Puberty And Menstrual Disorders 2

Question 1

Puberty is considered delayed when 1 of 4 things happen?

Answer 1

Secondary sex features don’t appear by 13
Thelarche not occurring by 14
No menarche by 15
Menses not happening 5 years after Thelarche started

Question 2

How do we define secondary amenorrhea?

Answer 2

Patient with prior menses has stopped for 6 months or more

Question 3

Patient presents with primary amenorrhea, after doing physical exam and taking history, what is the first question to ask?

Answer 3

Does the patient have secondary sex features?

Question 4

If the answer is no, what do I do and what are the results I am looking for?

Answer 4

Measure the FSH and LH
If the FSH and LH are less than 5, then it is hypogonadotropic hypogonadism
If the FSH is greater than 20 and the LH is greater than 40, then it is hypergonadotropic hypogonadism

Question 5

What would I do after figuring out its hyper? What would be my two results I am looking for?

Answer 5

Do a Karyotype analysis.
45 XO is tuner
46 XX premature ovarian failure

Question 6

Once we know it is hypo hypo, what test can we do? Also, what are 5 causes of hypo and which one is most common?k

Answer 6

MRI of Brain
Tumors or hypothalamus or pituitary 
Anorexia
Kallmann
Too much prolactin
Physiologic delay, most common

Question 7

What is the problem in kallmann syndrome?

Answer 7

Mutation in the KAL gene that prevents the migration of GnRH neurons into the hypothalamus

Question 8

What is one of the reasons we karyotype when we have hyper hypo?

Answer 8

To rule out there being a Y chromosome.

Question 9

What is the most common form of female gonadal dysgensis? What is 1 unique symptom/sign with this syndrome?

Answer 9

Turners

Coarctation of the aorta

Question 10

Let’s go back to our patient presenting with primary amenorrhea and you asked the question, are there secondary sex features and the answer is yes, what will you do next?

Answer 10

US the uterus

Question 11

Let’s say it is absent or abnormal, what do you do and what are the two results you are looking for?

Answer 11

Karyotype
46 XX is Müllerian agenesis
46 XY androgen insensitivity syndrome

Question 12

What is the uterus is normal, what will you do next? What are the two results you are looking for?

Answer 12

Check if there is outflow tract obstruction
If no, evaluate for secondary amenorrhea
If yes, imperforate hymen or transverse vaginal septum

Question 13

What is going on with androgen insensitivity syndrome? What does the female still have that is normal?

Answer 13

Testes in the ab wall that is secreting anti Müllerian Hormones so no uterus.
Male levels of testosterone with a defect in the androgen receptor.
Still have external female genitalia (no hair) and breast development

Question 14

How do we treat androgen insensitivity syndrome?

Answer 14

Take out gonads after puberty to prevent neoplasms

Question 15

What is normal and what is absent in mullerian agenesis?

Answer 15

Normal secondary features, external genitalia, female testosterone level, ovaries and Karyotype.
Absent uterus, upper vagina and commonly renal abnormalities.

Question 16

Müllerian agenesis is the most common cause of primary amenorrhea in what situation?

Answer 16

Women with normal breast development.

Question 17

What is an imperforate hymen, how do females usually present, unique identifier, how do we confirm diagnosis, and how do we treat?

Answer 17

Hymen completely obstructs the vagina
Complains of dysmenorrhea without vaginal bleeding
Vaginal bulge
US to confirm normal uterus and blood building up in vagina
Treat with hymenectomy

Question 18

Difference between transverse vaginal bulge and imperforate hymen? How do we diagnose and how do we treat?

Answer 18

No vaginal bulge
MRI
Surgery

Question 19

First thing you do when patient presents with secondary amenorrhea?

Answer 19

Pregnancy test

Question 20

After a negative pregnancy test, what do I do?

Answer 20

Check TSH and prolactin levels

Question 21

What if prolactin is normal, but thyroid is abnormal?

Answer 21

Have some form of thyroid disease.

Question 22

What is the most common thyroid disease, what does it usually present as, and how do we treat it?

Answer 22

Hypo
Hyper bleeding or irregular bleeding
Treat the low thyroid and should restore menses

Question 23

What if thyroid is normal and prolactin is high? What are we thinking and how can we treat it?

Answer 23

Pituitary adenoma (prolactinoma)
MRI the head
Microadenoma, maybe give dopamine agonist 
If macro, give dopamine agonist and surgery if needed.

Question 24

7 causes of a rise in prolactin, other than adenoma?

Answer 24

Ectopic production, breast feeding, excessive exercise, severe head trauma, hypothyroidism, liver or renal failure and meds.

Question 25

What do we do if the patient has normal TSH and normal Prolactin?

Answer 25

Do a progesterone challenge test and look for withdrawal bleeding

Question 26

Explain the results of the test and what is going on?

Answer 26

Once the progestin is taking away, if there is bleeding, the patient has enough estrogen to grow the uterus, but there is no ovulation going on.
If there is no bleeding at all, there is either low estrogen or an outflow tract problem.

Question 27

What if the patient does not have withdrawal bleeding, what do we do next? What are the results?

Answer 27

Well, we now need to determine between outflow tract issue and low estrogen, so we give estrogen/progesterone combo.
If there is bleeding, we then check FSH/LH levels to see if it is Hyper hypo or hypo hypo. Do MRI for adenoma, and if normal, hypothalamus is the problem.
If there is no bleeding, we know it’s outflow tract issue.

Question 28

What is the most common cause of anovulation?

Answer 28

PCOS

Question 29

What are the two outflow tract obstruction conditions?

Answer 29

Asherman syndome and cervical stenosis