Puberty And Menstrual Disorders 2 Flashcards
Puberty is considered delayed when 1 of 4 things happen?
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
How do we define secondary amenorrhea?
Patient with prior menses has stopped for 6 months or more
Patient presents with primary amenorrhea, after doing physical exam and taking history, what is the first question to ask?
Does the patient have secondary sex features?
If the answer is no, what do I do and what are the results I am looking for?
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
What would I do after figuring out its hyper? What would be my two results I am looking for?
Do a Karyotype analysis.
45 XO is tuner
46 XX premature ovarian failure
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
MRI of Brain Tumors or hypothalamus or pituitary Anorexia Kallmann Too much prolactin Physiologic delay, most common
What is the problem in kallmann syndrome?
Mutation in the KAL gene that prevents the migration of GnRH neurons into the hypothalamus
What is one of the reasons we karyotype when we have hyper hypo?
To rule out there being a Y chromosome.
What is the most common form of female gonadal dysgensis? What is 1 unique symptom/sign with this syndrome?
Turners
Coarctation of the aorta
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?
US the uterus
Let’s say it is absent or abnormal, what do you do and what are the two results you are looking for?
Karyotype
46 XX is Müllerian agenesis
46 XY androgen insensitivity syndrome
What is the uterus is normal, what will you do next? What are the two results you are looking for?
Check if there is outflow tract obstruction
If no, evaluate for secondary amenorrhea
If yes, imperforate hymen or transverse vaginal septum
What is going on with androgen insensitivity syndrome? What does the female still have that is normal?
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
How do we treat androgen insensitivity syndrome?
Take out gonads after puberty to prevent neoplasms
What is normal and what is absent in mullerian agenesis?
Normal secondary features, external genitalia, female testosterone level, ovaries and Karyotype.
Absent uterus, upper vagina and commonly renal abnormalities.
Müllerian agenesis is the most common cause of primary amenorrhea in what situation?
Women with normal breast development.
What is an imperforate hymen, how do females usually present, unique identifier, how do we confirm diagnosis, and how do we treat?
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
Difference between transverse vaginal bulge and imperforate hymen? How do we diagnose and how do we treat?
No vaginal bulge
MRI
Surgery
First thing you do when patient presents with secondary amenorrhea?
Pregnancy test
After a negative pregnancy test, what do I do?
Check TSH and prolactin levels
What if prolactin is normal, but thyroid is abnormal?
Have some form of thyroid disease.
What is the most common thyroid disease, what does it usually present as, and how do we treat it?
Hypo
Hyper bleeding or irregular bleeding
Treat the low thyroid and should restore menses
What if thyroid is normal and prolactin is high? What are we thinking and how can we treat it?
Pituitary adenoma (prolactinoma) MRI the head Microadenoma, maybe give dopamine agonist If macro, give dopamine agonist and surgery if needed.
7 causes of a rise in prolactin, other than adenoma?
Ectopic production, breast feeding, excessive exercise, severe head trauma, hypothyroidism, liver or renal failure and meds.
What do we do if the patient has normal TSH and normal Prolactin?
Do a progesterone challenge test and look for withdrawal bleeding
Explain the results of the test and what is going on?
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.
What if the patient does not have withdrawal bleeding, what do we do next? What are the results?
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.
What is the most common cause of anovulation?
PCOS
What are the two outflow tract obstruction conditions?
Asherman syndome and cervical stenosis