#3: Amennorhea

Question 1

PMDD 1st line TX: (4)

Answer 1

First-line: SSRI 
1-Citalopram 20-30mg PO daily
2-Paroxetine 20-30mg PO daily
3-Fluoxetine 20mg PO daily**MC
4-Sertraline 50 to 150mg PO daily
QD throughout month or QD during luteal phase (starting day 14)

Question 2

PMDD 2nd line TX: (3)

Answer 2

1- another SSRI
2- OCP
3- alpralozam (limited quantity to luteal phase i.e. 3 or 4 days)

Question 3

PMDD 3rd line TX:

Answer 3

GnRH agonist, but rq consult

Question 4

PMDD Behavioral SXS: MATS

Answer 4

1-Mood swings, sudden sadness, increased sensitivity to rejection
2-Anger, irritability
3-Sense of hopelessness, depressed mood, self-critical thoughts
4-Tension, anxiety, feeling on edge

Question 5

PMDD Physical SXS: BCDDEFS

Answer 5

1-Difficulty concentrating
2-Change in appetite: cravings, overeating
3-Diminished interest in usual activities
4-Easy fatigability/decreased energy
5-Feeling overwhelmed/out of control
6-Breast tenderness, bloating, weight gain, or joint/muscles aches
7-Sleeping too much/not sleeping enough

Question 6

PCOS SXS: (7)

HI MOM HI

Answer 6

1- hyperandrogenism
2- infertility: higher rates due to anovulation and higher rates of miscarriage
3- metabolic syndrome and hyperinsulinemia: almost half with CAD, lipid abnormalities, and metabolic syndrome
4- menstrual disorders: often since menarche
5- obesity: 1/2 of women with DX
6- hirsutism
7- insulin resistance/DM: *pre-DM MC, but 10% frank DM by 40yo

Question 7

Result of chronic anovulation on U/S:

Answer 7

Thickened cortex with “pearl necklace” appearance

Question 8

DX study of choice for ovarian torsion:

Answer 8

U/S to ID adnexal mass and evaluate blood flow

Question 9

MC cause of primary amenorrhea

Answer 9

Chromosomal abnormalities – gonadal dysgenesis

—Ovarian insufficiency due to premature depletion of all oocytes and follicles

Question 10

a reliable indicator of estrogen production or exposure to exogenous estrogens

Answer 10

breast development

Question 11

a reliable indicator of androgen production or exposure

Answer 11

presence of pubic hair growth

Question 12

assess the level of endogenous estrogen and the competence of the outflow tract

Answer 12

Progestin challenge test

Question 13

If prolactin is elevated: imaging to evaluate for prolactinoma

Answer 13

MRI

Question 14

Progestin Challenge Test: 3 choices include

Answer 14

1-Parenteral progesterone oil (200mg)
2-Oral micronized progesterone (300mg)
3-Oral medroxyprogesterone acetate (10mg) daily for 5 days

Question 15

Turner Syndrome Manifestations: 9

Answer 15

• Short stature
• webbed neck
• shield chest
• increased carrying angle at the elbow
• hypergonadotropic hypoestrogenic amenorrhea
• Lack of ovarian follicles
• no gonadal sex hormone production
• primary amenorrhea
• Perform a karyotype

Question 16

Mosaicism Manifestations: 4

Answer 16

• multiple cell lines of varying sex chromosome composition
• Presence of a Y chromosome: rq excision of gonadal areas
• Short stature (<63 inches)
• early menopause

Question 17

XY gonadal dysgenesis Manifestations: 3

Answer 17

• Female pt with XY karyotype
• palpable mullerian system
• normal female testosterone levels and lack of sexual development: Swyer’s Syndrome

Question 18

Gonadal atresia manifestations: 3

Answer 18

• May be due to viral and metabolic influences in early gestation or undiscovered genetic mutations
• Female development
• Remove gonadal streaks

Question 19

The resistant ovary syndrome manifestations: 4

Answer 19

• Rare
• amenorrhea and normal growth and development
• elevated gonadotropins with unstimulated ovarian follicles
• no evidence of autoimmune disease

Question 20

Premature ovarian failure manifestations: 3

Answer 20

• Early depletion of ovarian follicles
• 1% of women will experience this before 40yo
• Age of presentation depends on how fast the follicles are lost

Question 21

Premature ovarian failure etiology: 5

Answer 21

Genetic disorders
Chromosome anomalies
Autoimmune disease
Infection: mumps
Physical assault: chemo or XT

Question 22

In premature ovarian failure due to chemo, these agents pose the greatest risk:

Answer 22

alkylating agents

Question 23

In hypergonadotrophic chromosome evaluation, these pts DO rq a karyotype: 3

Answer 23

ovarian failure, elevated gonadotropins and age under 30yo

Question 24

In hypergonadotrophic chromosome evaluation, these pts DO NOT rq a karyotype: 1

Answer 24

over 30 yo
—premature ovarian failure aka premature menopause
(recommend empiric TX)

Question 25

What is Swyer’s Syndrome?

Answer 25

-normal female testosterone levels and lack of sexual development
(XY gonadal dysgenesis)

Question 26

Weight percentile and % body fat minimum for maintaining menstruation:

Answer 26

10th %ile at 16yo ~ 22% body fat

Question 27

Weight percentile and % body fat minimum for menarche to start:

Answer 27

10th %ile at 13yo ~ 17% body fat

Question 28

Post-contraceptive amenorrhea investigation should be pursued if patient is amenorrheic: 2

Answer 28

• 6 mos after discontinuing OCPs

- 12 mos after last injection of Depo-Provera

Question 29

Macroadenoma TX and F/U:

Answer 29

• If SXS – surgical resection
• High recurrence rate so radiation therapy is needed
• F/U imaging q6 mos for 1 year, then yearly for 3-5 years

Question 30

Microadenoma TX and F/U:

Answer 30

No treatment needed

F/U imaging every 1-2 years

Question 31

PRL >1000 in a prolacrtin secreting adenoma associations: 3

Answer 31

• invasive tumor
• treat with dopamine agonists
• amenorrhea due to prolactin inhibition of the pulsatile secretion of GnRH

Question 32

Transephenoidal surgery is indicated inPituitary Prolactin-Secreting Adenomas if: (2)

Answer 32

• visual changes persist

- pt unresponsive to dopamine agonists