Amenorrhea Flashcards by Rhèa Marie

When is normal menarche?

12-13 years

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What is the prevalence of amenorrhea?

1.8-3%

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What percent of patients with amenorrhea experience infertility?

20%

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What three things does normal menses require?

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

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What hormones/ anatomy is involved with menstrual cycle?

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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What is the prevalence, signs of primary amenorrhea?

Prevalence = 0.3%
no secondary sex characteristics by 14
no menses by 16

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What is the prevalence, signs of secondary amenorrhea?

1-3% prevalence

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

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What is oligomenorrhea?

3-6 menstruated cycles per year

- cycles greater than 35 days

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What are causes of primary amenorrhea?

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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What are more common causes of secondary amenorrhea?

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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What medications are associated with amenorrhea?

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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What are complications with amenorrhea?

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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What are initial labs for amenorrhea?

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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How do you rule out estrogen deficiency?

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What are Causes of amenorrhea with exercise?

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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What is premature ovarian failure?

“Early-menopause” “stein-levental syndrome”

- Before age 40

What are the causes of early menopause?

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

How do you make an accurate diagnosis of early menopause?

methodical work-up: FSH, LH, E2  Management:

How do you manage early menopause?

find underlying cause
associated complications
disease prevention

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

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

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

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

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

Monitor BP, lipids

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

vaginal atrophy, libido, insomnia, mood swings

What is PCOS

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.

What is the 3 criteria for PCOS?

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”

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

- Hirsutism 50% (Male pattern hair) - Obesity 40% - Infertility 20% - Amenorrhea 50%; AUB 30%

Women with PCOS seek medical care for. . .

- 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

How is PCOS diagnosed?

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

What are the hormonal implications of PCOS

- 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

PCOS has an increased risk for what diseases?

- Infertility - DM - CVD - Endometrial cancer

What is the PCOS management?

- 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

What are medications for PCOS?

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

What are supplements for PCOS?

- 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

What are lifestyle changes for PCOS?

- high protein, low carb, low bad fats - exercise/weight loss - acupuncture - electro-acupuncture and weight loss

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

10% insulin resistance Menses

What are botanicals for PCOS?

- 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)