Columbus: amenorrhea

Question 0

Describe GnRH and its origin.

Answer 0

Deca-peptide released by medial basal hypothalamus in pulsatile fashion

Question 1

Define amenorrhea.

Answer 1

Absence of menses for 6 months or a time equal to a total of 3 previous cycles

Question 2

What is the differential diagnosis for hypothalamic causes of amenorrhea?

Answer 2

Stress
Weight-loss
Strenuous exercise
Kallman syndrome
Tumor

Question 3

What is the the differential diagnosis for pituitary related causes of amenorrhea?

Answer 3

Hyperprolactinemia

Hypothyroidism

Question 4

How does hypothyroidism lead to anovulation?

Answer 4

Elevated TSH results from elevated TRH; TRH also causes prolactin release
Prolactin inhibits GnRH release leading to anovulation.

Question 5

When should imaging be ordered for possible pituitary adenoma?

Answer 5

Some say if prolactin is greater than 100. Others recommend universal imaging.

Question 6

What is the differential diagnosis for ovarian causes of amenorrhea?

Answer 6

Anovulation such as PCOS
Ovarian insufficiency or menopause
Turner syndrome or mosaicism

Question 7

What is the chance of pregnancy with primary ovarian insufficiency in a 33-year-old?

Answer 7

5-10%

Question 8

What does ASRM say about preconceptual counseling for Turner syndrome?

Answer 8

Turner syndrome is a relative contraindication for pregnancy and patient should be encouraged to consider alternatives such as gestational surrogacy or adoption

Question 9

What is the concerning sequelae associated with primary ovarian insufficiency?

What percentage will have adrenal insufficiency?

What percentage of pregnancies will result in miscarriage?

Answer 9

Fragile X pre-mutation (most common cause of inherited mental retardation)

2%

50%

Question 10

What is the genetic cause of fragile X?

What is incidence in Caucasians?

Answer 10

Expanded trinucleotide repeat of the FMR 1 gene
Greater than 200 will be affected, 61-200 will be phenotypically normal with at-risk offspring

1 in 317

Question 11

What does ACOG say regarding fragile X screening with premature ovarian failure?

Answer 11

Should be considered for all patients since children with premutation have increased risk of autism and adults with premutation have increased risk of early-onset neurodegenerative disorder

Question 12

What is the differential diagnosis for uterine causes of amenorrhea?

Answer 12

Mullerian agenesis

Ashermen’s syndrome

Question 13

What are the causes of Asherman’s syndrome?

Answer 13

Curettage after abortion 67%, postpartum curettage 21%, tuberculosis, myomectomy, D&C, molar evacuation

Pregnancy related risk probably associated with decreased estrogen after delivery

Question 14

What history should be emphasized when evaluating amenorrhea?

Answer 14

Weight changes, stress, neurological signs
Galactorrhea or thyromegaly
Obesity, hirsutism, hot flashes
History of D&C or absent uterus

Question 15

What laboratory testing should be ordered for the evaluation of amenorrhea?

Answer 15

hCG, TSH, prolactin, FSH

Progestin challenge

Question 16

How is a progestin challenge administered?

What should the patient expect?

What does it tell you clinically?

Answer 16

Progesterone in oil 200 mg IM or Provera 10 mg orally for five days

2-7 days after last pill and expect bleeding; occasionally will take up to 14 days

Bleeding in response to progestin indicates anovulation

Question 17

What is the primary treatment for symptomatic pituitary adenoma?

Answer 17

Cabergoline 0.25 mg twice per week, increased by 0.25 mg per week

More expensive then bromocriptine but less nausea vomiting and postural hypotension

Question 18

How would you counsel patients regarding the safety of bromocriptine in pregnancy?

Answer 18

No increased risk of malformation or miscarriage, no increased developmental anomalies.

Question 19

What percentage of people with hyperprolactinemia and infertility will ovulate within 3-4 cycles of starting a dopamine agonist?

Answer 19

80%