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Women's Health 1 > Amenorrhea > Flashcards

Amenorrhea Flashcards

1
Q

Menarche def

A

age at onset of menses

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2
Q

Thelarche def

A

age at onset of breast development

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3
Q

After menarche, what happens next 2-5 years

A

increasing regularly of cycle. Shortens into usual reproductive age pattern

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4
Q

Normal menstrual cycle

  • duration of flow
  • volume of blood loss
  • cycle length
A
  • 4-6 days
  • 30 mL
  • q 21-35 days
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5
Q

What is cycle length most dependent on?

A

follicular phase

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6
Q

what does a shorter cycle indicate?

A

accelerated follicular growth pattern due to changes in FSH patterns

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7
Q

What happens to follicles and cycle as age

A
  • fewer grow per cycle
  • cycles shorten in late reproductive period
  • 2-6 years prior to menopause, cycles increase to longer length
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8
Q

Polymenorrhea def

A

frequent menstrual bleeding (<=21 days)

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9
Q

Oligomenorrhea def

A

intervale >35 days

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10
Q

Menorrhagia def

A

regular interval but excessive flow (>80 mL) OR duration >7 days

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11
Q

Metrorrhagia def

A

irregular intervals and/or bleeding between periods

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12
Q

Menometrorrhagia def

A

excessive and irregular bleeding

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13
Q

Primary amenorrhea

- three types

A

(never got a period)

  1. No period age 13-14, no secondary sex characteristics
  2. No period age 15-16 even with secondary sex characteristics
  3. No period within 5 years of thelarche
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14
Q

Secondary amenorrhea

- two types

A

(had periods before, now does not)

  • no menses for 3-6 months
  • no menses for duration fo 3 typical menstrual cycles (oligomenorrhea)
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15
Q

Four “categories” of secondary amenorrhea

A

1: Hypothalamus (35%)
2: Anterior pituitary (19%)
3: Ovary (40%)
4: Outflow tract (5%)

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16
Q

Outline the 7 steps to amenorrhea workup

A
  1. H&P
  2. Preg test
  3. TSH and PRL
  4. Progestin challenge
  5. Estrogen/Progesterone challenge
  6. FSH/LH
  7. MRI of brain
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17
Q

Questions to ask/things to note during H&P for primary amenorrhea

A
  • age at presentation
  • growth / development delay? breast development?
  • Familial or childhood issues
  • genitourinary abnl?
  • Exam: outflow obstruction, genesis, etc.
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18
Q

Questions to ask/things to note during H&P for secondary amenorrhea

A
  • Hirsuitism, acne, virilization
  • weight change, dietary habits
  • psychological stressors
  • galactorrhea
  • neuro sx - cranial nerve deficits or changes
  • Hx obstetrical or bleeding problems, past surgeries
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19
Q

PE for primary amenorrhea

A
  • will ID obstructions
  • Is there a uterus??
  • Normal breast development?
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20
Q

what are examples of obstructions?

A
  • vaginal septum
  • genesis of the uterus
  • scarring
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21
Q

What to do if there is not a uterus?

A

check karyotype

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22
Q

What does it mean if there is normal breast development?

A

estrogen is present

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23
Q

What to do if there is no breast development (aka no estrogen?)

A

check FSH to see where problem is coming from

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24
Q

Step 2: pregnancy test

A

she gonna have a baby!!

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25
Q

Step 3: TSH and PRL

  • what is common TSH related finding that causes amenorrhea
  • type of disorder
  • pathophys explanation
A
  • hypothyroidism
  • pituitary disorder
  • Causes increased TRH and TSH which cause increased PRL which decreases GnRH pulsatility
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26
Q

Step 3: TSH and PRL

  • how to dx thyroid issue?
  • tx
A
  • TSH level
  • confirm with FT4
  • can check thyroid antibodies also
  • Tx: thyroid hormone replacement
27
Q

Step 3: TSH and PRL

  • hyperprolactinemia overview
  • type of disorder
A
  • 20% of amenorrhea!!
  • check twice to confirm elevated, levels can vary
  • may be associated with galactorrhea
  • pituitary disorder
28
Q

Step 3: TSH and PRL

- hyperprolactinemia pathophysiology

A
  • high PRL
  • increased dopamine (trying to inhibit PRL)
  • reduced GnRH secretion
29
Q

Step 3: TSH and PRL

- hyperprolactinemia 3 causes

A
  • prolactinoma
  • hypothryoidism
  • medications
30
Q

what are 4 common meds that cause hyperprolactinemia

A
  • Reglan
  • Tagamet (antacid/antihistamine)
  • spironolactone
  • anti-psychotics
31
Q

Step 3: TSH and PRL

- hyperprolactinemia treatement

A
  • medical (l-thyroxine, bromocriptine, cabergoline)

- sx

32
Q

Step 4: progestin challenge

- goal

A
  • 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
33
Q

Step 4: progestin challenge

- describe

A

10 mg progestin for 5-7 days and then wait

34
Q

Step 4: progestin challenge

  • what does it mean if she bleeds & type of disorder
  • what does it mean if she does not bleed
A
  • 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
35
Q

Step 5: Estrogen/progesterone challenge

- goal

A

checks for inadequate estrogen (hypogonadism) and outflow obstruction

36
Q

Step 5: Estrogen/progesterone challenge

- describe

A
  • 21 days of estrogen then
  • 5 days progestin
  • wait for bleed
37
Q

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
A
  • bleed: know it was an estrogen problem. Next step is figure out why
  • no bleed: obstruction somewhere (uterus/vagina disorder)
38
Q

Two main types of outflow obstruction

A
  • congenital

- acquired

39
Q

Four types of congenital outflow obstructions

A

Not Painful

  1. Mullerian genesis (renal abnl too)
  2. Androgen Insensitivity Syndrome (AIS)

Painful

  1. Transverse vaginal septum (2/3 up from introitus)
  2. Imperforate hymen (bluish vaginal mass)
40
Q

two types of acquired outflow obstructions

A
  1. Asherman’s syndrome: risk factor is prior D&C

2. Cervical stenosis: risk factors are prior cone biopsy

41
Q

Asherman’s syndrome

  • type of amenorrhea
  • MC cause
  • how to dx
  • tx
A
  • secondary amenorrhea
  • 90% dt aggressive curettage of endometrial lining
  • Hysteroscopy, sonohysterography, hysterosalpingogram
  • Tx: surgical
42
Q

Step #6: check FSH

- goal

A

trying to figure out why there isn’t enough endogenous estrogen
(this is the pt who DID bleed after estrogen/progesterone challenge)

43
Q

Step #6: check FSH

  • lab tests
  • caveat
A
  • check FSH and LH

- wait min 2 weeks from exogenous estrogen challenge

44
Q 
Step #6: check FSH
elevated FSH
- name
- whats up with the ovary
- whats up with the FSH
- what type of disorder
A
  • hypergonadotropic hypogonadism
  • called premature ovarian failure/insufficiency
  • dysfunctional or unresponsive ovary
  • FSH elevated bc no neg feedback inhibition by E or inhibin
  • ovarian disorders
45
Q

Step #6: check FSH
hypergonadotrophic hypogonadism
- primary/genetic causes

A
  • 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.)
46
Q

Step #6: check FSH
hypergonadotrophic hypogonadism
- secondary causes
- disorder type

A
  • Autoimmune dz (polyglandular failure)
  • Iatrogenic (radiation, chemo)
  • ovarian disorder
47
Q

Step #6: check FSH
hypergonadotrophic hypogonadism
- how to test for secondary causes

A
  • thyroid and adrenal Abs and TSH

- Ca, phosphate, A1C

48
Q

Step #6: check FSH
hypergonadotrophic hypogonadism
- how to treat secondary causes

A

estrogen and progesterone

49
Q 
Step #6: check FSH
&amp; FSH is low
- name
- type of disorder
- next step
A
  • hypogonadotropic hypogonadism
  • hypothalamic or pituitary issue
  • MRI of brain (with attention to sella turcica)
50
Q

Causes of hypogonadotropic hypogonadism overview

A
  • pituitary dysfunction (usually adenoma)
  • brain tumor
  • hypothalamic dysfunction (reduced GnRH)
  • abnl hypothalamic development (inherited)
51
Q

Causes of pituitary related hypogonadotropic hypogonadism

A
  1. pituitary adenoma (MC)
  2. Sheehan’s syndrome
  3. infiltration (sarcoidosis or TB)
  4. Other: head injury, trauma, brain metastasis, mass effect from brain tumor
52
Q

Pituitary adenoma

  • what causes hypogonadotropic hypogonadism?
  • two other things to test for
A
  • Prolacinoma releases elevated PRL (10% of amenorrhea!)
  • Acromegaly (IGF-1)
  • Cushing dz (24 hr free cortisol and ACTH)
53
Q

Sheehan’s syndrome describe

A

panhypopituitarism following postpartum hemorrhage that caused hypotension great enough to lead to pituitary ischemia

54
Q

Causes of hypothalamic related hypogonadotropic hypogonadism overview (4)

A
  • stress
  • anorexia nervousa
  • excessive exercise
  • Kallman syndrome
55
Q

How is stress related to hypogonadotropic hypogonadism. What type of amenorrhea?

A
  • secondary amenorrhea
  • increased CRH alters GnRH pulsatility
  • Cortisol directly disrupts GnRH function
  • excessive exercise can cause stress response too
56
Q

How is anorexia nervosa related to hypogonadotropic hypogonadism. What type of amenorrhea?

A
  • secondary amenorrhea
  • decreased leptin and increased neuropeptide Y alters GnRH release
    (also issues with insulin, cortisol, IGF-1)
57
Q

How is excessive exercise related to hypogonadotropic hypogonadism. What type of amenorrhea?

A
  • secondary amenorrhea

- increased endorphins alter GnRH pulsatility

58
Q

How is Kallman syndrome related to hypogonadotropic hypogonadism. What type of amenorrhea?

A
  • primary amenorrhea
  • X-linked inheritance
  • pt also can’t smell!
59
Q

How common is it to go from regular cycles to amenorrhea within 1 month?

A
  • ONLY going to happen with pregnancy

- usually have abnl uterine bleeding prior to amenorrhea

60
Q

Review:

List issues that arise at hypothalamus

A
  • primary: Kallman

- secondary: stress, psychiatric, anorexia, excessive exercise

61
Q

Review:

List issues that arise at pituitary

A
  • no primary

- secondary: hypothyroidism, pituitary prolactinoma/adenoma, Sheehan’s syndrome

62
Q

Review:

List issues that arise at ovary

A
  • primary: turner, premature ovarian failure, fragile x

- secondary: PCOS, autoimmune polyglandular failure, iatrogenic

63
Q

Review:

List issues that arise at uterus/vagina

A
  • primary: Mullerian genesis, androgen insensitivity syndrome, transverse vaginal septum
  • secondary: Asherman’s syndrome and cervical stenosis (scar), imperforate hymen

Women's Health 1 (17 decks)

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