Primary Amenorrhea, Secondary Amenorrhea, Breast Flashcards
At what age is menorrhagia delayed?
If no period at 16, no secondary sex characteristics by 14.
Differential if patient has breasts and uterus on US?
Imperforate hymen, anorexia/weight loss, pregnancy at first menses
Differential if patient has breasts but no uterus?
AIS, mullerian agenesis
Differential if patient has no breasts but a uterus
Craniopharyngioma, kallman syndrome, turner syndrome
Craniopharyngioma/kallman syndrome pathogenesis
Problem in brain where entire axis cannot be stimulated. Patient has anatomy but no secondary sex characteristics.
How to diagnose craniopharyngioma/kallman syndrome?
Look at levels of FSH and LH, get MRI
How to treat craniopharyngioma/kallman?
Remove tumor, replace hormones
Mullerian agenesis pathogenesis
No development of mullerian ducts, so no upper 1/3 of vagina, no cervix, no uterus.
Patient presentation with mullerian agenesis
Has ovaries so has secondary sex characteristics, has outer organs because x,x. No uterus, no cervix, no upper 1/3 of vagina
How to diagnose mullerian agenesis
Look at karyotype
Testicular feminization pathogenesis
Insensitive to androgens but xy. So has outer genitalia, has no pubic hair, and has no uterus.
How to diagnose testicular feminization?
T levels way up. FSH/LH normal (more or less). Get a karyotype.
How to work up secondary amenorrhea
First, pregnancy test. Then TSH and prolactin. Then look at meds, then look at HPA axis.
How does hypothyroidism cause amenorrhea
With hypothyroidism, TRH is high which stimulates prolactin causing decreased GNRH.
How does prolactin affect HPO axis?
Prolactin shuts off GnRH.
Algorithm for working up secondary amenorrhea.
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.
