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Amenorrhea Flashcards

1
Q

When is normal menarche?

A

12-13 years

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2
Q

What is the prevalence of amenorrhea?

A

1.8-3%

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3
Q

What percent of patients with amenorrhea experience infertility?

A

20%

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4
Q

What three things does normal menses require?

A
  • Normal functioning hypothalamic-pituitary-ovarian (HPO) axis
  • responsive endometrium (lining of uterus)
  • unobstructed outflow tract
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5
Q

What hormones/ anatomy is involved with menstrual cycle?

A

Hypothalamus (GnRH) -> anterior pituitary (FSH & LH) -> causes ovarian follicles to mature, secreting estrogens (& progesterone post ovulation) -> ovulation

If no fertilization -> drop in progesterone -> menses

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6
Q

What is the prevalence, signs of primary amenorrhea?

A
  • Prevalence = 0.3%
  • no secondary sex characteristics by 14
  • no menses by 16
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7
Q

What is the prevalence, signs of secondary amenorrhea?

A

1-3% prevalence

- no menses x 3 cycles or 6 months (whichever is sooner) in a woman with previous menses

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8
Q

What is oligomenorrhea?

A
  • 3-6 menstruated cycles per year

- cycles greater than 35 days

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9
Q

What are causes of primary amenorrhea?

A
  • CNS hypothalamic pituitary disorder
  • Membranous blockage of vagina (hymen)
  • Drastic weight loss / malnutrition/ eating disorder
  • Hypoglycemia
  • Extreme obesity
  • Thyroid disease
  • Anemia
  • Congenital abnormalities of genital system
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10
Q

What are more common causes of secondary amenorrhea?

A
  • Pregnancy (must R/O)
  • Weight reduction/ drastic gain
  • Stress/depression
  • Endocrine disorder
  • Hypothyroidism
  • PCOS (elevated estrogen & testosterone)
  • Obesity (elevated estrogen)
  • Increased prolactin (inhibits GnRH)
  • Premature ovarian failure (early menopause)
  • Drugs
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11
Q

What medications are associated with amenorrhea?

A
  • Hormonal contraception:
    — doesn’t require intervention
    — may consider change to different contraception
  • Antipsychotics
  • Antidepressants
    — inc. tricyclics and MAOIs
  • Cardiovascular meds
    — inc. Ca-blockers, Aldomet, Reserpine, Digoxin
  • Ovarian toxins (cytoxan, fluorouracin, cisplatin)
  • Marijuana
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12
Q

What are complications with amenorrhea?

A 
Long term amenorrhea
- If hypoestrogenic amenorrhea
— Bone mineral density loss (osteoporosis?)
- If hyperestrogenic amenorrhea
— Abnormal lipid levels- increased CAD
— Endometrial hyperplasia -Uterine CA
— DM
— Obesity
— Breast cancer
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13
Q

What are initial labs for amenorrhea?

A
  • B-hCG
  • TSH
  • PRL
  • Progesterone challenge test
    — uterine bleeding between 2-7 days after completion indicates adequate estrogen production, responsive endometrium, and patent outflow tract (thus, problem in inadequate progesterone production, presumably due to anovulation - one common cause is PCOS)
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14
Q

How do you rule out estrogen deficiency?

A

?

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15
Q

What are Causes of amenorrhea with exercise?

A
  • Low body fat <15%-19%; BMI < 18
  • Change in the muscle:fat ratio
    — Can be accomplished through a decrease in fat or an increase in muscle
  • Nutritional deficient state:
    — Energy output exceeds energy input.
    — Can result from dieting or increased exercise without increasing food intake
    — Exercising alone typically does not lead to amenorrhea
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16
Q

What is premature ovarian failure?

A

“Early-menopause” “stein-levental syndrome”

- Before age 40

17
Q

What are the causes of early menopause?

A
  • Autoimmune (thyroid, diabetes, RA, SLE)
  • Chemo/radiation, tamoxifen or similar
  • Family history
  • Surgical removal/damage
  • Chromosomal: fragile X and Turner’s
18
Q

How do you make an accurate diagnosis of early menopause?

A
  • methodical work-up: FSH, LH, E2  Management:
19
Q

How do you manage early menopause?

A
  • find underlying cause
  • associated complications
  • disease prevention
20
Q

What are complications of early menopause? How are these managed?

A

Estrogen deficiency symptoms

1) Hormone replacement therapy or OCP
2) SSRI’s
3) Botanical support (black cohosh, red clover)
4) General mind/body support
5) Diet and exercise and stress management

21
Q

What is the disease prevention for osteoporosis with premature ovarian failure?

A
  • Surveillance- DEXA
  • Calcium/Magnesium/Vitamin D
  • Exercise-weight bearing
  • OCPs vs HRT
  • Osteoporosis meds (Fosamax, Actonel)
22
Q

What is the disease prevention for CAD with premature ovarian failure?

A

Monitor BP, lipids

23
Q

What is the disease prevention for estrogen deficiency problems with premature ovarian failure?

A

vaginal atrophy, libido, insomnia, mood swings

24
Q

What is PCOS

A

Polycystic Ovarian Syndrome
- One of the most common endocrine d/o of women of reproductive age.
- What is a syndrome?
- Historically: Oligo-menorrhea, anovulation, irregular menses,
hirsutism, polycystic ovaries on U/S, obesity.

25
Q

What is the 3 criteria for PCOS?

A

1) Oligo-menorrhea
2) Biochemical or clinical evidence of hyperandrogenism
3) Exclusion of other known disorders, ie CAH or Hyperprolactinemia

  • Polycystic Ovaries are not required for diagnosis! When they are present, they are called a “string of pearls”
26
Q

Only 1/3 of women with PCOS have the full-blown clinical picture which are (4)?

A
  • Hirsutism 50% (Male pattern hair)
  • Obesity 40%
  • Infertility 20%
  • Amenorrhea 50%; AUB 30%
27
Q

Women with PCOS seek medical care for. . .

A
  • Menstrual cycle irregularities and infertility
  • Appearance, weight (obesity), excessive hair growth, acne, hair loss (alopecia)
  • Metabolic issues (associated with PCOS)
  • Hypoglycemic
  • Insulin resistant
  • Hyperlipidemia
  • Hypertension
28
Q

How is PCOS diagnosed?

A

Diagnosis of exclusion
- Symptoms: hirsutism, anovulation, irregular menses
- Fasting glucose/insulin
— 2hr postprandial glucose and insulin
- Free testosterone, DHEA-S
- Pelvic ultrasound for polycystic ovaries? Not necessary

29
Q

What are the hormonal implications of PCOS

A
  • Increased levels of estrone
    — Due to conversion of ovarian & adrenal
    androgens to estrone in body fat.
    — Suppress pituitary FSH
    — Ovary receives constant LH stimulation resulting in:
    —— Anovulation (LOW PROGESTERONE)
    —— Cysts
    —— Hyperplasia of theca cells -» more androgens
30
Q

PCOS has an increased risk for what diseases?

A
  • Infertility
  • DM
  • CVD
  • Endometrial cancer
31
Q

What is the PCOS management?

A
  • Treat insulin resistance, hyperinsulinemia
  • Address androgen excess problems
  • Address fertility issues/regulate menses
  • Address prevention of long-term PCOS complications
    — Diabetes, endometrial hyperplasia/ cancer, CVD/dyslipidemia, breast cancer, obesity, fertility issues
32
Q

What are medications for PCOS?

A
  • Progesterone
    — Normalize E:P, restore ovulation
  • Spironolactone:
    — Reduce androgens & reducing abnormal hair-growth.
  • Metformin
    — Regulates blood sugar & decreases hirsutism and anovulation
33
Q

What are supplements for PCOS?

A
  • Increase SHBG: soy, flax, nettles, ***green tea
  • Decrease androgens: saw palmetto,***green tea extract
  • Improve insulin resistance: vitamin C, Chromium, diet
  • Increase ovulation: vitex (chaste tree), rhodiola, tribulus

Takes about 3 months before any obvious change is present

34
Q

What are lifestyle changes for PCOS?

A
  • high protein, low carb, low bad fats
  • exercise/weight loss
  • acupuncture
  • electro-acupuncture and weight loss
35
Q

Weight loss of as little as __% can improve symptoms, decrease _____ _______ and restore ______

A

10%

insulin resistance
Menses

36
Q

What are botanicals for PCOS?

A
  • increase ovulation: vitex (chaste tree), rhodiola, tribulus
  • decrease T or conversion to DHT
    — Reishi (Ganoderma lucidum)
    —— inhibit T -> DHT decreasing acne & balding
    — Licorice
    —— phytoestrogens effects and inhibits T decreasing hirsutism
    — white peony
    — green tea
    —— also reduced risk of DM2 and CA
    — *** Spearmint
    —— decreases fT helping to reduced hirustism (sig: tea 2 cups qd)

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