secondary amenorrhea

Question 1

definition or when to evaluate for secondary amenorrhea?

Answer 1

• consider eval when irregular cycles in absence of OCPs etc x 3 months
• historically: amenorrhea x 3 months, irregular cycles x 6 months

Question 2

ddx for secondary ameonrrhea

Answer 2

• pregnancy
• hypothalamic disorders: CNS tumor/trauma/disease, vs functional - due to nutritional deficiency, exercise, stress, unexplained
• medications- especially psychotropics
• pituitary mass/infarction (sheehan’s syndrome)
• premature ovarian insufficiency
• uterine component (asherman’s, cervical stenosis)
• thyroid
• prolactin
• PCOS
• hyperandrogenism disorders: late onset CAH, cushing’s, adrenal or ovarian tumor

Question 3

how do you evaluate secondary amenorrhea?

Answer 3

• Full H&P
• HCG
• FSH, LH, estradiol
• TSH
• PRL
• testosterone, free testosterone, DHEA, DHEAS, 17 OHP, 24 hr cortisol vs dexamethasone suppression test
• consider SIS vs HSC to evaluate uterine cavity

Question 4

how is POI diagnosed?

Answer 4

FSH and estradiol 1 month apart
FSH in menopausal range 30-40
estradiol < 50

Normal TSH, PRL

Question 5

If POI diagnosed, what is ddx/what is follow-up testing?

Answer 5

• Karyotype
• FMR1 premutation analysis
• adrenal antibodies
• TVUS

Question 6

Treatment for POI

Answer 6

• HRT with progestin
• Bone loss - no clear recommendation on eval’ing BMD. Bisphosphonates have not been studied long term.
• No clear recommendation of evaluating for cardiac diseaes
• No clear recommendation for evaluation of autoimmune diseases; but reasonable to check thyroid function q1-2 years

Question 7

what are # repeat of CGGs to be concerned about with FMR1 testing?

Answer 7

55-200 = premutation
> 200 = mutation

over 90 has a very high risk of of next generation full mutation

Question 8

what percentage of POI due to FMR1 premutation? adrenal autoantibodies?

Answer 8

14% FMR1 gene

4% adrenal autoantibodies