Amenorrhea & Ovulation Flashcards
Primary vs. Secondary Amenorrhea?
Primary:
No menses in a women who has never menstruated by
- 13 w/out secondary sexual characteristics or
- 15 w/ normal secondary sexual characteristics
Secondary:
Absence of menses after establishment of menstruation for reasons other than pregnancy, lactation or menopause.
- must be absent for at least 3 of previous menstrual intervals or 6 months
3 common, “normal causes” of Amenorrhea?
1) Pregnancy
2) Normal Menopause
3) Lactation
Compartment I - causes of Amenorrhea?
Asherman’s Syndrome (7%)
Compartment = Uterus → Menses
Compartment II - causes of Amenorrhea?
Primary:
- Gonadal dysgenesis (0.5%)
- Ovarian failure/destruction (10%)
- – (Premature Ovarian Failure)
Secondary: Related to multiple karyotype abnormalities
Compartment = Ovary (E & P)
Compartment III - causes of Amenorrhea?
Prolactinoma (7.5%)
- also: Sheehan’s syndrome, Empty Sella syndrome, Hemochromatosis, & Sarcoidosis
Compartment = Ant. Pituitary (LH, FSH, TH)
Compartment IV - causes of Amenorrhea?
- Anovulation (28%)
- Anorexia (10%)
- Chronic Stress (10%)
When to think Amenorrhea is caused by Compartment IV issue?
– Normal Pituitary (Prolactin, TH)
– Low to normal gonadatropins
– Failure to demonstrate withdrawal bleed
(Dx of exclusion)
How to Anorexia & Stress cause Anovulation?
↑ CRH & ↑ Endorphins → ↓GnRH, ↑Cortisol, ↓TSH
How does a Prolactinoma cause Amenorrhea?
Increased prolactin causes increased dopamine which suppresses GnRH
Empty Sella Syndrome - what is it?
Congenital incompleteness of the diagphram of the sella turcica
Definition of “Premature Ovarian Failure”?
Amenorrhea with persistent elevated FSH levels and hypoestrogenism prior to the age of 40.
This affects 1% of women.
Compartment II- Iatrogenic causes?
Chemotherapy or radiation therapy
(w/ chemo, Alkylating agents, specifically)
- Karyotype should be done in women <30 yrs b/c likely chromosomal issue w/ them
(Turners, Mosaicism, etc.)
Premature Ovarian Failure - Tx?
Counselling is critical. Women lose their natural fertility. Will need oocyte donors or surogates.
Hormone replacement is critical for bone protection
GnRH, LH, FSH, E,P all being produced in a regular, orderly fashion, yet still no menses…
Where is the problem?
Compartment I - Uterus
can be absent, abnormal, or have blocked outflow
Asherman’s Syndrome - Tx?
Surgery – may need multiple procedures to produce desired menses and allow for future pregnancies
Asherman’s Syndrome - how is Dx made?
Hysterosalpingogram or saline u/s
What is Asherman’s Syndrome?
Presence of intrauterine adhesions, typically caused by surgery (iatrogenic)
What is Mayer-Rokitansky- Kuster-Hauser syndrome?
Complete vaginal agenesis
- also in 95% of these cases the uterus is also absent
- Ovaries typically normal
Mayer-Rokitansky- Kuster-Hauser syndrome — Dx?
Physical exam or Ultrasound
MRI if ultrasound not available
Most common obstructive condition of the female reproductive tract?
Imperforate Hymen
Imperforate Hymen - pathology?
Inferior aspect of the vaginal plate fails to open – causing this defect
Imperforate Hymen - Dx?
Dx typically made at birth
- infants will have mucocopos
- if not @ birth, will be diagnosed at puberty with hematocolpos (pt will have pain and will see a bulging blue mass on vaginal exam)
Female patient presents @ puberty w/ pain & a bulging blue mass on vaginal exam (hematocolpos). What is likely Dx?
Imperforate Hymen
though this is typically diagnosed @ birth
Imperforate Hymen - Tx?
Surgery
Transverse Vaginal Septum - Cause?
- Incomplete vertical fusion of the caudal aspect of the sinus tubercle and sinovaginal bulbs
- Can also be caused when the vaginal plate fails to canalize
- Can be at any level of the vagina
(extremely rare)
Which compartment is responsible for the majority of causes of amenorrhea?
Compartment IV
What is the order of the algorithm in Amenorrhea workup?
- Pregnancy test
- Prolactin & TSH levels
- Progestin challenge
- FSH & LH
→ suspect Uterus
- Stimulate uterus with E + P
- Image uterus
- If physical exam initially revealed blind pouch, would proceed to karyotype
PCOS - Sx?
– Oligomenorrhea/ Amenorrhea
– Hyperandrogenism
– Polycystic Ovaries
PCOS - ass’d metabolic findings?
- Insulin Resistance
- Hyperinsulinemia
- Hyperandrogenism
- – Hirsuitism
- – Acanthosis Nigricans
- Obesity
PCOS - Dx?
The Diagnosis is Clinical!
• Patient must have 2/3 main features:
- Oligomenorrhea
- Hirsuitism
- Polycystic Ovaries
• Oligomenorrhea is the hallmark symptom
PCOS - ______ is the hallmark symptom.
Oligomenorrhea
PCOS - ass’d lab findings?
- Increased LH:FSH
- Increased insulin levels (due to resistance)
- Increased testosterone levels
- Positive 2hr GTT or other diabetic screening
(though these are not req’d for Dx)
PCOS increases risk of what 3 clinical events?
- Endometrial cancer
- CV disease
- Diabetes
PCOS - Tx?
- Weight loss, diet, & exercise
(10% or greater loss will initiate normal menses in 80% of women) - Oral Contraceptives (if not interested in pregnancy)
- Antiandrogens: Spironolactone, finasteride or flutamide
(avoid in pregnancy) - Metformin (if interested in pregnant or Diabetic — only deemed Diabetic after OCPs started & attempts made @ weight loss)
Is Metformin a 1st-line agent in PCOS?
No, it should only be used in patients that:
- want to get pregnant as it helps increase odds
- are Diabetic (only deemed Diabetic after weight loss attempts are made & OCPs started)
Surgical Tx for PCOS?
- Ovarian Drilling
- Ovarian Wedge Resection
(though both are controversial)
By what mechanism does hypothyroidism cause amenorrhea?
- Low thyroxine
- High LH
- High dopamine
- High prolactin
- High prolactin
Dx?
Amenorrhea with persistent elevated FSH levels and hypoestrogenism prior to the age of 40.
Premature Ovarian Failure
Dx? Women w/ combo of 2/3 of these: - Hirsuitism - Oligomenorrhea - Polycystic ovaries
Polycystic Ovarian Syndrome
