oligomenorrhea + amenorrhea Flashcards
1
Q
primary amenorrhea definition
A
- no menses ever
- by age 14 if no sex dev
- by age 16 if breast + pubic hair dev
2
Q
secondary amenorrhea
A
- period stops, non for 6 mo if reg, none for 12 mo if irreg
3
Q
oligomenorrhea
A
light or infreq (>35 days, 4-9x/year)
4
Q
anovulatory bleed
A
noncyclic, from endometrium, due to hormones, no anatomic lesion
5
Q
differential diagnosis of amenorrhea
A
/w sex dev: anatomic: - mullerian agenesis - imperforate hymen - mullerian agenesis - androgen insensitivity syndrome
Hypergonadotropic hypogonadism - no sex dev
- turner’s syndrome
- primary ovarian insufficiency
- gonadal dysgenesis
hypogonadotropic hypogonadism
- constitutional delay
- PCOS
- hypothyroid
- hyperprolactinemia
- congenital CNS abnormalities, hypopituarism, or GnRH def, kallmans
6
Q
common differential for secondary amennorhea
A
hypogonadotropic
- weight loss
- hypothalamic “stress”
- PCOS / anovulation
- hypothyroidism
- cushings
- hyperprolactinemia
- pituitary tumor, empty sella, sheehan syndrome (pituitary necrosis)
hypergonadotropic
- POI
- abnormal karyotype
Anatomic
- ashermans
hyperandrogens
- ovarian tumour
- CAH
- undiagnosed
- (PCOS)
7
Q
work-up for primary amenorrhia
A
- history
- physical exam for sex dev + androgens, BMI
- BHCG, TSH, PRL, FSH, pelvic US if second dev, if virulization do testosterone + DHEAS (tumor)
- FSH low + all else normal: brain MRI, if normal = constitutional, hypothalamic, or pituitary dysfunction
- FSH high: karyotype (POI or turners)
- US no uterus: karyotype (XY + AIS or XX + mullerian agenesis)
8
Q
work-up for secondary amenorrha
A
- HCG, FSH, BMI, PRL, TSH, fasting glucose, testosterone, LH if suspect PCOS
- FSH high - POI - karyotype if under 30, can check estrogen /w prog challenge test
- FSH low - hypothalamic (+low androgens
- PCOS: high BMI, high androgens, high LH:FSH
- r/o adrenal tumour + NACH: DHEAS (rapid) + 17-hydroxyprogesteron
- PRL high: brain MRI or drugs or hypothyroidism, or renal failure
9
Q
work-up + tx for elevated prolactin
A
- drug hx, r/o hypothyroidism
- if no meds, brain MRI
- tx: bromocriptine (dopamine agonist)
- ## alt = transphenoidal excision, only if mass effects or med failure
10
Q
PCOS dx
A
- BP
- BMI, waist-hip
- signs of hyperandrogenism + insulin resitance
- pelvic exam (enlarged ovaries)
labs
- total +/- free testosterone
- DHEAS if rapid virulization
- 17-hydroxyprogesterone (CAH)
- TSH, prolactin - exclude
- consider acromegally (GH)
- HbA1c, 2 hr OGTT, fasting lipid + lipoproteins
optional
- ovary US (for fertility, rapid virulization)
- fasting insulin
- LH + FSH
- 24 hr urine for cortisol (late onset or looks like cushings)
11
Q
diagnostic criteria for PCOS
A
- two of:
- clinical or biochem hyperandrogenism, ovulatory dysfunction, or PCOs on US
12
Q
management of PCOS
A
not TTC:
- OCP: cycle reg, dec androgens, red endometrial Ca
- progestins: alt to OCP
- insulin sensitizers = 2nd line, decrease androgens, improve ovulation, and glucose tests
TTC
- exercise, weight loss
- letrozole for ovulation induction
- 2nd line: clomiphene citrate (alone or in combo) for ovulation
- 3rd line: gonadotropins
- metformin - alone or in combo, other insulin sentizers
- 3rd line = ovarian drilling
13
Q
premature ovarian failure management
A
- if before age 30, karyotype for sex chromosome translocation, deletions, or occult Y (remove gonads!)
- prog challenge test for E
- obtain fam Hx for autosomal disorders, genetics counselling
- autoimmune thyroiditis common
- tx: E + P until age 51, if adolescent mimic puberty by increasing E slowly and add P when breast mound developed
- note: rare spont ovulation possible
