Clinical Gynecology: Secondary Amenorrhea Flashcards
Secondary Amenorrhea
Definition
Absence of menses for 6 months or 3 cycles in a female who previously menstruated
Secondary Amenorrhea
Etiology
- Hypothalamus:
- Malnutrition: 15%
- Exercise: 10%
- Stress: 10%
- Pituitary:
- Prolactinoma: 18%
- Thyroid:
- Hypothyroidism: < 1%
- Ovary:
- PCOS: 30%
- POF: 10%
- Uterus:
- Asherman syndrome: 5%
Functional Hypothalamic Amenorrhea
Etiology
- Energy deficit: anorexia nervosa, excessive exercise
- Stress
Functional Hypothalamic Amenorrhea
Mechanism
Suppression of GnRH secretion
* Energy deficit: caloric imbalance; low leptin levels
* Stress: high cortisol & CRH levels
Prolactinoma
Mechanism
High PRL levels suppress hypothalamic GnRH secretion
- Amenorrhea
- Galactorrhea
- Infertility
- Headache
- Visual changes
Signs & Symptoms
Prolactinoma
Prolactinoma
Approach to Diagnosis
- Elevated PRL levels
- Head MRI
Prolactinoma
Approach to Therapy
Dopamine Agonists
* Bromocriptine
* Cabergoline
Hypothyroidism
Approach to Diagnosis
Elevated TSH levels
Hypothyroidism
Mechanism
High TSH levels stimulate PRL secretion
- Amenorrhea
- Weight gain
- Goiter
- Dry skin & hair
- Brittle nails
- Cold intolerance
Signs & Symptoms
Hypothyroidism
Polycystic Ovarian Syndrome (PCOS)
Mechanism
Impaired progesterone secretion
* Ovary fails to recruit a dominant follicle & ovulate
- Amenorrhea
- Irregular cycles
- Infertility
- Hirsutism
- Acne
- Elevated BMI
Signs & Symptoms
Polycystic Ovarian Syndrome (PCOS)
PCOS
Approach to Diagnosis
Rotterdam criteria: at least 2 of 3
1. Androgen excess: clinical or biochemical
2. Ovulatory dysfunction: oligo- or anovulation
3. Polycystic ovaries
PCOS
Potential Long-Term Complications
- Obesity
- Insulin resistance, T2DM
- Dyslipidemia
- CVD
- Obstructive sleep apnea
- Non-alcoholic fatty liver disease
- Endometrial cancer
PCOS
Approach to Diagnosis
Metformin
PCOS
Approach to Treatment
Metformin
Asherman Syndrome
Pathology
Presence of adhesions (scarring) insude uterine cavity
Asherman Syndrome
Etiology
1 cause is iatrogenic intrauterine manipulation
- D&C: Dilation & Curettage
Asherman Syndrome
Approach to Diagnosis
- Hysterosalpingogram (HSG): multiple filling defects
- Hysteroscopy: adhesions
Primary Ovarian Failure (POF)
Etiology
- Idiopathic: 39-57%
- Genetic abnormalities: 10-30%
- Autoimmune ovarian damage: 5-17%
- Iatrogenic factors (radiation, CTX, surgery): 6-40%
- Other (infectious, etc.): < 1%
Idiopathic POF = Dx of exclusion; must rule out others
POF
Workup
- Rule out genetic causes
* Karyotype –> rule out X chromosome abnormaltiies, Fragile X syndrome - Rule out autoimmune causes
- Screen for thyroid, parathyroid, and adrenal dysfunction
Evidence of autoimmune POF
Etiology
- Presence of lymphocytic oophoritis
- Identification of anti-ovary Abs
- Associated autoimmune disorders
POF
Apporach to Therapy
- Hormone replacement
- Counseling
Sheehan’s Syndrome
Etiology
Postpartum hemorrhagic infarction of pituitary gland
Sheehan’s Syndrome
Mechanism
Hypopituitarism –> LH & FSH deficiency
Sheehan’s Syndrome
Clinical Featuers
- History of postpartum hemorrhae
- Lactation failure
- Amenorrhea
- Breast atrophy
- Hypopigmentation
