Clinical Gynecology: Secondary Amenorrhea

Question 1

Secondary Amenorrhea

Definition

Answer 1

Absence of menses for 6 months or 3 cycles in a female who previously menstruated

Question 2

Secondary Amenorrhea

Etiology

Answer 2

• Hypothalamus:
  
  • Malnutrition: 15%
  • Exercise: 10%
  • Stress: 10%
• Pituitary:
  
  • Prolactinoma: 18%
• Thyroid:
  
  • Hypothyroidism: < 1%
• Ovary:
  
  • PCOS: 30%
  • POF: 10%
• Uterus:
  
  • Asherman syndrome: 5%

Question 3

Functional Hypothalamic Amenorrhea

Etiology

Answer 3

• Energy deficit: anorexia nervosa, excessive exercise
• Stress

Question 4

Functional Hypothalamic Amenorrhea

Mechanism

Answer 4

Suppression of GnRH secretion
* Energy deficit: caloric imbalance; low leptin levels
* Stress: high cortisol & CRH levels

Question 5

Prolactinoma

Mechanism

Answer 5

High PRL levels suppress hypothalamic GnRH secretion

Question 6

• Amenorrhea
• Galactorrhea
• Infertility
• Headache
• Visual changes

Signs & Symptoms

Answer 6

Prolactinoma

Question 7

Prolactinoma

Approach to Diagnosis

Answer 7

1. Elevated PRL levels
2. Head MRI

Question 8

Prolactinoma

Approach to Therapy

Answer 8

Dopamine Agonists
* Bromocriptine
* Cabergoline

Question 9

Hypothyroidism

Approach to Diagnosis

Answer 9

Elevated TSH levels

Question 10

Hypothyroidism

Mechanism

Answer 10

High TSH levels stimulate PRL secretion

Question 11

• Amenorrhea
• Weight gain
• Goiter
• Dry skin & hair
• Brittle nails
• Cold intolerance

Signs & Symptoms

Answer 11

Hypothyroidism

Question 12

Polycystic Ovarian Syndrome (PCOS)

Mechanism

Answer 12

Impaired progesterone secretion
* Ovary fails to recruit a dominant follicle & ovulate

Question 13

• Amenorrhea
• Irregular cycles
• Infertility
• Hirsutism
• Acne
• Elevated BMI

Signs & Symptoms

Answer 13

Polycystic Ovarian Syndrome (PCOS)

Question 14

PCOS

Approach to Diagnosis

Answer 14

Rotterdam criteria: at least 2 of 3
1. Androgen excess: clinical or biochemical
2. Ovulatory dysfunction: oligo- or anovulation
3. Polycystic ovaries

Question 15

PCOS

Potential Long-Term Complications

Answer 15

• Obesity
• Insulin resistance, T2DM
• Dyslipidemia
• CVD
• Obstructive sleep apnea
• Non-alcoholic fatty liver disease
• Endometrial cancer

Question 16

PCOS

Approach to Diagnosis

Answer 16

Metformin

Question 17

PCOS

Approach to Treatment

Answer 17

Metformin

Question 18

Asherman Syndrome

Pathology

Answer 18

Presence of adhesions (scarring) insude uterine cavity

Question 19

Asherman Syndrome

Etiology

Answer 19

1 cause is iatrogenic intrauterine manipulation

• D&C: Dilation & Curettage

Question 20

Asherman Syndrome

Approach to Diagnosis

Answer 20

• Hysterosalpingogram (HSG): multiple filling defects
• Hysteroscopy: adhesions

Question 21

Primary Ovarian Failure (POF)

Etiology

Answer 21

1. Idiopathic: 39-57%
2. Genetic abnormalities: 10-30%
3. Autoimmune ovarian damage: 5-17%
4. Iatrogenic factors (radiation, CTX, surgery): 6-40%
5. Other (infectious, etc.): < 1%

Idiopathic POF = Dx of exclusion; must rule out others

Question 22

POF

Workup

Answer 22

• Rule out genetic causes
  * Karyotype –> rule out X chromosome abnormaltiies, Fragile X syndrome
• Rule out autoimmune causes
  
  • Screen for thyroid, parathyroid, and adrenal dysfunction

Question 23

Evidence of autoimmune POF

Etiology

Answer 23

1. Presence of lymphocytic oophoritis
2. Identification of anti-ovary Abs
3. Associated autoimmune disorders

Question 24

POF

Apporach to Therapy

Answer 24

1. Hormone replacement
2. Counseling

Question 25

Sheehan’s Syndrome

Etiology

Answer 25

Postpartum hemorrhagic infarction of pituitary gland

Question 26

Sheehan’s Syndrome

Mechanism

Answer 26

Hypopituitarism –> LH & FSH deficiency

Question 27

Sheehan’s Syndrome

Clinical Featuers

Answer 27

• History of postpartum hemorrhae
• Lactation failure
• Amenorrhea
• Breast atrophy
• Hypopigmentation