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Pocket Primary Care > Amenorrhea > Flashcards

Amenorrhea Flashcards

1
Q

Primary Amenorrhea

A

Absence of menarche in >16 y w/secondary sex characteristics or > 14 w/o secondary sex characteristics

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2
Q

Secondary Amenorrhea

A

Absence of menses X 3 months w/previous menstruation or 9 mos w/previous oligomenorrhea

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3
Q

Oligomenorrhea

A

<9 menstrual cycles per year

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4
Q

Normal physiology

A

Pulsatile GnRH release by hypothalamus -> LH, FSH release by anterior pituitary -> ovulation, estrogen/progesterone productions by ovaries; estrogen cuases uterine lining proliferation, progesterone induces maturation -> corpus luteum atresia -> progesterone levels decrease -> shedding of uterine lining

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5
Q

Epidemiology

A

incidence of primary amenorrhea =0.3% general population, secondary amenorrhea =1-3% of general population; can be associated with infertility, osteopenia, increase CV risk

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6
Q

Primary amenorrhea etiologies

A

rare, initial w/u usually w/pediatrician; etiologies include causes of secondary amenorrhea, anatomic and genetic defects (craniopharyngiomam primary ovarian insufficiency, turner syndrome, kallman syndrome, Mullerian agenesis, androgen insensitivity); eval for secondary sex characteristics, presence of uterus/vagina; referral to pediatric endocrine or gyn.

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7
Q

Secondary amenorrhea etiologies

A

always consider pregnancy firsts; PCOS, hypothalamic amenorrhea, hyperprolactinemia, and ovarian failure are most common medical causes

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8
Q

Secondary amenorrhea etiologies

Thalamus

A

Hypothalamic: frequently 2/2 eating d/o (esp anorexia nervosa), excess exercise/wt loss, increase stress; female athlete triad ( restrictive eating -> amenorrhea + osteoporosis)

Also: hypothalamic destruction, CNS tumor, cranial XRT

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9
Q

Secondary amenorrhea etiologies

Ovarian

A

PCOS (anovulation w/hyperandrogenism); Obesity, hirstutism, acne, male pattern baldness

Ovarian insufficiency or failure “premature” = age <40y (can be primary (POI) or 2/2 autoimmune disease, iatrogenic/chemo/XRt, genetic, 17-hydroxylase deficieny, mumps, pelvic XRT, idiopathic), mosaic turners

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10
Q

Secondary amenorrhea etiologies

Uterine

A

Asherman syndrome (uterine scarring 2/2 dandc, infection)

Cervical stenosis (seen more with primary amenorrhea

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11
Q

Secondary amenorrhea etiologies

Pituitary

A

Hyperprolactinemia: 2/2 pituitary adenoma, medications (antipsychotics), breastfeeding, idiopathic

Hypopituitarism ( decrease Lh and/or FSH): infiltrative, sheehans

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12
Q

Secondary amenorrhea etiologies

Other

A

Pregnancy, hypo/hyperthyroidism, celiac dz, increase androgen (cushing, nonclassical CAH, steroids)

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13
Q

General Approach

A

Majority of dx can be made w/ careful history and basic labs

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14
Q

History

gyn

A

age ate menarche, pattern of missed periods, prior pregnancies, sexual hs, contraception hx, prior dandc/pid (ashermans), current breastfeeding

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15
Q

History

medical

A

obesity, DM (PCOS), thyroid disease, genetic d/o, prior pelvic or CNS chemo/XRT

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16
Q

History

Medications

A

OCPs. antipsychotics, H2 blockers, opiates, cocaine, SSRIs, glucocorticoids

17
Q

History

lifestyle

A

Exercise patterns + wt changes (eating d/o, female athlete triad), stress

18
Q

History

Fhx

A

irregular menses, infertility, premature menopause, congenital abnormalities

19
Q

ROS

A

HA, visual disturbances, galactorrhea (pituitary tumor); hot flashes (ovarian failure); breast tenderness (pregnancy); s/sx of adrenal/thyroid disease, cyclic abdominal pain (Mullerian agenesis or outflow tract obstruction);anosmia (kallmann syndrome)

20
Q

Exam

A

Ht, wt, BMI, secondary sex characteristics, pelvic exam (imperforate hymen, transverse vaginal septum); signs of androgen excess ( acne, hirsutism, clitoromegaly), insulin resistance (acanthosis nigricans), estrogen deficiency (vaginal mucosal atrophy), Cushing disease (striae, buffalo hump, central obesity, ecchymoses, HTN, proximal muscle weakness), thyroid disease (nodules, goiter, skin changes, abnl reflexes), pituitary adenoma (galactorrhea, visual field defects)

21
Q

Initial Labs

A

b-hcg, TSH, PRL and FSH

22
Q

TSH increase or decrease

A

Rx thyroid disease

23
Q

Prolactin greatly elevated

A

MRI of pituitary, referral

24
Q

Prolactin elevated but less than 40

A

recheck and if still elevated

MRI of pituitary, referral

25
Q

FSH elevated

A

Ovarian source: consider POI, also PCOS, mosaic turners (rare); check LH, consider progestin challenge, referral

26
Q

FSH decreased or normal

A

hypothalamic: increase wt or hyperandrogenism then do PCOs eval

Increase stress or exercise, or decrease wt or nutrition then counseling

if neither then referral

27
Q

Additional testing

A

May be useful in specific circumstances

Progesterone challenge
Progesterone/estrogen challenge
Free T, DHEAS
Serum Estrogen
Pelvic U/S
28
Q

Progesterone challenge

A

Administer progesterone (provera 10mg po QD X 7-10 days); presence of progesterone should mature uterine lining and w/d should lead to menses, lack of response indicates low-estrogen state; however, poor se/sp (50% of POI pts have some w/d bleeding)

29
Q

Progesterone/estrogen challenge

A

Evaluates uterine response to nl hormone levels; w/d should lead to menses; abnl test suggestive of uterine abnormality

30
Q

Free T, DHEAS

A

To detect hyperandrogenism when PCOS suspected; if c/w PCOS, check fasting glucose or 2 h GTT, r/o other causes of androgen excess

31
Q

Serum estrogen

A

Variable in physiologic + pathologic states; may help interpret FSH levels

32
Q

Pelvic U/S

A

consider if uterine pathology suspected

33
Q

Treatment overview

A

Based on causative factor and desire for fertility; general goals= prevention of complications (osteoporosis, endometrial hyperplasia, CVD, preservation of fertility)

34
Q

Treatment

thyroid

A

return of menses may take several mos after tx

35
Q

Treatment

PCOS

A

wt loss via diet and exercise, OCPs or cyclic progestational agents to maintain nl endometrium, metformin use

36
Q

Treatment

Female athlete tirad

A

Counsel re: need for increase caloric intake or decrease energy expenditure; consider DEXA scan, encourage adequate Ca/VitD, consider estrogen tx in conjuction w/specialist; CBT to decrease stress may restore ovulation

37
Q

When to refer

A

Suspected ovarian insuffiency, unclear dx, lack of response to tx, or desired pregnancy in setting of persistent amenorrhea -> reproductive endocrinology (gyn)

Prolactinoma; hyperthyroidism or other endocrinopathies -> medical endocrinology

consideration of estrogen tx -> gynecology or endocrinology

Uterine pathology or outflow obstruction -> gynecology

Pocket Primary Care (18 decks)

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