Amenorrhea Flashcards
What is the menstrual cycle controlled by?
Menstrual cycle controlled by hormones produced by the hypothalamus, pituitary, and ovary.
Hypothalamus produces gonadotropin releasing hormone (GnRH)
Pituitary gland produces FSH and LH
Stimulates ovary to produce estrogen
After ovulation, ovary primarily produces progesterone
what is primary amenorrhea?
No menarche by age 16 with signs of pubertal development (breasts/pubic hair)
No onset on pubertal development by 14 yo
What is secondary amenorrhea?
Secondary Amenorrhea:
Absence of menstruation for 3 months or more in a previously menstruating woman of reproductive age
Absence of menstruation for 9 or more months in a woman with previous oligomenorrhea
What are common causes of primary amenorrhea?
Chromosomal abnormalities Hypothalamus abnormalities Pituitary problems Reproductive organ abnormalities Structural abnormalities Pregnancy (uncommon)
what is are the common causes of secondary amenorrhea? what is the most common?
pregnancy is most common. other causes: Thyroid abnormalities Pituitary abnormalities Medications (inc. contraceptives) Breast-feeding Stress Illness Excessive exercise/low body weight Polycystic Ovarian Syndrome (PCOS) Premature menopause
Why should you eval a patient who has amenorrhea?
Inability to conceive - anovulation Lack of estrogen - osteoporosis excess exercise Eating disorders - life threatening Pregnancy - early care, statutory rape Pituitary tumors - life and sight threat Adrenal or ovarian tumors Psychosocial issues - related to body and menses
What info is important to gather from the patient’s history?
Menarche and menstrual history Sexual history Medications or illicit drug use Exercise - Weight Loss - Nutrition Stress Illness (chemo treatment) Genetic defects Infertility Menarche history of mother and sisters Growth delays
What labs are important for amenorrhea?
Labs: -Pregnancy test (urine/serum) -LH, FSH, Prolactin, TSH, T4, testosterone, progesterone, estrogen, DHEAS and Serum 17-hydroxyprogesterone (adrenal hyperplasia, Cushing's syndrome, PCOS/masculinizing ovarian tumors) Diagnostics: -Pelvic U/S (include transvaginal) -MRI - head
What is Turner’s Syndrome?
Turner’s Syndrome: Genetic condition occurs only in females
- 45 XO karyotype
- Neck webbing, short stature
- Congenital heart defects
- No development of ovaries
- Absence of secondary sexual characteristics - breast buds possible
How should you eval for Turner’s syndrome?
Pelvic exam
LH and FSH both HIGH
Karyotyping–> 45 XO karyotype
Pelvic U/S - reproductive organs and kidneys (see no development of ovaries)
EKG and echocardiogram (heart defects common)
What are the complications of Turner’s syndrome?
Complications:
- Heart defects – coarctation, aortic valve disease, aortic dissection
- Kidney abnormalities – horseshoe kidney
- HTN / CVD
- Obesity
- Diabetes
- Cataracts
- Arthritis
- Scoliosis
How do you treat Turner’s Syndrome?
Exogenous Estrogen
Human Growth Hormone
Describe delayed puberty:
Common - 20% Under stature and delayed bone age (wrist joint xray) Positive family history Diagnosis by exclusion and follow-up Good prognosis - late developer
Is delayed puberty a primary or secondary cause of amenorrhea?
primary
What is a good way to use diagnostic imaging to check on delayed puberty? How about history questions to ask?
can use wrist joint X-ray to examine hand
could ask about a family history
THIS IS A DIAGNOSIS OF EXCLUSION
Describe Congenital Adrenal Hyperplasia:
-Inherited disorder
-Decreased cortisol and aldosterone production due to lack of enzyme needed
-Increased androgen production (male characteristics)
—>Puberty - voice deepens, facial hair
Ovaries, uterus, fallopian tubes present
–>possibly ambiguous genitalia
If severe type, can be fatal in newborn
What will you see on lab results that is suggestive of Congential Adrenal hyperplasia?
- Aldosterone and cortisol levels (LOW)
- High urinary 17-ketosteroids
- Electrolyte panel (“salt wasting” - low Na+, high K+)
- Karyotyping
How do you treat Congenital Adrenal Hyperplasia?
- Cortisol
- Reconstructive surgery of genitals (1-3 mo)
- Education and side effects of long-term steroid therapy
What is a Mullerian Defect?
Malformation of genital tract
absent hormone in embryonic development
What do you normally see with a Mullerian Defect?
Normal breasts, pubic hair, normal external genitalia Normal female range testosterone level Absent vagina - normal ovaries Karyotype 46-XX 15-30% skeletal and middle ear anomalies
What is the treatment for Mullerian Defect?
Treatment: Create vagina
***You may need to be aware of the skeletal and middle ear problems, could cause hearing issues or easily broken bones.
Is Mullerian Defect a Primary or Secondary amenorrhea?
primary
What is Outflow Tract Obstruction?
There are 2 types:
- Primary:
Imperforate hymen
2. Secondary: Secondary to curettage from surgery, to control heavy bleeding after delivery or abortion – “Asherman’s Syndrome” walls of uterus become adherent Cervical Stenosis Fibroids Polyps
How can Hyperprolactinemia cause amenorrhea?
It is a secondary cause. Causes include:
- Pituitary tumor (prolactinoma)
- Hypothyroidism
- Medications - antidepressants, antipsychotics, opiates, oral contraceptives
- Stress
What are the signs and symptoms of hyperprolactinemia?
Galactorrhea, infertility, amenorrhea
What labs are needed to diagnose hyperprolactinemia?
What is the treatment?
Prolactin level, TSH, MRI of pituitary gland
Treatment: Medical (dopamine agonists), surgical, radiation
Describe Hypothyroidism:
Signs/Sxs: -Dry skin, fatigue, coarse hair, goiter, weight gain, "cold", memory problems, amenorrhea, constipation Evaluation: -TSH, free T4 Treatment: -Levothyroxine
What is Cushing’s syndrome?
Glucocorticoid excess:
1. Endogenous: secreted by the adrenal cortex
or
2. Exogenous: long-term steroids
What are the signs and symptoms of Cushing’s?
Truncal obesity, moon facies, buffalo hump, amenorrhea, osteoporosis, hirsutism, acne, abdominal striae, HTN
How do you evaluate for Cushing’s?
Corticotropin Releasing Hormone stimulation test
Dexamethasone suppression test
24-hour urine free cortisol level
What is the treatment for Cushing’s?
- Surgery if pituitary adenoma or adrenal tumor discovered
- Decrease steroid use if possible (if not, treat effects aggressively)
What labs will be elevated in Premature Ovarian Failure?
what other signs/symptoms are present?
FSH AND LH LEVELS HIGH!!
Hot flashes, menopausal sxs, and increased risk of osteoporosis (so may have breaks).
(check TSH, glucose, and cortisol levels to help rule out other diseases)
What is the treatment for Premature Ovarian Failure?
Oral contraceptives may help
What is often the first sign of an eating disorder?
amenorrhea
How do you want to evaluate for an eating disorder?
What is the treatment?
CBC, Electrolytes, TSH, free T4, FSH, LH
tx: Increase body weight
Not easy, intensive therapy and counseling
Family needs to be involved
What is the female athlete triad?
Weight loss, Amenorrhea, Osteoporosis
Treatment:
Oral contraceptives
Ca+ and Vit D intake
Exercise moderation
Describe PCOS
a common hormonal disorder among women of reproductive age. The name of the condition comes from the appearance of the ovaries in most, but not all, women with the disorder — enlarged and containing numerous small cysts located along the outer edge of each ovary (polycystic appearance)
How do patients with PCOS present?
Amenorrhea or oligomenorrhea most common Obesity Masculine body type Hirsutism, acne Glucose intolerance
Describe what causes PCOS:
Underlying defect not well understood - prime underlying abnormality most likely pituitary
Increased GnRH secretion resulting in increased LH and LSH/FH ratio
Increased ovarian androgen production
Lack of ovulation, leads to endometrium with unopposed estrogen
Hyperinsulinemia is an independent contributory factor, association between POS and DM
What is the workup for PCOS?
Exam:
Possibly enlarged ovaries
Evaluation:
Labs: lipids, fasting glucose, LH and LH/FSH ratio (3:1 - high probability), testosterone level, prolactin
Pelvic U/S: multiple ovarian follicles - “Pearl Necklace”
What is the treatment for PCOS?
Treatment:
-Oral contraceptives or progestin-only
-Spironolactone (off-label) - androgen receptor antagonist
-Metformin - oral antidiabetic agent
reduces insulin resistance, may help with fertility
-GnRH analogs - Lupron
-Referral to Endocrinologist
What is the first thing you should do for amenorrhea?
PREGNANCY TEST!!
if negative, then progesterone challenge
What is the progesterone challenge?
10mg of progesterone for 10 days
If bleed…
1. amenorrhea due to anovulation
(consider PCOS, idiopathic–> may benefit from OCs)
If NO bleed…
- add estrogen to P by way of oral contraceptives.
- –> if bleed= patient lacks sufficient estrogen, think ovarian failure or hypothalamic dysfunction - if still no bleed –> then get LH, FSH, TSH, and prolactin level.
In secondary amenorrhea, and no bleeding after progesterone challenge or estrogen being added…then what can you do?
-LH/FSH ratio > 3 = PCOS
-FSH >40 = premature ovarian failure, menopause
-Increased prolactin level = MRI, r/o pituitary tumor
-Increased TSH = Hypothyroidism
-Decreased FSH and LH = hypothalamic or thyroid malfunction
-Stress, weight loss, excessive exercise, eating disorder
(Treatment based on underlying disorder)
What is dysfunctional uterine bleeding?
abnormal uterine bleeding in terms of quantity, frequency, duration, or regularity in the ABSENCE of pelvic disease, pregnancy, or medical illness.
When is DUB most common? What is the most common cause?
Most common at menarche and peri-menopause
>90% due to anovulatory cycle
Patient usually presents with irregular and/or heavy flow affecting their lifestyle
DIAGNOSIS OF EXCLUSION
What kind of diagnosis is DUB?
diagnosis of exclusion
What is hypermenorrhea?
cycles regular and normal duration, blood loss excessive
what is menorrhagia?
interval normal, excessive duration and flow
what is metrorrhagia?
interval irregular, duration and flow excessive
What is menometrorrhagia?
interval irregulation, duration and flow excessive and intermenstrual bleeding
oligomenorrhea:
interval is >35 days
polymenorrhea:
interval is <21 days
hypomennorrhea:
cycles regular, blood loss abnormally decreased
What are the two most common causes of DUB?
Anovulatory – estrogen breakthrough bleeding
- Estrogen production unaccompanied by cyclic leutinizing hormone production leads to unopposed estrogen
- Peri-menopause – gradual ovarian failure
Ovulatory
- Persistent progesterone production
- Prematurely decreased progesterone
- Mid-cycle spotting due to decreased estrogen following ovulation
What are some contributing factors to DUB?
Anxiety and stress
Body habitus (Obesity, anorexia)
Somatization
Smoking (Heavier periods)
How do you treat DUB?
Combination oral contraceptives Cyclical progesterone (21-day cycle) D&C Endometrial Ablation Hysterectomy
In what patient population is OC considered high risk?
smokers older than 35
Post-menopausal bleeding needs…
endometrial biopsy and U/S
