D. Amenorhea Flashcards by Brian McDaniel

What does nulligravid mean?

No pregnancies

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What is hirsutism?

Female with increased hair on upper lip, chin, inner mammary area, inter scapular, back of hands & forearms

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What are the 3 stages of pubertal development & the related ages?

Thelarche - 8/9
Adrenarche/pubarche - 9/10
Growth spurt
Menarche - 12/13

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What is Thelarche?

Breast development

1st stage

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What is Adrenarche/Pubarche?

Hair development

2nd stage

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What is Menarche?

Begin menses, 12/13

Could start later in malnourished (need certain body weight)

Last stage

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Hormone pathway?

Hypothalamus –> GnRH (low level prepuberty & pulsatile after) –> Ant pit –> LH & FSH

LH –> theca –> estrogens
FSH –> granulosa –> estradiol

Rising estradiol –> triggers mid cycle LH surge –> ovulation –> Corpus luteum makes progesterone

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What are the 2 cell types of the ovary? What do they make?

Theca Cells = cells that surround granulosa that make estrogen

Granuosa Cells = right around the egg that makes estradiol

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What are the 2 endometrial stages & what hormone causes them?

Estradiol –> proliferative endometrium (1st half cycle)

Progesterone –> secretory endometrium

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Cycle length?

Normally 21-35 (28 day avg)

Duration = 3-5 days (first day or two is heavy)

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Definition of Primary Amenorrhea?

No menses, growth or secondary sexual characteristics by age 14

No menses by 16, but everything else seems normal

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Definition of Secondary Amenorrhea?

Miss 3 periods after starting menses

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Causes of Primary Amenorrhea & treatment?

Vaginal Agensis

Vaginal Septum (Corrective surgery)

Turner Syndrome/45x (IVF & egg donation)

Androgen insensitivity/46XY (stay female)

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Most common cause of secondary Amenorrhea?

Pregnancy

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What is the first test done for secondary amenorrhea?

Urine hcg

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What tests are performed for primary amenorrhea?

anatomical assessment & karyotype

What test is performed for secondary amenorrhea if the urine hcg is negative?

TSH (hypothyroidism can cause it)

What test(s) is(are) performed for secondary amenorrhea if the patient is not pregnant or hypothyroid?

FSH & Progesterone challenge test

What is the progesterone challenge test?

Give progesterone (medroxyprogesterone acetate oral) for 5 days then stop –> should bleed 2-7 days later

Any bleeding = + (dont need regular amount of flow

What does withdrawal bleeding from a Progesterone Challenge Test mean generally?

Estradiol levels are ok (the endometrium was primed)

Outflow tract is ok

What is the cause of secondary amenorrhea with withdrawal bleeding? What causes this disorder?

Hypo-pit dysfunction due to stress, weight change or polycystic ovarian disease

What is the treatment for Hypo-Pit Dysfunction?

If having sex but dont want to get pregnant –> give oral contraceptive (induces cycle)

If not sexually active & dont want to get pregnant –> induce cycle every couple months with Progestin

If want to get pregnant –> make ovulate with Clomiphene Citrate

Weight loss if obese

Treat DM with metformin

Cosmetic meaasures to remove hair

Causes of Hypo-pit failure?

Extreme stress & low body fat –> atheletes (ballet, marathon runner & gymnastics), anorexia or pit tumors

Cause of secondary amenorrhea if no withdrawal bleeding from progesterone test, low FSH & elevated prolactin? Confirmatory test?

Pit tumor

MRI for pit adenoma
Visual field exam (upper outer fields gone)

Cause of secondary amenorrhea if no withdrawal bleeding from progesterone test & low FSH?

Hypo-pit failure

How to treat hypo-pit failure?

Dont want to get preg --> hormone replacement to prevent bone loss Want to get preg --> induce with gonadotropins Pit adenoma --> dopamine agonist

Cause of secondary amenorrhea if no withdrawal bleeding from progesterone test & high FSH?

Ovarian Failure

Causes of ovarian failure?

Menopause if over 40 X mosaicism (less eggs) if under 40

Treatment for Ovarian Failure?

Premature menopause if don't want to get preg --> hormone replacement Premature menopause if want to be preg --> egg donation IVF Normal menopause --> hormone replacement

Cause of secondary amenorrhea if no withdrawal bleeding & normal FSH?

IUD or prior curettage --> Asherman Syndrome Confirmatory test with HSG, hysteroscopy or saline infusion sonogram

What are FSH levels for Hypo-pit dysfunction?

Normal

Which type of secondary amenorrhea is linked to high hirsuitism?

Hypo-pit dysfunction Testasterone will be elevated. DHEA can be elevated if due to an adrenal tumor

What is hypo-pit dysfunction?

Mild decrease or imbalance in hormones from pit Think about it as an LH deficiency (or estrogen excess) = Endometrial hyperplasia --> no ovulation Linked to obesity & DM (fat can make androgen/estrogen)

What is hypo-pit failure?

Neither of the pit hormones (LH or FSH) --> no ovulation (LH) or proliferative phase (estrogen)

What is ovarian failure?

Hypo-pit axis is working fine, but the ovary doesnt work so the hormones being released can't work

HSG (Hysterosalpingography) is used for the diagnosis of what disorder?

Asherman

What is HSG (Hysterosalpingography)?

radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes. It entails the injection of a radio-opaque material into the cervical canal and usually fluoroscopy with image intensification.

What is Asherman's Syndrome?

Buildup of scar tissue that prevents ovulation --> even though hormones are normal egg gets stuck