset of menses at approximately 12 yr
- Menarche typically occurs within 2 yr of onset of breast development
Name: DDx of 1° amenorrhea (21)
- Hypothalamus 35% (↓ FSH/LH)
- Constitutional delay
- Stress
- Hypothalamic tumor
- Infiltrate/inflammation/infection/irradiation/surgery of hypothalamus
- Congenital GnRH deficiency (i.e., Kallmann syndrome)
- Pituitary gland 19%
- CNS/pituitary tumor
- 1° hypopituitarism
- Hyperprolactinemia (with or without prolactinoma)
- Irradiation/surgery to pituitary
- Thyroid: Hyper/hypothyroidism
- Adrenals
- Adrenal tumor—hormone secreting
- Congenital adrenal hyperplasia (CAH)
- Cushing syndrome
- Addison syndrome
- Ovaries 40%
- PCOS (chronic anovulation)
- Androgen insensitivity—XY
- Gonadal dysgenesis (Turner syndrome XO)
- Primary ovarian insufficiency
- Irradiation/surgery to ovaries
- Uterine/out low tract 5%
- Imperforate hymen
- Congenital Müllerian duct abnormalities:
Name DDx of 1° amenorrhea: Stress (5)
- Anorexia/bulimia
- Nutritional deprivation
- Excessive exercise
- Emotional stress
- Systemic illnes
Name DDx of 1° amenorrhea: Congenital Müllerian duct abnormalities (2)
- Transverse vaginal septum
- Vaginal agenesis (i.e., Mayer-Rokitansky-Kuster-Hauser syndrome)
Name: DDx of 2° amenorrhea (18)
- Hypothalamus 35% (↓ FSH/LH)
- Stress
- Hypothalamic tumor
- Cushing disease
- Drugs (i.e., OCP, danazol phenothiazines, neuroleptics)
- Pituitary gland 19%
- Sheehan syndrome (postpartum pituitary necrosis after significant PPH)
- CNS/pituitary tumor (i.e., prolactinoma)
- Lactation
- Thyroid: Hyper/hypothyroidism
- Adrenals
- Adrenal tumor—hormone secreting
- Adult onset Congenital adrenal hyperplasia (CAH)
- Ovaries 40%
- Menopause
- Primary ovarian insufficiency
- Radiation
- Testosterone injections
- Chemotherapy
- Uterine/out low tract 5%
- pregnancy
- Cervical stenosis
- Asherman syndrome (i.e., intrauterine adhesions after endometritis, D&C, or scarring after delivery)
Name DDx of 2° amenorrhea: Stress (5)
- Anorexia/bulimia
- Nutritional deprivation
- Excessive exercise
- Emotional stress
- Systemic illness
Describe Epidemiology of 2° Amenorrhea (when pregnancy exclude) (5)
- Ovarian causes—40%
- Hypothalamic causes—35%
- Pituitary disease—19%
- Uterine disease—5%
- Other—1%
Describe patient hx: Amenorrhea/oligomenorrhea (9)
- HPI: menstrual Hx, abdo pain (cyclic or noncyclic)
- Puberty Hx: menarche, thelarche, pubarche
- Gynecologic Hx: contraceptive Hx, sexual Hx, gynecologic, surgery Hx (e.g., multiple D&C’s)
- Obstetric Hx: GTPAL, postpartum hemorrhage
- Review of systems:
- CNS mass symptoms: headaches, vision changes, constitutional symptoms
- Hypothalamus: chronic illness, previous radiation, trauma, • diet, exercise, stress, eating disorders, Anosmia (Kallmann)
- Thyroid: hyper- or hypothyroid symptoms
- Prolactin: galactorrhea, headaches, vision changes
- Androgens: hirsutism, acne, male-pattern baldness, voice changes, clitoromegaly
- Pelvic mass symptoms: abdo pain, early satiety
- Adrenal symptoms: weakness, fatigue, easy bruising, prolonged recovery from illness, striae
- Growth Hx
- Hx of ambiguous genitalia at birth
- Drug intake
Describe FHX: Amenorrhea/oligomenorrhea (9)
- Menarche
- Menstrual Hx
- Parental height
- Parental pubertal Hx
- Infertility
- Genetic defects
- Low IQ (Fragile X syndrome)
- Congenital abnormalities
- Endocrinopathies
Describe Physical Exam: Amenorrhea/oligomenorrhea (10)
- Vital signs, growth chart, BMI
- Tanner staging—breast and pubic hair
- Thyroid gland exam
- Cranial nerve exam and visual acuity
- Abdo exam
- External genitalia (estrogenization, imperforate hymen, atrophic vagina, absence of cervical mucus, etc.)
- Bimanual exam (enlarged uterus, cystic ovaries, etc.)
- Acne, virilization, galactorrhea, hirsutism
- Dysmorphisms (i.e., Turner—web neck, widely spaced nipples)
- Signs of Cushing disease (striae, central obesity, proximal muscle wasting)
Describe: Approach to Dx of 1° amenorrhea. (Figure)
Describe: Primary Ovarian Insufficiency (POI) (2)
- Most women with POI retain intermittent ovarian function for many years → can still become pregnant and need counseling on contraception
- POI ≠ menopause
Describe Management of 2° amenorrhea: Primary Ovarian Insufficiency (POI) (3)
- Patient education (diagnosis)
- Hormone replacement therapy until age of menopause
- Maintain age-appropriate bone density
- Cardiovascular health
- Yearly F/U of HRT, TSH levels; bone scan as needed
Describe: Functional Hypothalamic Amenorrhea (FHA) (2)
- Dx of exclusion (must R/O other causes)
- Suppression of pulsatile GnRH secretion from hypothalamus
Describe management: Functional Hypothalamic Amenorrhea (FHA) (5)
- Patient education
- Nutritional counseling re: ↑ caloric intake
- Ca2+ and Vit D supplementation if warranted
- Monitor bone density
- Referral to eating disorder clinics/specialist if needed
Describe: Endocrinologic Causes (2)
- Normal FSH, Normal E
- Endocrine disorders disrupt hypothalamic–pituitary axis
Describe RX: Endocrinologic Causes (4)
Rx of underlying etiology:
- Thyroid hormone replacement or treatment of hyperthyroidism
- Normalization of prolactin (dopamine agonist ± surgery)
- OCPs to decrease clinical hyperandrogenism and prevent endometrial hyperplasia in PCOS
- Steroid replacement in CA
