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Essentials - Gynecology > 1. Amenorrhea and Oligomenorrhea > Flashcards

1. Amenorrhea and Oligomenorrhea Flashcards

1
Q

Describe: PRIMARY Absence or Cessation of Menstruation (1)

A

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

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2
Q
A
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3
Q

Describe: SECOND Absence or Cessation of Menstruation (2)

A
  • cessation of previously normal menstruation for > 6 mo
  • or no menses for 3 or more normal cycles
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4
Q

What’s the avg age of onset of menarche?

A

avg. age of onset 12 yr

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5
Q

What’s the avg age of onset of menopause

A
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6
Q

Name stages of puberty (5)

A

AGTpM

  • Adrenarche
  • Gonadarche
  • Thelarche
  • Pubarche
  • Menarche
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7
Q

Define: Adrenarche (1)

A

↑ secretion of adrenal androgens approximately 2 yr pregonadarche

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8
Q

Define: Gonadarche (1)

A

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

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9
Q

Define: Thelarche (1)

A

breast development begins at 9 to 11 yr

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10
Q

Describe: Tanner staging for breast development (5)

A
  • None
  • Breast bud
  • ↑ Size areola and breasts
  • 2° mound of areola and papilla
  • Areola recessed to contour of breast
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11
Q

Define: Pubarche (1)

A

pubic and axillary hair development begins at 11 to 12 yr

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12
Q

Desribe: Tanner staging for pubic hair (5)

A
  • 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
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13
Q

Define: Menarche (2)

A
  • avg. onset of menses at approximately 12 yr
  • Menarche typically occurs within 2 yr of onset of breast development
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14
Q

Name: DDx of 1° amenorrhea (21)

A
  • 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:
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15
Q

Name DDx of 1° amenorrhea: Stress (5)

A
  • Anorexia/bulimia
  • Nutritional deprivation
  • Excessive exercise
  • Emotional stress
  • Systemic illnes
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16
Q

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

A
  • Transverse vaginal septum
  • Vaginal agenesis (i.e., Mayer-Rokitansky-Kuster-Hauser syndrome)
17
Q
A
18
Q

Name: DDx of 2° amenorrhea (18)

A
  • 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)
19
Q

Name DDx of 2° amenorrhea: Stress (5)

A
  • Anorexia/bulimia
  • Nutritional deprivation
  • Excessive exercise
  • Emotional stress
  • Systemic illness
20
Q

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

A
  • Ovarian causes—40%
  • Hypothalamic causes—35%
  • Pituitary disease—19%
  • Uterine disease—5%
  • Other—1%
21
Q

Describe patient hx: Amenorrhea/oligomenorrhea (9)

A
  • 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
22
Q

Describe FHX: Amenorrhea/oligomenorrhea (9)

A
  • Menarche
  • Menstrual Hx
  • Parental height
  • Parental pubertal Hx
  • Infertility
  • Genetic defects
  • Low IQ (Fragile X syndrome)
  • Congenital abnormalities
  • Endocrinopathies
23
Q

Describe Physical Exam: Amenorrhea/oligomenorrhea (10)

A
  • 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)
24
Q

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

A
25
Q

Describe: Primary Ovarian Insufficiency (POI) (2)

A
  • Most women with POI retain intermittent ovarian function for many years → can still become pregnant and need counseling on contraception
  • POI ≠ menopause
26
Q

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

A
  • 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
27
Q

Describe: Functional Hypothalamic Amenorrhea (FHA) (2)

A
  • Dx of exclusion (must R/O other causes)
  • Suppression of pulsatile GnRH secretion from hypothalamus
28
Q

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

A
  • 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
29
Q

Describe: Endocrinologic Causes (2)

A
  • Normal FSH, Normal E
  • Endocrine disorders disrupt hypothalamic–pituitary axis
30
Q

Describe RX: Endocrinologic Causes (4)

A

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

Essentials - Gynecology (14 decks)

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