Amenorrhoea Flashcards
What are the two different types of amenorrhea?
1) Primary: Menstruation has never occured
2) Secondary: Menstruation was established and then ceases for 6+ months
At what age would you consider someone to have primary amenorrhea? (hint: two ages depending on circumstances)
1) 15 years old if development of secondary sexual characteristics is present
2) 13 years old if no development of secondary sexual characteristics
What are the two main anatomical causes for primary amenorrhea?
1) Congenital abscence of uterus (failed development of mullerian ducts)
2) Imperforate hymen (blood retained within the vagina)
What is a progesterone challenge test?
A progestogen is given orally for 5 days and then stopped, bleeding should occur due to withdrawal in normal tests
Test for estrogenation
How long must a patient have no menstruation before they are considered to have secondary amenorrhea?
- 6 months in the absence of pregnancy
What are the three most common causes of secondary amenorrhea?
- Weight loss
- Polycystic ovarian syndrome (PCOS)
- Hyperprolactinoma
What are the most common causes of amenorrhea during a womans reproductive years?
- Pregnancy
- Lactation
Ensure you rule these out in any pt complaining of amenorrhea
What is the pathophysiology behind lactational amenorrhea?
- High postpartum prolactin production
- Prolactin is inhibitory to secretion of gonadotrophins
Physical and emotional stress can lead to amenorrhea by which mechanism?
- Suppression of the hypothalamic-pituitary-ovarian axis
- leading to low pituitary gonadotrophins in association with low prolactin and estrogen
Aside from amenorrhea, what other symptom may someone have if high prolactin levels were causing their amenorrhea?
- Galactorrhea
Bitemporal hemianopia in a pt with amenorrhea will lead you to suspect what diagnosis?
- Pituitary adenoma
- Increased prolactin from pituitary (large pituitary putting pressure on optic chiasm)
What is premature ovarian failure?
- The term used to describe the cessation of ovarian function before the age of 40
- As in menopause the failure is typically due to depletion of premordial follicles
What are the criteria for polycystic ovarian syndrome (PCOS)
At least two of the following three:
- Oligo/Amenorrhea
- Clinical evidence of excess androgen (acne, hirsutism, of biochemical evidence -ie raised Test)
- U/S appearance of large volume ovaries (>10cm3) and/or multiple small follicles (12+ that are under 12mm)
- Ruled out other causes of amenorrhea and hyperandrogenism **
With PCOS there are 3 typical presenting problems all of which can alter treatment what are they?
1) Menstrual irregularities
2) Hirsutism
3) Infertility
How can you treat menstrual irregularities in PCOS?
- OCP
How can you treat hirsutism in PCOS?
- Combined OCP can suppress ovarian androgen production
- Waxing and other cosmetic procedures
- Anti-androgen medication (Cyproterone acetate) - in Diane 35, spironolactone
Women taking anti-androgen medication should use contraception during and for 3 months following discontinuation. How come?
- Potential risk of teratogenicity, specifically feminization of a male fetus
How can you treat infertility in PCOS?
- Weight reduction in cornerstone treatment
- Insulin sensitizing agents like metformin (questionable benefit)
- medical induction of ovulation (using anti estrogen medication)
Long term, patients with PCOS are at increased risk for which conditions?
- Endometrial hyperplasia and carcinoma (due to anovulation and unopposed estrogen)
- T2DM
- Cardiovascular disease
- HTN
- Lipids
- Vascular disease
How can thyroid problems cause amenorrhea?
- Thyrotoxicosis: High serum sex hormine binding globulin results in hormonal changes causing anovulation
- Hypothyroidism: Increased thyrotrophin-releasing hormone stimulates prolactin production which inhibits gonadotrophs
What is asherman syndrome (AKA Fritsch or Fritsch-Asherman syndrome)?
- Occurs due to excessive curettage
- The basal layer of endometrium is inadvertantly removed resulting in adhesions which block menstrual flow
- Interesting point: Endometrial ablation is essentially medically inducing asherman syndrome*
What is Sheehan syndrome?
- Post partum pituitary necrosis causing hypopituitarism.
- Occurs following post-partum hemorrhage leading to hypovolemic shock and ischemic necrosis of pituitary.
What are the pituitary hormones (7) that would be affected by Sheehan syndrome
FLAGTOP
- Follicle stimulating hormone
- Luteinizing hormone
- Adrenocorticotropic hormone (ACTH)
- Growth hormone
- Thyroid stimulating hormone
- melanOcyte stimulating hormone
- Prolactin
The LH to FSH ratio expected in PCOS is what?
- Greater than 2:1
- LH chronically high with FSH mid range to low
Which tests will you order when working up PCOS?
- DHEA-S
- Androstenedione
- Free testosterone (most sensitive)
- Test for insulin resistance
- FSH and LH for ratio greater than 2:1
