4. Disorders of Menstruation Flashcards
Name DDX of primary amenorrhea with: Normal breast and pelvic (4)
- Hypothyroidism
- Hyperprolactinemia
- PCOS
- Hypothalamic dysfunction
Name DDX of amenorrhea with: Normal breast, abnormal uterine development (4)
- Androgen insensitivity
- Anatomic abnormalities
- Müllerian agenesis
- uterovaginal septum
- imperforate hymen
Name DDX of primary amenorrhea with: High FSH (hypergonadotropic hypogonadism) (2)
- Gonadal dysgenesis
- Abnormal sex chromosome (Turner’s XO)
- Normal sex chromosome (46XX, 46XY)
Name DDX of primary amenorrhea with: Low FSH (hypogonadotropic hypogonadism) (8)
- Constitutional delay (rare in girls)
- Congenital abnormalities Isolated
- GnRH deficiency
- Pituitary failure (Kallman syndrome, head injury, pituitary adenoma, etc.)
- Acquired endocrine disorders (type 1 DM)
- Pituitary tumours
- Systemic disorders (IBD, JRA, chronic infections, etc.)
- Functional hypothalamic amenorrhea
Name: Most Common Causes of Primary Amenorrhea (3)
- Müllerian agenesis
- Abnormal sex chromosomes (Turner’s syndrome)
- Functional hypothalamic amenorrhea
Name the most common cause of secondary amenorrhea
Functional hypothalamic amenorrhea
Name ddx secondary amenorrhea: With Hyperandrogenism (4)
- PCOS
- Autonomous hyperandrogenism (androgen secretion independent of the HPO axis)
- Ovarian: tumour, hyperthecosis Adrenal androgen-secreting tumour
- Late onset or mild congenital adrenal hyperplasia (rare)
Name DDX secondary amenorrhea: Without Hyperandrogenism (5)
- Hypergonadotropic hypogonadism (i.e. primary ovarian insufficiency: high FSH, low estradiol)
- Idiopathic
- Autoimmune: type 1 DM, autoimmune thyroid disease, Addison’s disease
- Iatrogenic: cyclophosphamide drugs, radiation
- Hyperprolactinemia
- Endocrinopathies: most commonly hyper or hypothyroidism
- Hypogonadotropic hypogonadism (low FSH):
- Pituitary compression or destruction: pituitary adenoma, craniopharyngioma, lymphocytic hypophysitis, infiltration (sarcoidosis), head injury, Sheehan’s syndrome
- Functional hypothalamic amenorrhea (often related to stress excessive exercise and/or anorexia)
Describe diagnostic approach to amenorrhea (figure)
Describe investigation: Amenorrhea (4)
- β-hCG, hormonal workup (TSH, prolactin, FSH, LH, androgens, estradiol)
- progesterone challenge to assess estrogen status
- medroxyprogesterone acetate (Provera®) 10 mg PO OD for 10-14 d
- any uterine bleed within 2-7 d after completion of Provera® is considered to be a positive test/ withdrawal bleed
- withdrawal bleed suggests presence of adequate estrogen to thicken the endometrium; thus withdrawal of progesterone results in bleeding
- if no bleeding occurs, this may be secondary to inadequate estrogen (hypoestrogenism), excessive androgens, or progesterones (decidualization) or pregnancy
- karyotype: indicated if primary ovarian insufficiency or absent puberty
- U/S to confirm normal anatomy, identify PCOS
Describe management of Primary Amenorrhea: Androgen insensitivity syndrome (3)
- Gonadal resection after puberty
- Psychological counselling
- Creation of neo-vagina with dilation
Describe management of Primary Amenorrhea: Müllerian dysgenesis (MRKH syndrome) (3)
- Psychological counselling
- Creation of neo-vagina with dilation
- Diagnostic study to confirm normal urinary system and spine
Describe management of Primary Amenorrhea:
Describe management of Primary Amenorrhea:
Anatomical
- Imperforate hymen
- Transverse vaginal septum
- Cervical agenesis
- Imperforate hymen: Surgical management
- Transverse vaginal septum: Surgical management
- Cervical agenesis: Suppression and ultimately hysterectomy
Describe management of Secondary Amenorrhea: HP-axis dysfunction (2)
- Identify modifiable underlying cause
- Combined OCP to decrease risk of osteoporosis, maintain normal vaginal and breast development (NOT proven to work)
Describe management of Secondary Amenorrhea: Hyperprolactinemia (3)
- MRI/CT head to rule out lesion
- If no demonstrable lesions by MRI
- Bromocriptine, cabergoline if fertility desired
- Combined OCPs if no fertility desired
- Demonstrable lesions by MRI: surgical management
Describe management of Secondary Amenorrhea: Premature ovarian failure (2)
- Screen for DM, hypothyroidism, hypoparathyroidism, hypocorticolism
- Hormonal therapy with estrogen + progestin to decrease risk of osteoporosis; can use OCP after induction of puberty
Describe management of Secondary Amenorrhea: Uterine defect, Asherman’s syndrome (2)
- Evaluation with hysterosalpingography or sonohysterography
- Hysteroscopy: excision of synechiae