Amenorrhea, Oligomenorrhea and Hyperandrogen Disorders -Gambone

Question 1

What is the difference between primary and secondary amenorrhea?

Answer 1

primary: menarche has not occurred by age 16
secondary: absence of menses for 6+ months

Question 2

What are the potential causes of primary amenorrhea with sexual infantilism?

Answer 2

1. due to a lack of gonadotropin secretion (low FSH and E2) –> hypogonadotropic hypogonadism (
2. due to inability of ovaries to respond to gonadotropin (high FSH and low E2)
   - -> hypergonadotropic hypogonadism

Question 3

What are some features of hypogonadotropic hypogonadism?

Answer 3

low FSH

absence of breast development (because low estrogen)

can have pubic hair–> caused by androgens from the adrenals

Question 4

What are 3 potential causes of hypogonadotropic hypogonadism ?

Answer 4

causes:
-Kallman’s syndrome (inadequate GnRH synthesis/release from the median eminence of the hypothalamus)–> would have anosmia as well (order smell test)

• lesions of the hypothalamus or pituitary (craniopharyngioma or CNS tumor) (order MRI or other pituitary hormones)
• delayed puberty (diagnosis of exclusion

Question 5

What are the symptoms of hypergonadotropic hypogonadism? What is one potential cause? What test should be ordered?

Answer 5

gonadal agenesis/dysgenesis

FSH elevated

Turner’s syndrome=45 XO:

• streak gonads
• short stature
• web neck
• coarctation of the aorta

order a karyotype

Question 6

What are some clinical findings associated with primary amenorrhea with breast development and mullerian anomalies? What are 2 potential causes and how do you differentiate between them?

Answer 6

no visible or palpable uterine cervix on pelvic exam

causes:

1. androgen insensitivity (46XY) (high testosterone levels)
2. 46 XX karyotype (Meyer-Rokitansky-Kuster-Hauser Syndrome)

serum testosterone

Question 7

What is Meyer-Rokitansky-Kuster-Hauser Syndrome?

Answer 7

46 XX female with varying degrees of absence of mullein structures

• make vagina from Frank dilators or McIndoe vaginoplasty
• may have renal abnormalities

Question 8

Why are large breasts seen in androgen insensitivity?

Answer 8

lack of estrogen opposition

Question 9

What tests should be ordered for a pt presenting with amenorrhea/oligomenorrhea with breast development and normal Mullerian structures? What are some potential causes?

Answer 9

• pregnancy test*
• serum prolactin
• FSH and E2 levels (or progestin challenge instead of E2)
  causes: Asherman’s syndrome, Sheehan’s syndrome, hyperprolactinemia, premature ovarian failure

Question 10

How can hyperprolactinemia cause amenorrhea? What can cause hyperprolactinemia?

Answer 10

high PRL can stimulate DA –> stimulate opiods–> inhibit GnRH

causes of hyperprolactinemia:

1. things that decrease dopamine (normally inhibits PRL):
   - Tranquilizers
   - Antidepressants
   - Antihypertensive drugs
   - Narcotics
   - Metaclopramide
   - Estrogens
2. primary hypothyroidism: low T4-> inc TRH –> inc TSH and PRL
3. pituitary adenoma
4. Empty Sella syndrome
5. acute or chronic renal failure
6. peripheral nerve stimulation

Question 11

What is the treatment for hyperprolactinemia?

Answer 11

• Mild forms do not need treatment
• Treat galactorrhea when cycles are irregular or if symptoms are annoying
• Treat macroadenomas (>1cm) medically with bromocriptine
• Monitor visual fields for defects
• Transphenoidal hypophysectomy to remove tumor rarely needed

Question 12

What is Premature Ovarian Failure? When should a karyotype be done?

Answer 12

menopause before the age of 40 yo

karyotype if before the age of 30 because may have mosaicism with Y chromosome

Question 13

What is “runner’s amenorrhea” due to?

Answer 13

high endorphin levels inhibit GnRH secretion

Question 14

What are the signs and symptoms of PCOS? How many of these are necessary for a diagnosis?

Answer 14

Hyperadrogenism with signs of hirsutism, acne, male-pattern baldness and in it’s severe form signs of virilization such as clitoral enlargement (> 1 cm at the base) and deepening of the voice =virulization

Chronic anovulation: oligomenorrhea/amenorrhea (oligo is more common in PCOS)

Polycystic ovaries

• need 2 for diagnosis* (don’t have to have the polycystic ovaries
• can also have Insulin resistance (can see acanthosis nigricans) –> not in diagnostic criteria

Question 15

What is the difference between hirsutism and virilism?

Answer 15

Hirsutism: more apparent facial and chest terminal hair growth (in the male pattern)

Virilism: Hirsutism with temporal balding, deepening voice and clitoromegaly (> 1 cm diameter at base)

Question 16

What is the pathophysiology of PCOS in chronic anovulation?

Answer 16

increased sensitivity of pituitary to GnRH ==> LH persistently elevated -> increased androgens –> aromatized to E1 (estrone) –> suppress FSH