Primary Amenorrhea, Secondary Amenorrhea, Breast

Question 1

At what age is menorrhagia delayed?

Answer 1

If no period at 16, no secondary sex characteristics by 14.

Question 2

Differential if patient has breasts and uterus on US?

Answer 2

Imperforate hymen, anorexia/weight loss, pregnancy at first menses

Question 3

Differential if patient has breasts but no uterus?

Answer 3

AIS, mullerian agenesis

Question 4

Differential if patient has no breasts but a uterus

Answer 4

Craniopharyngioma, kallman syndrome, turner syndrome

Question 5

Craniopharyngioma/kallman syndrome pathogenesis

Answer 5

Problem in brain where entire axis cannot be stimulated. Patient has anatomy but no secondary sex characteristics.

Question 6

How to diagnose craniopharyngioma/kallman syndrome?

Answer 6

Look at levels of FSH and LH, get MRI

Question 7

How to treat craniopharyngioma/kallman?

Answer 7

Remove tumor, replace hormones

Question 8

Mullerian agenesis pathogenesis

Answer 8

No development of mullerian ducts, so no upper 1/3 of vagina, no cervix, no uterus.

Question 9

Patient presentation with mullerian agenesis

Answer 9

Has ovaries so has secondary sex characteristics, has outer organs because x,x. No uterus, no cervix, no upper 1/3 of vagina

Question 10

How to diagnose mullerian agenesis

Answer 10

Look at karyotype

Question 11

Testicular feminization pathogenesis

Answer 11

Insensitive to androgens but xy. So has outer genitalia, has no pubic hair, and has no uterus.

Question 12

How to diagnose testicular feminization?

Answer 12

T levels way up. FSH/LH normal (more or less). Get a karyotype.

Question 13

How to work up secondary amenorrhea

Answer 13

First, pregnancy test. Then TSH and prolactin. Then look at meds, then look at HPA axis.

Question 14

How does hypothyroidism cause amenorrhea

Answer 14

With hypothyroidism, TRH is high which stimulates prolactin causing decreased GNRH.

Question 15

How does prolactin affect HPO axis?

Answer 15

Prolactin shuts off GnRH.

Question 16

Algorithm for working up secondary amenorrhea.

Answer 16

Pregnancy test, tsh, prolactin level. If that’s negative. Must look at HPA axis. So do a prolactin challenge. If the patient bleeds then the problem is anovulation (PCOS). If the patient doesn’t bleed, do an estrogen and progesterone challenge to see if endometrium is working. If it doesn’t bleed, then endometrial dysfunction from aschermans or endometrial ablation. If it does bleed, then there is a signal issue, so get FSH/LH and a ratio. If FSH and LH are up, then there’s an ovary problem. Get an ultrasound to see if there are follicles. Menopause or savage (which is FSH receptor deficiency). If the levels of FSH and LH are down, then its a brain issue and there’s sheehans or apoplexy.