Secondary Amenorrhea Flashcards
Gold standard to test for Cushing syndrome?
24 hour urinary free cortisol
Amenorrhea
Acne
Hirsutism
Clitoromegaly
Deeping of voice
Sertoli-Leydig Tumor
Rotterdam Criteria - what are they and how many do you need?
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”
Treatment for prolactinoma?
Dopamine Agonist
Caberagoline and bromocriptine
Can you diagnose PCOS within 2 years of puberty?
NOPE!
Describe pathogenesis of PCOS
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
Chronic conditions linked to PCOS?
T2DM OSA HLD Metabolic Syndrome NAFLD
Increased risk of T2DM in women > 30 yo w/ PCOS?
12% increased risk (2-5 fold)
DHEAS is almost exclusively produced by what organ?
Adrenal glands
Extremely high levels (> 700) require additional work up and is suggestive of a hormone secreting adrenal tumor
What amount of weight loss will help improve symptoms of PCOS?
5% of initial body weight
How to OCPS work to treat PCOS?
- Suppression of LH secretion
- Suppression of ovarian androgen secretion
- Increase sex hormone binding globulin circulating > decreases free testosterone
Criteria for metabolic syndrome?
BP > 130/85
BG > 100
HDL < 50
TG > 150
Waist > 35 inches
FDA approved treatment for Hirsutism?
Eflornithine
Eflornithine is an inhibitor of ornithine decarboxylase, which is an important enzyme related to hair growth
How does spironolactone work for treatment of hirsutism?
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
What is the best ovulation induction agent for someone with PCOS?
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
What cells in the ovaries produce androgens?
Theca cells
US criteria for PCOS?
12 or more antral follicles (2-9 mm)
“string of pearls”
Ovarian volume 10 cm^3 or greater
Labs to working up oligomenorrhea?
PREGNANCY TEST!
Prolactin
TSH
Free testosterone
DHEAS
LH to FSH ratio (2.5:1) - loose finding with PCOS
Estradiol Level
Pelvic Ultrasound
Define secondary amenorrhea
No menses > 3 months in females with normal menstural cycles or > 6 months in females with irregular menstrual cycles
Differential diagnosis for secondary amenorrhea
PREGNANCY
Hypogonadotropic Hypogonadism
Thyroid disease
Hyperprolactinemia
PCOS
CAH
Androgen secreting tumors (adrenal or ovarian)
Premature ovarian insufficiency
Asherman’s Syndrome
What tests would confirm POI?
FSH > 30
LH > 20
Neg preg test
Normal PRL + TSH
*need to repeat at least 1 month apart
Differential diagonsis for POI?
What labs would you obtain next?
Turner’s Syndrome: Karytoype
Premutation for FMR1 gene (Fragile X): Genetic testing
Endocrinopathies: hypoparathryoid, hypoadrenalism
Autoimmune: 21 alpha hydroxyalse antibodies, TPO antibodies/TSH
Treament for POI?
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
Differenital diagnosis Hirsutism?
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)
Work-up for hyperprolactinemia?
- 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
Differential Dx for Hyerprolactinemia
Pregnancy!
Medications?
Thyroid dysfunction
Macroprolactinemia (not biologically active)
Microprolactinoma < 1 cm
Macroproalctinoma = 1 cm or greater
Why is cabergoline prefered treatment for hyperprolactinemia?
DOPAMINE AGONIST
Longing acting (less frequent dosing)
More effective
Less side effects
Cabergoline dosing?
Twice weekly 0.25 mg
Can increase dose every 4 weeks
When is surgery indicated for prolactinoma?
Medications ineffective
Macroadenoma + symptomatic
*Macroadenomas are likely to grow during pregnancy
How do OCPs work to decrease testosterone?
Decreased androgen production
Increases SHBG levels thus less free androgens
How does spironolactone work to decrease testosterone?
Blocks androgen receptor
Inhibits 5 alpha reductase
