Naz teaches Amenorrhea Flashcards
What defines amenorrhea
No period for 3 cycles.
OR 6 months
Primary amenorrhea is ?
the absence of menarche by age 16 or 4 years after thelarche.
_______ is the onset of female breast development.
Thelarche
_________ is the onset of androgen-dependent body changes such as growth of axillary and pubic hair, body odor, and acne.
Adrenarche
______ is the appearance of pubic hair.
Pubarche
Etiologies of Primary Amenorrhea
Outflow tract abnormalities
Imperforate hymen Transverse vaginal septum Vaginal agenesis Vaginal atresia Testicular feminization Uterine agenesis with vaginal dysgenesis MRKH syndrome
Etiologies of Primary Amenorrhea
End-organ disorders
- Ovarian agenesis
- Gonadal agenesis 46,XX
- Swyer syndrome/gonadal agenesis 46,XY
- Ovarian failure
- Enzymatic defects leading to decreased steroid biosynthesis
- Savage syndrome—ovary fails to respond to FSH and LH
- Turner syndrome
Etiologies of Primary Amenorrhea
Central disorders
Trauma Tuberculosis Sarcoidosis Irradiation Kallmann syndrome—congenital absence of GnRH Pituitary Damage from surgery or radiation therapy Hemosiderosis deposition of iron in pituitary Hypothalamic Local tumor
Swyer syndrome/gonadal agenesis 46,XY is?
congenital absence of the testes in an XY, testes never develop, have normal internal and external female genitalia.
NO estrogen–> will not develop breasts.
phenotypical picture similar to that of ovarian agenesis.
Mayer-Rokitansky-Küster-Hauser syndrome is?
it is Müllerian agenesis
They may have
complete vaginal agenesis and absence of a uterus or partial
vaginal agenesis with a rudimentary uterus and distal vagina.
“female” without uterus and Amenorrhea
Karyotype: testicular feminization, Müllerian agenesis, 46,XY steroid enzyme defects, pure gonadal dysgenesis, or anorchia
androgen insensitivity vs mullerian agenesis
androgen insensitivity will have no pubic hair (they do have testes so go cut em out)
both have blind pouch vagina and breasts
Vaginal atresia is?
where the Müllerian system is developed but the distal vagina is composed of fibrosed tissue.
Describe progesterone challenge
progesterone or oral medroxyprogesterone acetate given.
If sufficient serum estradiol (greater than 50 pg/mL), withdrawal bleeding 2-7 days after the progestin is withdrawn, indicating that the patient’s amenorrhea is due to anovulation.
If no bleeding occurs after withdrawal, then the patient’s amenorrhea is likely to be due to either a) low serum estradiol, b) hypothalamic-pituitary axis dysfunction, c) a nonreactive endometrium or d) a problem with the uterine outflow tract, such as cervical stenosis or uterine synechiae
If no bleeding occurs after progesterone challenge withdrawal, then the patient’s amenorrhea is likely to be due to either ?
a) low serum estradiol
b) hypothalamic-pituitary axis dysfunction
c) a nonreactive endometrium
d) a problem with the uterine outflow tract, such as cervical stenosis or uterine synechiae
Patients with hyperprolactinemia require rx?
bromocriptine
With progesterone challenge failure, the differential diagnosis becomes:
hypergonadotropic or hypogonadotropic hypogonadism
that can be differentiated by an FSH measurement.
Anatomic abnormalities including Asherman syndrome and cervical stenosis may lead to secondary amenorrhea. These patients
_________ to estrogen and progesterone withdrawal.
fail to respond to estrogen and progesterone withdrawal.
In the absence of breasts and presence of a uterus, FSH will differentiate between
hypergonadotropic and hypogonadotropic
hypogonadism. Karyotype may be necessary to rule out gonadal agenesis in a 46,XY.
The causes of hypothalamic-pituitary amenorrhea are:
- functional (weight loss, obesity, excessive exercise)
- drugs (marijuana and tranquilizers)
- neoplasia (pituitary adenomas)
- psychogenic (chronic anxiety and anorexia nervosa)
PCOS cancer risks
unopposed estrogen exposure that accompanies women with PCOS, these individuals carry a higher risk of developing endometrial hyperplasia and cancer.
PCOS is considered to increase the risk of ovarian cancer.
PCOS labs
Testosterone levels will be helpful to confirm the diagnosis
An increased LH/FSH ratio is observed to be elevated in PCOS
progesterone levels are helpful during medical treatment to check if the woman is ovulating.
____________ are the first-line of treatment for ovulatory dysfunction in PCOS patients.
Metformin and ovulation induction agents
what is imipramine.
TCA
s/e= hyperprolactinemia
exercise-induced hypothalamic amenorrhea, which is characterized by ____ (labs)
normal FSH and low estrogen levels
A clomiphene challenge test, which consists of ?0,
giving clomiphene citrate days five to nine of the menstrual cycle and checking FSH levels on day three and day 10
When do you have sex if you want a baby
The day you ovulate
egg is good for 24 hours
sperm are good for 3 days
Women are most fertile during the middle of their cycle when they are ovulating. Assuming normal cycles every 28 days, a woman is most likely to ovulate on day 14.
Women are most fertile during the middle of their cycle when they are ovulating. Assuming normal cycles every 28 days, a woman is most likely to ovulate on day ____?
14 of her cycle
Women aged 21-29 years should have a Pap test every ?
three years.
Women aged 30-65 years should have a Pap test and an HPV test (co-testing) every ___________
every five years (preferred). It is acceptable to have a Pap test alone every three years.
Women should stop having cervical cancer screening when?
-after age 65 years
-if no hx of dysplasia/ cancer
-three negative Pap test results in a row or…
-two negative co-test results in a row within the past 10 years,
need to meet all criteria
The major symptom associated with myomas is ?
menorrhagia,
1) ↑ uterine cavity size that leads to greater surface area for endometrial sloughing;
2) an obstructive effect on uterine vasculature that leads to endometrial venule ectasia and proximal congestion in the myometrium/endometrium resulting in hypermenorrhea.
*Most uterine fibroids are asymptomatic and do not require any treatment.
___________ myomas are most likely to cause lower pregnancy and implantation rates.
Submucosal or intracavitary
Growth of uterine fibroids is stimulated by _________
estrogen
________________ inhibit endogenous estrogen production by suppressing the hypothalamic-pituitary-ovarian axis. They can result in a 40-60% reduction in uterine size.
Gonadotropin-releasing hormone agonists
Hot flashes are experienced by >75% of patients
abnormally heavy bleeding at menstruation
Menorrhagia
Gonadotropin-releasing hormone agonists s/e
Hot flashes are experienced by >75% of patients
_________ is the surgical removal of fibroids from the uterus
Myomectomy
