Amenorrhea

Question 1

Define:
Primary Amenorrhea
Secondary Amenorrhea

Answer 1

Primary - No menarche by age 16 w/ signs of pubertal development, or no signs of pubertal development by age 14
Secondary - Absence of menstration for 3+ months in previously menstrating woman, or absense for 9+ months in previously oligomenorrhea

Question 2

Causes of Primary Amenorrhea

Answer 2

Chromosomal, Hypothalamus, Pituitary, Structural
Turner’s, Delayed Puberty, Congenital Adrenal Hyperplasia, Mullerian Defect
Outflow Tract Obstruction (Can be primary or secondary)

Question 3

Causes of Secondary Amenorrhea

Answer 3

PREGNANCY! Thyroid, Pituitary, Meds, Breast-feeding, Stress, Illness, Exessive exercise/low body weight, PCOS, Premature menopause

Question 4

Labs for Aenorrhea

Answer 4

Pregnancy tests!!!!
thyroid, sex hormones, 17-hydroxyprogesterone
Pelvic U/S, MRI of head

Question 5

Turners Syndrome

Answer 5

45 XO karyotype
Short stature with normal GH
Primary amenorrhea or early ovarial failure
Epicanthal folds, webbed neck, short fourth metacarpas
Renal and Cardio anomalies (coarct, aortic valve, aortic dissect, horseshoe kidney)
TX: GH injection + andorgen. @ 12 yrs, GH + estrogen

Question 6

Delayed Puberty

Answer 6

Primary amenorrhea
Good prognosis
Wrist Joint X-Ray
Family Hx, and Follow up

Question 7

Congenital Adrenal Hyperplasia

Answer 7

Primary Amenorrhea
Inc. Androgen - male caracteristiccs
Sex organs present
Possibly ambiguous genitalia
Tests: Karyotype, Low aldoseterone and cortisol, high urinary 17 ketosteriods, electrolytes: “Salt wasting” low Na, high K.
Treatment: Cortisol, Reconstructive surgery of genitalia, education of long term steroid therapy

Question 8

Mullerian Defect

Answer 8

Primary Amenorrhea
Malformation of genital tract - Absent vagina
Normal breasts, pubic hair, external genitalia
Karyotype 46-XX
TX: Create vagina

Question 9

Outflow Tract Obstruction

Answer 9

Primary - imperforate hymen
Secondary - curretage from surgery (“Askerman’s syndrome” - walls of uterus become adherent), cervical stenosis, fibroids, polyps

Question 10

Hyperprolactinemia

Answer 10

Secondary Amenorrhea
Causes: Pituitary tumor, hypothyroid, meds, stress
Signs: Galactorrhea, ifertility, amenorrhea
Labs: Prolactin, TSH, MRI
TX: Dopamine agonists, surgery, radiation

Question 11

Hypothyroidism

Answer 11

Secondary Amenorrhea
Signs: Dry skin, fatigue, coarse hair, goiter, weight gain, “cold”, memory problems, amenorrhea
Labs: TSH, FT4
TX: Levothyroxine

Question 12

Cushing’s Syndrome

Answer 12

Secondary Amenorrhea
Edogenous - excess glucocorticoid secreted by adrenal cortex
Exogenous - long term steriods
Signs: Trunk obesity, moon facies, buffalo hump, amenorrhea, osteoporosis, hirsutism, acne, abdominal striae, HTN
Labs: Corticotropin Releasing Hormone stimulation tests, Dexamethasone suppresion test, 24 urine free cortisol
TX: Surgery, Dec. steroid use, treat effects aggressively

Question 13

Premature Ovarian Failure

Answer 13

Secondary Amenorrhea
Menopausal Sx: hot flash
Labs: FSH, LH levels are HIGH. Also check TSH, glucose, cortisol.
TX: Oral contraceptives as hormonal treatment

Question 14

Eating Disordors (anorexia, bulemia)

Answer 14

Secondary Amenorrhea is first sign
BMI <17
Sx: Menstrual irregularity, emaciated appearance, loss of fat distribution, dry skin, flat affect, brittle hair
Labs: CBC, electrolyte, TSH/T4, FSH/LH
TX: Inc. body weight, intense therapy and counseling, family involvment

Question 15

Excessive Exercise (Female Athlete Triad)

Answer 15

Triad: Weight loss, secondary amenorrhea, osteoporosis
hypothalamic disorder (depression
TX: oral contraceptions, Ca2+ and Vit D, Exercise moderation

Question 16

Polycystic Ovarian Syndrome (PCOS)

Answer 16

Amenorrhea or oligomenorrhea is most common
Obesity, masculine body, hirsutism, acne, glucose intolerance
Labs: GnRH, LH/FSH (inc. LH/FSH ratio), androgens, glucose, lipids, testosterone, prolacitn
Pelvic U/S: “Pearl Necklace”
TX: Oral contraceptives, progestin only. Spironolactone. Metformin. GnFH analogs - Lupron. Weight loss.

Question 17

Algorithm for diagnosis

Answer 17

Pregnancy test first ALWAYS.
If neg. Progesterone challenge. Take 10 mg progesterone x 10 days.
If withrawl bleed: amenorrhea due to anovulation. consider PCOS / idiopathic. TX w/ OCs or progesterone every 3 months to prevent endoetrail hyperplasia
If NO bleed: Add estrogen to progesterone using OCs. Then if withdrawl bleed: Pt lacks endogenous estrogen. Consider hypothalamic dysfunction.
If still NO bleed: Check LH, FSH, TSH, Prolactin

Question 18

Lab Values Indicate Which Disease?
LH/FSH raio >3
FSH >40
Increased prolactin
Increased TSH
Decreased FSH and LH

Answer 18

LH/FSH raio >3 - PCOS
FSH >40 - premature ovarian failure or menopause
Increased prolactin - get MRI, r/o pituitary tumor
Increased TSH - hypothyroidism
Decreased FSH and LH - hypothalamic or thyroid malfuction (stress, weight loss, excessive excercise, eating disorder)