14, 15 Amenorrhea Flashcards
Primary amenorrhea
Differential diagnosis (4) and how to dx if:
Breast: -
Uterus: +
- Turner’s: high LH,FSH
- Craniopharyngioma: low LH,FSH, tumor on MRI
- Kallman’s: low LH,FSH
- Anorexia/weight loss: low LH, FSH
Do LH,FSH and MRI
Kallman syndrome
- how to dx
- what needs to be done
Breast/pubes-, uterus+
Anosmia
Give E+P to allow puberty.
Secondary amenorrhea
-how to initiate workup?
Start with 3 MCC: Pregnancy, thyoid issue (hypothyroidism), prolactin issue (tumor/meds)
Do UPT, TSH, Prolactin. Then, look at HPO axis in reverse order.
Primary amenorrhea
Differential diagnosis (2) and how to dx if:
Breast/pubes: +
Uterus: -
- Mullerian agenesis: normal T, XX
- AIS: high T, XY
Dx and diff by karyotype and T.
Primary amenorrhea:
How to think about diagnosing?
You want to see if patient has:
1) functioning HPO axis. Test this by looking at breasts, axillary, pubic hair.
2) proper anatomy (uterus). Test this by doing U/S.
Mullerian agenesis
-how to dx
primary amenorrhea.
Dx: Breast/pubes+, uterus-
XX, and normal T
Craniopharyngioma
- how to dx
- what must be done for pt
Breast/pubes-, uterus +
MRI will show tumor.
Pt needs to get E+P for puberty
Secondary amenorrhea
How do prolactin issues cause this?
DA suppresses Prolactin secretion.
- prolactinoma
- Meds–antipsychotics block DA
How to initiate workup for suspected primary amenorrhea? (3 things)
- Wrist XR (to determine bone age)
- B-HCG
- LH,FSH
Primary amenorrhea
Differential diagnosis (3) and how to dx, if:
Breast: +
Uterus: +
- imperforate hymen: visual inspection
- Anorexia/weight loss: hx and visual.
- Pregnant before 1st period: B-HCG
Turner syndrome, causing primary amenorrhea
- how to dx
- what needs to be done
Appearance (webbed neck, broad chest)
Breast/pubes-, Uterus+
high LH,FSH and XO
-give E+P as HRT to allow puberty to occur
Secondary amenorrhea
How can issue in thyroid levels cause this?
high TRH stimulates Prolactin secretion, which inhibits HPO axis.
Hypothyroidism will cause increased TRH.
Secondary amenorrhea
What are the full diagnostic algorithm steps and dx, after ruling out 3 MCC?
First, r/o 3 MCC: pregnancy, thryoid, prolactin. Look at HPO axis backwards, starting with endometrium.
- Is endometrium ready to bleed? (Progesterone challenge)
If can, then anovulation.
- Can endometrium bleed? (E+P challenge)
If can’t, then endometrial dysfxn (Ashermans, ablation)
- Is endometrium getting signal from ant pit? (LH,FSH)
4a. If LH,FSH low/normal, is there an ant pit issue? (MRI)
MRI will show adenoma/apoplexy/Sheehan’s. If not, then hypothalamic issue (stress/weight loss/anorexia)
4b: If LH,FSH high, are there follicles in ovaries? (U/S)
If yes, then problem is resistant ovaries (Savage). If no follicles, you have menopause.
Secondary amenorrhea
definition
Repro aged woman that had periods before, now stopped for 6 months. However, many doctors start diagnostic intervention after 2 cycles without period.
Prolactinoma:
Tx (2)
- bromocriptine (DA agonist)
- surgery
