SECONDARY AMENORRHEA (TB Dr. u Flashcards by Shiela Micah Gascon

What is the first step in evaluating a patient with secondary amenorrhea?

“Request a pregnancy test to rule out pregnancy.”

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What physiologic conditions can cause secondary amenorrhea?

“Pregnancy and postpartum (lactational amenorrhea).”

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How long can lactational amenorrhea last in an exclusively breastfeeding mother?

“Up to 6 months.”

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Is amenorrhea itself a pathologic entity?

“No. it is a sign or symptom. not a final diagnosis.”

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What defines primary amenorrhea?

“Absence of menstruation by age 16.”

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What defines secondary amenorrhea?

“Absence of menses for at least 6 months in a previously menstruating woman.”

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Which three organs must synchronize for regular menstruation?

“Hypothalamus. pituitary gland. and ovary.”

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Describe sex hormone levels during childhood.

“Estrogen. LH. and FSH are low.”

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What happens when estrogen is low in childhood?

“The hypothalamus secretes GnRH to stimulate FSH and LH production. increasing estrogen.”

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What happens if the hypothalamus cannot sense low estrogen?

“Menstruation stops.”

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How does the CNS-HPO axis respond to low estrogen levels?

“It is extremely sensitive to negative feedback effects of low circulating estrogen.”

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What triggers the onset of puberty regarding hormone sensitivity?

“Reduced sensitivity of CNS-hypothalamic axis to estrogen.”

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What hormones increase prior to puberty?

“GnRH. LH. and FSH.”

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What is the most common cause of secondary amenorrhea?

“CNS-hypothalamic causes (62%).”

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What are the causes of CNS-hypothalamic amenorrhea?

“Lesions. drugs. stress. exercise. weight loss. PCOS. and functional hypothalamic amenorrhea.”

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What lesions can affect the hypothalamus causing amenorrhea?

“Craniopharyngiomas. granulomatous diseases. sequelae of encephalitis.”

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What is the hormonal pattern in hypothalamic lesions?

“Low GnRH → low FSH and LH → low estrogen.”

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What is the effect of progesterone challenge in hypothalamic lesions?

“No withdrawal bleeding.”

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Name drugs that can cause hypothalamic amenorrhea.

“Phenothiazines. antihypertensives. and oral contraceptives.”

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What is postpill amenorrhea?

“Persistent hypothalamic-pituitary suppression after discontinuing OCPs.”

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What is the maximum duration for postpill amenorrhea to resolve?

“6 months.”

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How do oral contraceptives suppress ovulation?

“By inhibiting GnRH. FSH. and LH secretion.”

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How does stress cause amenorrhea?

“Increases catecholamines and β-endorphins. inhibiting GnRH release.”

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How does strenuous exercise affect LH and FSH levels?

“It decreases LH and FSH.”

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What effect does catechol estrogen have on GnRH?

"Inhibits GnRH by increasing dopamine."

What effect do β-endorphins have on GnRH?

"They inhibit norepinephrine's stimulation of GnRH."

What happens to menstruation when stress abates?

"Normal ovarian function and menses usually resume."

How does simple weight loss affect menstruation?

"Decreases GnRH → decreases LH/FSH → leads to amenorrhea."

How does severe weight loss affect menstruation?

"Involves hypothalamic and pituitary dysfunction."

What hormone abnormalities occur in anorexia nervosa?

"Low T3. normal T4. elevated GH. high cortisol. low ACTH and DHEA-S."

What LH pattern is seen in anorexia nervosa?

"Prepubertal pattern."

What is functional hypothalamic amenorrhea?

"No structural lesions. disruption of GnRH pulsatility causing amenorrhea."

What CNS abnormalities may cause functional hypothalamic amenorrhea?

"Increased opioid activity and neurotransmitter abnormalities."

What is the role of GnRH in menstruation?

"Stimulates the pituitary to produce LH and FSH. leading to ovarian stimulation."

What are the diagnostic criteria for PCOS (1990 NIH)?

"Chronic anovulation + signs of hyperandrogenism."

What are the diagnostic criteria for PCOS (2003 ESHRE/ASRM)?

"2 of 3: Oligo/anovulation. hyperandrogenism. polycystic ovaries."

How many criteria are needed to diagnose PCOS in teenagers?

"All 3 criteria."

How many criteria are needed to diagnose PCOS in adults?

"At least 2 out of 3."

What are signs of hyperandrogenism in PCOS?

"Thinning of scalp hair. facial/body hair growth. acne."

What happens to fertility in PCOS?

"Anovulation leads to reduced chance of pregnancy."

What is functional hypothalamic amenorrhea characterized by?

"Absence of normal LH pulsatility and persistent luteal pattern."

What percentage of secondary amenorrhea cases are due to pituitary causes?

"16%."

What causes hypoestrogenic amenorrhea from the pituitary?

"Neoplasms (adenomas) and non-neoplastic lesions (ischemia. hemorrhage)."

How does a chromophobe adenoma cause amenorrhea?

"Decreases LH and FSH. reducing estrogen."

What is Sheehan syndrome?

"Postpartum pituitary infarction due to hypotension from hemorrhage."

When should menstruation normally resume postpartum?

"Within 6 months."

How long can amenorrhea persist in Sheehan syndrome?

"1-2 years or longer."

What is Simmonds disease?

"Hypotension unrelated to pregnancy causing pituitary damage and amenorrhea."

What percentage of secondary amenorrhea cases are due to ovarian causes?

"12%."

What hormonal pattern is seen in ovarian causes?

"Hypoestrogenism."

What conditions can cause premature ovarian failure?

"Autoimmune disease. radiation. chemotherapy. ovarian sclerosis."

What is the age cut-off for diagnosing premature ovarian failure?

"Before 40 years old."

What is the best management for ovarian cysts causing amenorrhea?

"Cystectomy."

Why is oophorectomy avoided when managing ovarian cysts?

"To preserve estrogen production and prevent surgical menopause."

What is surgical menopause?

"Removal of both ovaries leading to estrogen deficiency and cessation of menstruation."

What percentage of secondary amenorrhea cases are due to uterine causes?

"7%."

What uterine condition commonly causes amenorrhea?

"Intrauterine adhesions (Asherman's syndrome)."

What procedures increase the risk for intrauterine adhesions?

"Post-abortal curettage. D&C. myomectomy. cesarean delivery."

How does endometritis cause uterine adhesions?

"Infection leads to fibrosis and scarring."

What infections can cause endometritis?

"Sexually transmitted infections like chlamydia."

What uterine condition follows missed abortion or endometrial TB?

"Adhesions leading to amenorrhea."

In uterine causes, are the problems anatomical or hormonal?

"Anatomical."

What is the difference between post-abortive curettage and D&C in non-pregnant women?

"Post-abortive curettage removes retained products. D&C investigates abnormal bleeding."

What is the typical duration of normal menstruation?

"3-8 days."

What is the effect of severe endometritis?

"Scarring of the endometrium leading to amenorrhea."

What are the two main steps in the initial diagnostic evaluation of secondary amenorrhea?

"History and physical examination then ancillary diagnostic tests."

What are the initial ancillary diagnostic tests for secondary amenorrhea?

"CBC. Urinalysis. TSH assay. Serum E2. Progesterone challenge test. Endometrial imaging via TVS. Serum FSH. Prolactin."

Why is a pregnancy test not included in the diagnostic workup for secondary amenorrhea?

"Pregnancy should have already been ruled out before starting the workup."

What does an estrogen (E2) level above 30 to 40 pg/mL suggest?

"Possible PCOS or hypothalamic pituitary dysfunction."

What diagnosis is suggested if E2 is normal and PCO is seen on ultrasound?

"Polycystic ovary syndrome PCOS."

What diagnosis is suggested if E2 is normal but no PCO is seen and there is history of stress. drug ingestion. weight loss. or exercise?

"Hypothalamic pituitary dysfunction."

What diagnosis is suggested if E2 is low and FSH is low?

"CNS lesion or hypothalamic pituitary failure."

What diagnosis is suggested if E2 is low and FSH is high?

"Primary ovarian failure."

What additional tests are done if CNS lesion or HP failure is suspected?

"CT scan or MRI."

What autoimmune markers can be checked in premature ovarian failure?

"Antithyroid and antinuclear antibodies."

What are the primary hormones tested when evaluating secondary amenorrhea?

"TSH. FSH. Prolactin. Estradiol."

What is the purpose of a progesterone challenge test?

"To check if the endometrium will respond and induce bleeding."

If TSH is elevated what is the likely cause of secondary amenorrhea?

"Hypothyroidism."

If TSH is low is hypothyroidism the cause of amenorrhea?

"No."

If TSH is normal is the thyroid the cause of amenorrhea?

"No."

If prolactin is above 100 ng/mL what is the diagnosis?

"Hyperprolactinemia."

What is the treatment for hyperprolactinemia?

"Bromocriptine."

If prolactin is normal what hormone should be checked next?

"Estradiol E2."

What does a normal estrogen level suggest in secondary amenorrhea?

"Ovarian function is likely normal."

What is the next step if estrogen is normal and PCO is seen on ultrasound?

"Do a progesterone challenge test."

What is the expected response to progesterone challenge in PCOS?

"Onset of menstruation."

What are the three diagnostic criteria for PCOS according to 2003 ESHRE ASRM?

"Oligo or anovulation. Clinical or biochemical signs of hyperandrogenism. Polycystic ovaries on ultrasound."

If E2 is low and PCT does not induce bleeding where could the problem be?

"Hypothalamus or pituitary."

If both estrogen and FSH are low what is the diagnosis?

"Hypothalamic pituitary dysfunction."

If estrogen is low but FSH is high what is the diagnosis?

"Premature ovarian failure."

What is the sequence of hormone production in the HPO axis?

"Hypothalamus produces GnRH. Pituitary produces LH and FSH. Ovary produces estrogen."

If estrogen is normal but progesterone challenge is needed what is the likely cause?

"PCOS."

If estrogen is low where is the primary problem?

"Ovary or central axis."

If estrogen is low and FSH is high where is the problem?

"Ovary."

If estrogen is low and FSH is low where is the problem?

"Hypothalamus or pituitary."

If hypothalamic or pituitary lesions are suspected what imaging should be done?

"CT scan or MRI."

What does management of secondary amenorrhea depend on?

"Diagnosis and desire for pregnancy."

What is the treatment if the cause is hypothyroidism?

"Give thyroid hormone."

What is the treatment if the cause is hyperprolactinemia?

"Give bromocriptine."

What is the treatment if the cause is PCOS?

"Regulate menses with hormonal pills and myo-inositol."

What is the treatment if estrogen is low?

"Give estrogen therapy."

What is the management if the problem is a brain lesion?

"Remove the lesion."

When should nonprolactin-secreting tumors be excised?

"If possible."