Amenorrhea

Question 1

Workflow algorithm for amenorrhea

Answer 1

1. H&P, pregnancy test
2. prolactin and TSH
3. progestin challenge: yes bleeding = PCOS, no bleeding = move on
4. estradiol (or given estradiol and progestin): nl estradiol = outflow tract problem, low estradiol = move on
5. FSH/LH: high = ovarian failure, low = hypothalamic or pituitary disorder

Question 2

Asherman syndrome prognosis

Answer 2

best to worst: endometrial adhesions > myometrial adhesions > atrophic and sclerotic endometrium w/o adhesions (post radiation/TB)

Question 3

Asherman syndrome RF

Answer 3

least likely to cause Asherman to most likely: curettage after incomplete abortion or molar pregnancy < curettage after missed abortion < postpartum curettage combined w/ hypoestrogen states (breast feeding, hypogonadotropic hypogonadism)

Question 4

Causes of secondary amenorrhea
hypothalamic - 
pituitary - 
ovarian - 
outflow -

Answer 4

hypothalamic: stress, hypothyroidism (-> high TRH -> high PRL -> low GnRH), hyperprolactinemia
pituitary: Sheehan, irradiation, pituitary surgery

Ovarian: PCOS, premature ovarian failure

Outflow: intrauterine adhesions, cervical stenosis

Question 5

Workup for PCOS

Answer 5

TSH, prolactin (pituitary cause of secondary amenorrhea)

17-OH (congenital cause)

testosterone-ovarian and DHEA-adrenal (androgen-secreting tumor)

lipid, glucose (PCOS)

endometrial biopsy (assess for malignancies 2/2 unopposed estrogen)