Amenorrhea Flashcards
List the four categories for amenorrhea causes.
- Disorders of the outflow tract or uterus
- Disorders of the ovary
- Disorders of the ant. pit.
- Disorders of the hypothalamus
Step 0 in an amenorrhea workup.
Pregnancy Test
What 3 tests are done in step 1 of an amenorrhea workup?
TSH
Prolactin
Progestational Challenge
What can the prolactin test tell a clinician in an amenorrhea workup?
If prolactin is at normal levels and there is no galactorrhea then no pituitary evaluation is needed. If the prolactin is elevated it is most likely caused by a pituitary microadenoma. Medication is used first and surgery is reserved to a lack of response to medication.
What is the progestational challenge test?
Assess the level of endogenous estrogen and the competence of the outflow tract.
The test involves administration of a progesterone analog drug for 5 days. (Medroxyprogesterone, micronized progesterone, or parenteral progesterone) A positive test is menses occurring in 7 days after the last day meds were taken.
How is a progestational challenge test interpreted?
(+) test: menses 7 days after medication. Indicates the TSH and PRL levels are fine and that the problem is anovulation
(-) test means the clinician must proceed to step 2 of the amenorrhea workup.
What is step 2 of an amenorrhea workup?
Administer estrogen analog medication for 21 days and add progesterone for at least the last 5 days.
- if there is no withdrawal bleed then something is wrong with the end organ (uterus or outflow tract).
- if no bleed occurs, the physician should proceed to a physical exam.
-if a bleed occurs, the outflow tract is fine and the physician should proceed to step 3
What is step 3 of an amenorrhea workup?
This step differentiates between an ovarian problem and a CNS/pituitary problem. A serum FSH and LH is drawn.
- elevated FSH and LH means ovarian failure
- normal FSH and LH means pituitary or CNS failure (use MRI to find out which is the source, pit or CNS)
Which outflow tract defect involves adhesions forming in the uterus usually following aggressive D&C? How is it treated?
Asherman Syndrome
Tx:
-lyse all adhesions
-insert a pediatric foley to prevent re-adherence
-estrogen and progesterone for two months to allow endometrial proliferation
What is Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome?
Congenital absence of the vagina, and/or variable uterine development, sometimes associated with cervical or uterine agenesis.
What is the presentation of MRKH syndrome?
Normal functioning ovaries lead to normal secondary sex characteristics, normal external genitalia.
Type 1: only genital anomaly
Type 2: associated with renal, vertebral, auditory and/or cardiac deformities.
What is complete androgen insensitivity?
A 46XY genotypic male develops as a phenotypic female. There are no testosterone receptors to allow development of male secondary sex characteristics. Absence of upper vagina, uterus, fallopian tubes. usually undescended testes (which should be removed to prevent cancer risk).
What are some common ovarian defects (compartment 2) that can result in amenorrhea?
Turner Syndrome Mosaicism XY gonadal dysgenesis or agenesis resistant ovary syndrome premature ovarian failure
What are 3 pituitary (compartment 3) defects that can cause amenorrhea?
Pituitary tumor
Nonfunctioning pituitary adenoma
Prolactin Secreting Pituitary adenoma
What are common hypothalamic (compartment 4) defects that can cause amenorrhea?
Weight loss, anorexia, bulimia
exercise induced
anovulation
hypothyroidism
