Secondary Amenorrhea

Question 1

Gold standard to test for Cushing syndrome?

Answer 1

24 hour urinary free cortisol

Question 2

Amenorrhea
Acne
Hirsutism
Clitoromegaly
Deeping of voice

Answer 2

Sertoli-Leydig Tumor

Question 3

Rotterdam Criteria - what are they and how many do you need?

Answer 3

You need 2

• menstural dysfunction (< 9 per year)
• Hyperandrogenism (clinical signs or lab evidence)
• US w/ polycystic ovaries (12 or more antral follicles measuring 2-9 mm)

“string of pearls”

Question 4

Treatment for prolactinoma?

Answer 4

Dopamine Agonist

Caberagoline and bromocriptine

Question 5

Can you diagnose PCOS within 2 years of puberty?

Answer 5

NOPE!

Question 6

Describe pathogenesis of PCOS

Answer 6

chronically elevated LH and insulin levels lead to increased androgen production with-in the ovarian theca

Hyperinsulinemia suppresses hepatic production of sex hormone binding globulin, which results in increased levels of free testosterone

Usually low levels of androgens increase aromatase activity within the follicle, but levels that are too high lead to follicular atresia

Question 7

Chronic conditions linked to PCOS?

Answer 7

T2DM
OSA
HLD
Metabolic Syndrome
NAFLD

Question 8

Increased risk of T2DM in women > 30 yo w/ PCOS?

Answer 8

12% increased risk (2-5 fold)

Question 9

DHEAS is almost exclusively produced by what organ?

Answer 9

Adrenal glands

Extremely high levels (> 700) require additional work up and is suggestive of a hormone secreting adrenal tumor

Question 10

What amount of weight loss will help improve symptoms of PCOS?

Answer 10

5% of initial body weight

Question 11

How to OCPS work to treat PCOS?

Answer 11

• Suppression of LH secretion
• Suppression of ovarian androgen secretion
• Increase sex hormone binding globulin circulating > decreases free testosterone

Question 12

Criteria for metabolic syndrome?

Answer 12

BP > 130/85
BG > 100
HDL < 50
TG > 150
Waist > 35 inches

Question 13

FDA approved treatment for Hirsutism?

Answer 13

Eflornithine

Eflornithine is an inhibitor of ornithine decarboxylase, which is an important enzyme related to hair growth

Question 14

How does spironolactone work for treatment of hirsutism?

Answer 14

K Sparing diuretic

• inhibiting steroidogenesis in the ovary and adrenal gland
• Competing for the androgen receptor in the hair follicle
• Directly inhibiting 5-alpha reductase

Question 15

What is the best ovulation induction agent for someone with PCOS?

Answer 15

Letrazole (aromatase inhibitor)

• Increased ovulation rates
• Increased clinical pregnancy rates
• Increased live birth rates
• Decreased risk of multiples

compared to clomid

*Although not FDA approved

Question 16

What cells in the ovaries produce androgens?

Answer 16

Theca cells

Question 17

US criteria for PCOS?

Answer 17

12 or more antral follicles (2-9 mm)

“string of pearls”

Ovarian volume 10 cm^3 or greater

Question 18

Labs to working up oligomenorrhea?

Answer 18

PREGNANCY TEST!
Prolactin
TSH
Free testosterone
DHEAS
LH to FSH ratio (2.5:1) - loose finding with PCOS
Estradiol Level
Pelvic Ultrasound

Question 19

Define secondary amenorrhea

Answer 19

No menses > 3 months in females with normal menstural cycles or > 6 months in females with irregular menstrual cycles

Question 20

Differential diagnosis for secondary amenorrhea

Answer 20

PREGNANCY
Hypogonadotropic Hypogonadism
Thyroid disease
Hyperprolactinemia
PCOS
CAH
Androgen secreting tumors (adrenal or ovarian)
Premature ovarian insufficiency
Asherman’s Syndrome

Question 21

What tests would confirm POI?

Answer 21

FSH > 30
LH > 20
Neg preg test
Normal PRL + TSH
*need to repeat at least 1 month apart

Question 22

Differential diagonsis for POI?
What labs would you obtain next?

Answer 22

Turner’s Syndrome: Karytoype
Premutation for FMR1 gene (Fragile X): Genetic testing
Endocrinopathies: hypoparathryoid, hypoadrenalism
Autoimmune: 21 alpha hydroxyalse antibodies, TPO antibodies/TSH

Question 23

Treament for POI?

Answer 23

100 mcg Transdermal patch
200 mg prometrium cyclic 12 days/month
Yearly TSH, TPO antibodies
If + adrneal antibodies, will need yearly 0800 cortisol as at high risk for developing adrenal insufficency
*should use barrier method/IUD for contraception, 5-10% spontaenously concieve

Question 24

Differenital diagnosis Hirsutism?

Answer 24

Familial
PCOS (elevated free testosterone)
Non classic CAH (elevated 17-OHP > testosterone)
Sertoli Leydig = Sex cord stromal tumor (elevated testosterone)
Adrenal tumor (elevated DHEAS)
Cushing Disease (elevated cortisol)

Question 25

Work-up for hyperprolactinemia?

Answer 25

• Repeat PRL in AM, fasting, with no exerise/sex/nipple stim for 3 days
• Pregnancy Test
• Review medications (looking for DA antagonists)
• TSH
• Test for macroprolactinemia
• Brain MRI

Question 25

Differential Dx for Hyerprolactinemia

Answer 25

Pregnancy!
Medications?
Thyroid dysfunction
Macroprolactinemia (not biologically active)
Microprolactinoma < 1 cm
Macroproalctinoma = 1 cm or greater

Question 26

Why is cabergoline prefered treatment for hyperprolactinemia?

Answer 26

DOPAMINE AGONIST
Longing acting (less frequent dosing)
More effective
Less side effects

Question 27

Cabergoline dosing?

Answer 27

Twice weekly 0.25 mg
Can increase dose every 4 weeks

Question 28

When is surgery indicated for prolactinoma?

Answer 28

Medications ineffective
Macroadenoma + symptomatic
*Macroadenomas are likely to grow during pregnancy

Question 29

How do OCPs work to decrease testosterone?

Answer 29

Decreased androgen production
Increases SHBG levels thus less free androgens

Question 30

How does spironolactone work to decrease testosterone?

Answer 30

Blocks androgen receptor
Inhibits 5 alpha reductase