D. Amenorhea Flashcards
What does nulligravid mean?
No pregnancies
What is hirsutism?
Female with increased hair on upper lip, chin, inner mammary area, inter scapular, back of hands & forearms
What are the 3 stages of pubertal development & the related ages?
Thelarche - 8/9
Adrenarche/pubarche - 9/10
Growth spurt
Menarche - 12/13
What is Thelarche?
Breast development
1st stage
What is Adrenarche/Pubarche?
Hair development
2nd stage
What is Menarche?
Begin menses, 12/13
Could start later in malnourished (need certain body weight)
Last stage
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
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
What are the 2 endometrial stages & what hormone causes them?
Estradiol –> proliferative endometrium (1st half cycle)
Progesterone –> secretory endometrium
Cycle length?
Normally 21-35 (28 day avg)
Duration = 3-5 days (first day or two is heavy)
Definition of Primary Amenorrhea?
No menses, growth or secondary sexual characteristics by age 14
No menses by 16, but everything else seems normal
Definition of Secondary Amenorrhea?
Miss 3 periods after starting menses
Causes of Primary Amenorrhea & treatment?
Vaginal Agensis
Vaginal Septum (Corrective surgery)
Turner Syndrome/45x (IVF & egg donation)
Androgen insensitivity/46XY (stay female)
Most common cause of secondary Amenorrhea?
Pregnancy
What is the first test done for secondary amenorrhea?
Urine hcg
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
