Amenorrhea Flashcards
primary amenorrhea
NO menses by 13 + absence of growth of secondary sex characteristics
NO menses by 15 but secondary sex characteristics present
secondary amenorrhea
previously had menses AND
absence of menses more than 3 mo in girls who had REGULAR menses
OR 6 mo in girls who had IRREGULAR menses
causes of primary amenorrhea
genetic, anatomic abnormalities
- chromosome
- absence of structure
- physiologic delay
- PCOS
- Isolated GnRH deficiency
- transverse vaginal septum/imperforate hymen
- weight loss/anorexia
- pituitary disease
MC cause of secondary amenorrhea
pregnancy
HPO axis
hypothalamus -> GnRH -> anterior pituitary -> LH/FSH -> ovaries -> progesterone and estrogen -> hypothalamus
amenorrhea work up
- Serum HCG (r/o pregnancy)
- TSH, FSH, Prolactin
- pelvic U/S
- Progestin Challenge Test
- +/- MRI
Progestin Challenge Test
why do we do it>
asses level of endogenous estrogen and competence of outflow track
give stimulant to start
Progestin Challenge Test options (3) for step 1
- parenteral progesterone oil
- oral micronized progesterone
- oral medroxyprogesterone acetate
what to we look for in step 1 of Progestin Challenge Test ? what does it mean?
Did vaginal bleeding occur in 2-7 days?
yes: bleeding = anovulation
no: hypogonadism
why do we treat anovulatory patients?
if untreated unopposed estrogen can cause endometrial hyperplasia
tx: provera at beginning of month + OCP
Progestin Challenge Test
withdrawal bleeding NOT occur - management
target organ outflow tract is not working - estrogen proliferation of endometrium has not occurred
give estrogen and progesterone (STEP 2)
following step 2: if bleeding does NOT occur possible etiology
Progestin Challenge Test
endometrium or outflow tract obstruction
RARE
causes of endometrium or outflow tract
aggressive curettage/Asherman’s
infection
genetic anomaly (Mullareian dysgenesis or agenesis)
Progestin Challenge Test bleeding occurs following step 2
issue is with body’s ability to stimulate estrogen production
continue to step 3
step 3 of Progestin Challenge Test
bioassay levels of gonadotropins
2 weeks after e/p test
draw LH and FH levels
hypergonadotrophic causes (main)
bilateral oophorectomy
post menopausal
ovarian failure
hypergonadotrophin increases GnRH
- ectopic gonadotropin
- perimenopausal period (rising FSH)
- gonadotropin secreting pituitary adenomas
- resistant or insensitive ovary syndrome
5-7. autoimmune dz, galactosemia, 17 hydroxylase
causes of hypogonadotrophic
- pre pubertal
- hypothalamic dysfunction
- pituitary dysfunction
evaluation of hypogonadotrophc
imaging of sella turcica = MRI
micro adenomas - not important
macro adenoma= refer and serious
disorder of outflow tract of uterus (list)
- asherman’s syndrome
- mullarian anomalies
- mullein agenesis
- androgen insensitivity
asherman’s syndrome
intrauterine scaring and adhesions
diagnosed by hysteroscopy
tx: lysis of adhesions
complications of asherman’s
infertility
miscarriage
dysmenorrhea
mullerian anomalies
causes
imperforate hymen
obliteration of oriface
presence or absence of uterus or cervix
mullerian anomalies
associated s/s
pelvic pain
infertility or recurrent miscarriages
mullerian agenesis
complete lack of mullerian development
mayer rokitansky-kuster Hauser syndrome
absence or hypoplasia of internal vagina
workup of mullerian agenesis and tx
karyotype
tx: vaginal dilators and surgery
androgen insensitivity
complicate androgen insensitivity
male karyotype with female appearance
nil or elevated testosterone
disorders of the ovary list
- Turner syndrome
- mosaicism
- XY gonadal dysgenesis
- gonadal atresia
- resistant ovary syndrome
- premature ovarian failure
Turner syndrome `
short stature, webbed neck, shield chest,
hypergonadotropic hypoestrogenic amenorrhea
lack of ovarian follicles, no sex hormone production, primary amenorrhea
premature ovarian failure
early depletion of follicles causing periods to stop around 40
what may cause disorder of the ovary
radiation and chemotherapy
who do you karyotype in patients with hypergonadotrophic ovarian disorders
ovarian failure
elevated gonadotropins
age under 30
if over 30 –> DO NOT karyotype
premature ovarian failure tx
hormone replacement therapy
estrogen with progestin due to intact uterus
mimic NML physiology
exervise
smoking cessation
pituitary tumors
grow and cause compression of optic chasm = visual change
nonfunctioning adenomas
prolactin secreting adenomas
nonfunctioning adenomas
reduces level of dopamine
secrete FSH and LH
elevated PRL on eval
treatment of nonfunctioning adenoma
micro= no tx
macro= surgical resection + radiation
MC pituitary tumors
prolactin secreting tumors
prolactin secreting tumors tx
dopamine agonist (bromocriptine)
if pt wants to get prig, d/c when temperature indicates ovulation
bromocriptine regression in prolactin secreting tumors
regress with tx
shrinkage occurs
surgery of prolactin secreting tumors
transphenoidal neruosurgery
if amenorrhea continues = PRL level q 6 mo
pregnancy and prolactin adenomas
80% achieve pregnancy with dopamine agonist tx
some women resume cyclic menses after pregnancy and bromocriptine is safe in pregnancy
Sheehan;s syndrome
infarction and necrosis of pituitary gland due to post part hemorrhage and shock
failure of lactation and loss of pubix.axillary hair
List of CNS disorders
- hypothalamic amenorrhea
- weight loss, anorexia, bulimia
- exercise and amenorrhea
- eating disorders and pregnancy
- inherited genetic defects
- post pill amenorrhea
