Amenorrhea Flashcards
Menarche def
age at onset of menses
Thelarche def
age at onset of breast development
After menarche, what happens next 2-5 years
increasing regularly of cycle. Shortens into usual reproductive age pattern
Normal menstrual cycle
- duration of flow
- volume of blood loss
- cycle length
- 4-6 days
- 30 mL
- q 21-35 days
What is cycle length most dependent on?
follicular phase
what does a shorter cycle indicate?
accelerated follicular growth pattern due to changes in FSH patterns
What happens to follicles and cycle as age
- fewer grow per cycle
- cycles shorten in late reproductive period
- 2-6 years prior to menopause, cycles increase to longer length
Polymenorrhea def
frequent menstrual bleeding (<=21 days)
Oligomenorrhea def
intervale >35 days
Menorrhagia def
regular interval but excessive flow (>80 mL) OR duration >7 days
Metrorrhagia def
irregular intervals and/or bleeding between periods
Menometrorrhagia def
excessive and irregular bleeding
Primary amenorrhea
- three types
(never got a period)
- No period age 13-14, no secondary sex characteristics
- No period age 15-16 even with secondary sex characteristics
- No period within 5 years of thelarche
Secondary amenorrhea
- two types
(had periods before, now does not)
- no menses for 3-6 months
- no menses for duration fo 3 typical menstrual cycles (oligomenorrhea)
Four “categories” of secondary amenorrhea
1: Hypothalamus (35%)
2: Anterior pituitary (19%)
3: Ovary (40%)
4: Outflow tract (5%)
Outline the 7 steps to amenorrhea workup
- H&P
- Preg test
- TSH and PRL
- Progestin challenge
- Estrogen/Progesterone challenge
- FSH/LH
- MRI of brain
Questions to ask/things to note during H&P for primary amenorrhea
- age at presentation
- growth / development delay? breast development?
- Familial or childhood issues
- genitourinary abnl?
- Exam: outflow obstruction, genesis, etc.
Questions to ask/things to note during H&P for secondary amenorrhea
- Hirsuitism, acne, virilization
- weight change, dietary habits
- psychological stressors
- galactorrhea
- neuro sx - cranial nerve deficits or changes
- Hx obstetrical or bleeding problems, past surgeries
PE for primary amenorrhea
- will ID obstructions
- Is there a uterus??
- Normal breast development?
what are examples of obstructions?
- vaginal septum
- genesis of the uterus
- scarring
What to do if there is not a uterus?
check karyotype
What does it mean if there is normal breast development?
estrogen is present
What to do if there is no breast development (aka no estrogen?)
check FSH to see where problem is coming from
Step 2: pregnancy test
she gonna have a baby!!
Step 3: TSH and PRL
- what is common TSH related finding that causes amenorrhea
- type of disorder
- pathophys explanation
- hypothyroidism
- pituitary disorder
- Causes increased TRH and TSH which cause increased PRL which decreases GnRH pulsatility
Step 3: TSH and PRL
- how to dx thyroid issue?
- tx
- TSH level
- confirm with FT4
- can check thyroid antibodies also
- Tx: thyroid hormone replacement
Step 3: TSH and PRL
- hyperprolactinemia overview
- type of disorder
- 20% of amenorrhea!!
- check twice to confirm elevated, levels can vary
- may be associated with galactorrhea
- pituitary disorder
Step 3: TSH and PRL
- hyperprolactinemia pathophysiology
- high PRL
- increased dopamine (trying to inhibit PRL)
- reduced GnRH secretion
Step 3: TSH and PRL
- hyperprolactinemia 3 causes
- prolactinoma
- hypothryoidism
- medications
what are 4 common meds that cause hyperprolactinemia
- Reglan
- Tagamet (antacid/antihistamine)
- spironolactone
- anti-psychotics
Step 3: TSH and PRL
- hyperprolactinemia treatement
- medical (l-thyroxine, bromocriptine, cabergoline)
- sx
Step 4: progestin challenge
- goal
- trying to figure out if there is a lack of progesterone or a lack of estrogen
- also helps determine if there is an outflow obstruction
Step 4: progestin challenge
- describe
10 mg progestin for 5-7 days and then wait
Step 4: progestin challenge
- what does it mean if she bleeds & type of disorder
- what does it mean if she does not bleed
- bleed: know there is estrogen, likely pt was just not ovulating. Could be no ovulation = no corpus luteum producing progesterone. likely PCOS. This is an ovary disorder
- no bleed: know either not enough E or obstruction
Step 5: Estrogen/progesterone challenge
- goal
checks for inadequate estrogen (hypogonadism) and outflow obstruction
Step 5: Estrogen/progesterone challenge
- describe
- 21 days of estrogen then
- 5 days progestin
- wait for bleed
Step 5: Estrogen/progesterone challenge
- what does it mean if she bleeds
- what does it mean if she does not bleed and what type of disorder
- bleed: know it was an estrogen problem. Next step is figure out why
- no bleed: obstruction somewhere (uterus/vagina disorder)
Two main types of outflow obstruction
- congenital
- acquired
Four types of congenital outflow obstructions
Not Painful
- Mullerian genesis (renal abnl too)
- Androgen Insensitivity Syndrome (AIS)
Painful
- Transverse vaginal septum (2/3 up from introitus)
- Imperforate hymen (bluish vaginal mass)
two types of acquired outflow obstructions
- Asherman’s syndrome: risk factor is prior D&C
2. Cervical stenosis: risk factors are prior cone biopsy
Asherman’s syndrome
- type of amenorrhea
- MC cause
- how to dx
- tx
- secondary amenorrhea
- 90% dt aggressive curettage of endometrial lining
- Hysteroscopy, sonohysterography, hysterosalpingogram
- Tx: surgical
Step #6: check FSH
- goal
trying to figure out why there isn’t enough endogenous estrogen
(this is the pt who DID bleed after estrogen/progesterone challenge)
Step #6: check FSH
- lab tests
- caveat
- check FSH and LH
- wait min 2 weeks from exogenous estrogen challenge
Step #6: check FSH elevated FSH - name - whats up with the ovary - whats up with the FSH - what type of disorder
- hypergonadotropic hypogonadism
- called premature ovarian failure/insufficiency
- dysfunctional or unresponsive ovary
- FSH elevated bc no neg feedback inhibition by E or inhibin
- ovarian disorders
Step #6: check FSH
hypergonadotrophic hypogonadism
- primary/genetic causes
- Turner syndrome
- Fragile X syndrome
- Androgen insensitivity syndrome
- Dx: karyotype and fragile X DNA test
(should have been noted on PE - lack of breast development, etc.)
Step #6: check FSH
hypergonadotrophic hypogonadism
- secondary causes
- disorder type
- Autoimmune dz (polyglandular failure)
- Iatrogenic (radiation, chemo)
- ovarian disorder
Step #6: check FSH
hypergonadotrophic hypogonadism
- how to test for secondary causes
- thyroid and adrenal Abs and TSH
- Ca, phosphate, A1C
Step #6: check FSH
hypergonadotrophic hypogonadism
- how to treat secondary causes
estrogen and progesterone
Step #6: check FSH & FSH is low - name - type of disorder - next step
- hypogonadotropic hypogonadism
- hypothalamic or pituitary issue
- MRI of brain (with attention to sella turcica)
Causes of hypogonadotropic hypogonadism overview
- pituitary dysfunction (usually adenoma)
- brain tumor
- hypothalamic dysfunction (reduced GnRH)
- abnl hypothalamic development (inherited)
Causes of pituitary related hypogonadotropic hypogonadism
- pituitary adenoma (MC)
- Sheehan’s syndrome
- infiltration (sarcoidosis or TB)
- Other: head injury, trauma, brain metastasis, mass effect from brain tumor
Pituitary adenoma
- what causes hypogonadotropic hypogonadism?
- two other things to test for
- Prolacinoma releases elevated PRL (10% of amenorrhea!)
- Acromegaly (IGF-1)
- Cushing dz (24 hr free cortisol and ACTH)
Sheehan’s syndrome describe
panhypopituitarism following postpartum hemorrhage that caused hypotension great enough to lead to pituitary ischemia
Causes of hypothalamic related hypogonadotropic hypogonadism overview (4)
- stress
- anorexia nervousa
- excessive exercise
- Kallman syndrome
How is stress related to hypogonadotropic hypogonadism. What type of amenorrhea?
- secondary amenorrhea
- increased CRH alters GnRH pulsatility
- Cortisol directly disrupts GnRH function
- excessive exercise can cause stress response too
How is anorexia nervosa related to hypogonadotropic hypogonadism. What type of amenorrhea?
- secondary amenorrhea
- decreased leptin and increased neuropeptide Y alters GnRH release
(also issues with insulin, cortisol, IGF-1)
How is excessive exercise related to hypogonadotropic hypogonadism. What type of amenorrhea?
- secondary amenorrhea
- increased endorphins alter GnRH pulsatility
How is Kallman syndrome related to hypogonadotropic hypogonadism. What type of amenorrhea?
- primary amenorrhea
- X-linked inheritance
- pt also can’t smell!
How common is it to go from regular cycles to amenorrhea within 1 month?
- ONLY going to happen with pregnancy
- usually have abnl uterine bleeding prior to amenorrhea
Review:
List issues that arise at hypothalamus
- primary: Kallman
- secondary: stress, psychiatric, anorexia, excessive exercise
Review:
List issues that arise at pituitary
- no primary
- secondary: hypothyroidism, pituitary prolactinoma/adenoma, Sheehan’s syndrome
Review:
List issues that arise at ovary
- primary: turner, premature ovarian failure, fragile x
- secondary: PCOS, autoimmune polyglandular failure, iatrogenic
Review:
List issues that arise at uterus/vagina
- primary: Mullerian genesis, androgen insensitivity syndrome, transverse vaginal septum
- secondary: Asherman’s syndrome and cervical stenosis (scar), imperforate hymen
