Amenorrhea

Question 1

Primary amenorrhea

Answer 1

No menarche by age 16 or 4 years after thelarche

Pt 16 years old or younger - just reassure if no menses yet!

Question 2

Primary amenorrhea etiologies

Answer 2

Outflow tract anomalies
Mullerian agenesis = MRKH syndrome
Androgen insensitivity
Swyer syndrome
Ovarian failure
Kallman syndrome

Question 3

Outflow tract anomalies

Answer 3

Imperforate hymen
Transverse vaginal septum
Vaginal atresia
All treated with surgery

Question 4

Mullerian agenesis = MRKH syndrome

Answer 4

Patient with no menses, blind pouch vagina, but normal body hair
Get a renal ultrasound to check for other commonly associated abnormalities

Question 5

Androgen insensitivity

Answer 5

Patient with primary amenorrhea with absence of body hair
Get a karyotype to confirm 46,XY
Do have testes → MIF secreted → no mullerian structures; blind pouch vagina

Question 6

Swyer syndrome

Answer 6

46,XY with congenital absence of testes

NO MIF → mullerian structures present, as opposed to AIS

Question 7

Ovarian failure

Answer 7

See low estrogen but high gonadotropins
Savage syndrome: no LH/FSH response 2/2 receptor defect
Turner syndrome (45,XO) - rapid atresia of ovaries → no estrogen

Question 8

Kallman syndrome

Answer 8

No menses, no secondary sex characteristics, normal external genitalia. Central disorder - low GnRH → low FSH/LH → low estrogen (labs look like anorexia, etc)
Dx with olfactory challenge. Tx with pulsatile GnRH

Question 9

Secondary amenorrhea etiologies

Answer 9

Pregnancy
Anatomic abnormalities
Premature ovarian failure
PCOS = Stein-Leventhal syndrome
Hyperprolactinemia
H-P-A axis disruption: stress, anorexia, etc

Question 10

What is the #1 cause of secondary amenorrhea?

Answer 10

Pregnancy is #1 cause!

Question 11

Anatomic abnormalities causing 2nd amenorrhea

Answer 11

Asherman syndrome (intrauterine synechiae/adhesions in pt s/p myomectomy, C/S, D&C, endometritis)
Cervical stenosis 2/2 surgical, obsetric trauma

Question 12

Premature ovarian failure

Answer 12

Often idiopathic, also 2/2 torsion, surgery, infection, radiation, chemo
Symptoms of menopause before age 40; do chromosomes if < 35 y/o

Question 13

PCOS = Stein-Leventhal syndrome

Answer 13

Chronic anovulation, oligomenorrhea / amenorrhea, hirsutism, obesity, enlarged polycystic ovaries
Increased LH:FSH ratio → kills follicle, more androgens → hirsutism
Screen these pts for for T2DM

Question 14

Treatment of PCOS

Answer 14

Treat with OCPs / cyclic progestins / Depo to suppress endometrial hyperplasia / etc
Treat with Clomid if fertility desired, however.

Question 15

Hyperprolactinemia

Answer 15

Amenorrhea, galactorrhea
Prolactinoma is #1 cause; everybody should get imaging to r/o prolactinoma
Hypothyroidism → increased TSH → increases PRL secretion as well
Meds: dopamine agonists (Haldol, Reglan, other antipsychotics), TCAs, MAOis

Question 16

Treatment of prolactinoma

Answer 16

Rx with cabergoline / bromocriptine (dopamine agonists) if asymptomatic / microadenoma, or surgery if big & causing problems

Question 17

H-P-A axis disruption

Answer 17

Stress, anorexia, etc.

Question 18

Workup of secondary amenorrhea:

Answer 18

Beta-HCG first, then TSH / PRL levels
MRI of sella if needed
Progesterone challenge test if PRL normal

Question 19

Progesterone challenge test: withdrawal bleeding present

Answer 19

Outflow tract is patent & estrogen present in good enough quantities
Think anovulation (PCOS, ovarian / adrenal tumors , Cushing syndrome, thyroid disorders, adult-onset CAH)
These patients should all get progesterone to prevent endometrial hyperplasia

Question 20

Progesterone challenge test: withdrawal bleeding absent

Answer 20

Do combined estrogen / progesterone challenge…
If still no bleeding, think outflow tract obstruction
If bleeding present now, think not enough estrogen - get LH/FSH levels
If LH/FSH normal or low, think hypothalamus or pituitary
If LH/FSH high, think premature ovarian failure