Sept5 A2-Oligomenorrhea_Amenorrhea Flashcards
primary amenorrhea def
no prior menses
secondary amenorrhea def
menses stopped
oligomenorrhea def
<9 menstrual cycles per year
causes of oligo, ameno
- H
- P
- O not responding to HP
- uterus not responding to P and E
- distal problem (vagina). like imperforate hymen
some causes of primary amenorrhea
- 45,X and variants (Turner)
- Mullerian agenesis
- Eating disorders, stress, excess exercise
some causes of secondary ameno
- PCOS (chronic anovulation)
- Sheehan syndrome
- high prolactin level
top ddx causes of primary amenorrhea
- primary POF (hypergonadotropic hypogonadism)
- HH (hypogonadotropic hypogonadism)
- PCOS
- hyperPRLemia
- weight related
top ddx causes of secondary amenorrhea
- PCOS
- POF
- hyperPRLemia
- weight
- HH
- exercise induced
top ddx causes of anovulatory infertility
- PCOS
2. POF
POF sx
- amenorrh, oligomeno
- hot flushes
- vaginal dryness
- infertility
POF labs
- high FSH (bc no estradiol and inhibin B)and LH
- low AMH
- low antral follicular count (AFC)
AFC in POF vs PCOS
POF = low PCOS = high
(imp) most common cause of POF caused by gonadal dysgenesis
Turner syndrome
(imp) Turner nuances
- pure turner
- some cells X, some XX
- some cells X, some cells XY
- all females*
(imp) most common PE featurs of Turner
- webbed neck
- low stature
- brown spots nevi
- folds of skin in the neck
how Turner dx
karyotype
Turner problems long term
no P and E made so increased risk of CVD and osteoporosis
turner tx
HRT
mullerian agenesis (MRKH syndrome) def
uterus, cervix and upper part of vagina are absent
PCOS def
increased AFC, lot of follicles, big swollen ovaries, follicles pockets
NO CYSTS
clinical pres of PCOS
- obesity
- insulin resistance (diabetes and acanthosis nigricans)
- hirsuitism
- acne
- oligo, amenor
- lean PCOS (not all sx, still periods, normal weight)
criteria of PCOS dx
2 of the following 3:
- > 12 follicles on one ovary on US
- ameno, oligorrhea
- hyperandrogenism (clinical evidence lab evidence)
main factor in PCOS to act on and why
- reduce obesity
- bc main pathophgy is obesity causing insulin resistance leading to anovulation via diff steps. this anovulation is also caused by high androgen activity
consequences of PCOS
- infertility
- chronic anovulation (unopposed E on endometrium = endometrial hyperplasia, ca)
- long term (metabolic syndrome, glucose intolerance, CVD, obesity, dyslipidemia, OSA, FLD)
PCOS: decreases in weight corresponds with what
higher rate of return to ovulation
PCOS tx if want conception
- oral agents (clomiphene citrate and letrozole) = aromatase inhibitors. low estrogen = higher FSH
- injected gonadotropin (FSH)
- metformin
- IVF
- ovarian drilling, less theca cells, less androgen prod
PCOS tx if don’t want conception
- OCP
- cyclic progesterone
- LNG-IUS
- anti-androgens
- 3 first for endometrial protection*
HH def
englobes diff congenital and acquired diseases of HPO axis leading to hyposecretion of FSH and LH
- estrogen low bc no FSH
- either hypothalamic or pituitary causes
Kallman’s syndrome
non functional GnRH neurons. primary amenorrhea
main causes of hypothalamic HH
-weight loss
-intense exercise
(Kallman’s)
tx of hypothalamic HH
- GnRH pump
- exogenous gonadotropins (FSH, LH) injections
Sheehan’s syndrome (a cause of pituitary HH) def
- pit apoplexy secondary to hypovolemic shock due to postpartum hemorrhage
- pit enlarged in pregnancy so prone to infarction
- get panhypopituitarism
(imp) hyperPRLemia: what happens
- PRL disrupts GnRH pulsatile secretion
- PRL inhibited by dopamine from hypothalamus
hypothalamic hormone that STIMULATES PRL (dopamine inhibits it)
TRH
so hyperPRLemia is seen in hypothyroidism sometimes bc low TH = high TRH
causes of hyperPRLemia
- phgy (pregnancy, lactation, non-REM sleep, stress, nipple stim
- pharmaco (dopamine Rs antag, dopamine depletors, cocaine, opiates, etc.)
- pathological (stalk effect tumor compressing, stopping dopamine from reaching ant pit), prolactinomas, other pit tumors
tx or hypePRLemia
- dopamine agonists
- transsphenoidal (through the nose) hypohysectomy, pituitary radiotherapy
(imp) long term complications of amenorrhea
- endometrial hyperplasia, cancer (in PCOS)
- bone loss and vascular disease (POF)
