1. Amenorrhea and Oligomenorrhea

Question 1

Describe: PRIMARY Absence or Cessation of Menstruation (1)

Answer 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

Question 3

Describe: SECOND Absence or Cessation of Menstruation (2)

Answer 3

• cessation of previously normal menstruation for > 6 mo
• or no menses for 3 or more normal cycles

Question 4

What’s the avg age of onset of menarche?

Answer 4

avg. age of onset 12 yr

Question 5

What’s the avg age of onset of menopause

Question 6

Name stages of puberty (5)

Answer 6

AGTpM

• Adrenarche
• Gonadarche
• Thelarche
• Pubarche
• Menarche

Question 7

Define: Adrenarche (1)

Answer 7

↑ secretion of adrenal androgens approximately 2 yr pregonadarche

Question 8

Define: Gonadarche (1)

Answer 8

↑ secretion of gonadal sex steroids (onset at ~8 yr)

Question 9

Define: Thelarche (1)

Answer 9

breast development begins at 9 to 11 yr

Question 10

Describe: Tanner staging for breast development (5)

Answer 10

• None
• Breast bud
• ↑ Size areola and breasts
• 2° mound of areola and papilla
• Areola recessed to contour of breast

Question 11

Define: Pubarche (1)

Answer 11

pubic and axillary hair development begins at 11 to 12 yr

Question 12

Desribe: Tanner staging for pubic hair (5)

Answer 12

• 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

Question 13

Define: Menarche (2)

Answer 13

• avg. onset of menses at approximately 12 yr
• Menarche typically occurs within 2 yr of onset of breast development

Question 14

Name: DDx of 1° amenorrhea (21)

Answer 14

• 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:

Question 15

Name DDx of 1° amenorrhea: Stress (5)

Answer 15

• Anorexia/bulimia
• Nutritional deprivation
• Excessive exercise
• Emotional stress
• Systemic illnes

Question 16

Name DDx of 1° amenorrhea: Congenital Müllerian duct abnormalities (2)

Answer 16

• Transverse vaginal septum
• Vaginal agenesis (i.e., Mayer-Rokitansky-Kuster-Hauser syndrome)

Question 18

Name: DDx of 2° amenorrhea (18)

Answer 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)

Question 19

Name DDx of 2° amenorrhea: Stress (5)

Answer 19

• Anorexia/bulimia
• Nutritional deprivation
• Excessive exercise
• Emotional stress
• Systemic illness

Question 20

Describe Epidemiology of 2° Amenorrhea (when pregnancy exclude) (5)

Answer 20

• Ovarian causes—40%
• Hypothalamic causes—35%
• Pituitary disease—19%
• Uterine disease—5%
• Other—1%

Question 21

Describe patient hx: Amenorrhea/oligomenorrhea (9)

Answer 21

• 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

Question 22

Describe FHX: Amenorrhea/oligomenorrhea (9)

Answer 22

• Menarche
• Menstrual Hx
• Parental height
• Parental pubertal Hx
• Infertility
• Genetic defects
• Low IQ (Fragile X syndrome)
• Congenital abnormalities
• Endocrinopathies

Question 23

Describe Physical Exam: Amenorrhea/oligomenorrhea (10)

Answer 23

• 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)

Question 24

Describe: Approach to Dx of 1° amenorrhea. (Figure)

Answer 24

Question 25

Describe: Primary Ovarian Insufficiency (POI) (2)

Answer 25

* Most women with POI retain intermittent ovarian function for many years → can still become pregnant and need counseling on contraception * POI ≠ menopause

Question 26

Describe Management of 2° amenorrhea: Primary Ovarian Insufficiency (POI) (3)

Answer 26

* 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

Question 27

Describe: Functional Hypothalamic Amenorrhea (FHA) (2)

Answer 27

* Dx of exclusion (must R/O other causes) * Suppression of pulsatile GnRH secretion from hypothalamus

Question 28

Describe management: Functional Hypothalamic Amenorrhea (FHA) (5)

Answer 28

* 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

Question 29

Describe: Endocrinologic Causes (2)

Answer 29

* Normal FSH, Normal E * Endocrine disorders disrupt hypothalamic–pituitary axis

Question 30

Describe RX: Endocrinologic Causes (4)

Answer 30

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