Amenorrhea Flashcards
(28 cards)
A 16 yo girl is brought to you by her worried parents because she has never had a menstrual period. She denies any vaginal spotting, sexual activity, or cyclical pain. A pregnancy test is negative.
Physical examination of the patient demonstrates Tanner V development of breasts and of pubic and axillary hair. There is no evidence of vaginal agenesis or imperforate hymen. A pelvic ultrasound is unremarkable. Lab data reveal no abnormalities. You diagnose the patient with hypothalamic-pituitary-adrenal-ovarian axis immaturity, and recommend she return in 3-6 months if she has not yet menstruated.
definition and etiologies
-No menses by 15yo, OR no 2ndary sex characteristics by 13yo
-2.5% of all pts
-MC etiology- Hypothalamic-pituitary-adrenal-ovarian axis immaturity
-Local etiologies:
-Imperforate hymen
-Vaginal agenesis
-Androgen insensitivity
-Ovarian etiologies:
-Primary ovarian insufficiency due to:
-Iatrogenesis- Chemo, Radiation
-Illness- Viruses (mumps, varicella), Malaria, TB, Autoimmune
-Genetic etiologies- Turner syndrome, Fragile X syndrome
-Hypogonadotropic hypogonadism- Kallman’s syndrome
-Sheehan’s syndrome- Pituitary dysfunction from surgery or radiation therapy
-Hypothalamic amenorrhea- Anorexia nervosa, Excessive exercise
imperforate hymen
-Vaginal vault is present, but the vaginal introitus is not patent
-Treat with hymenotomy (an outpatient procedure)
hematocolpos due to imperforate hymen
vaginal agenesis
-no vaginal vault present
-due to a mullerian tract anomaly
-may affect formation of cervix and/or uterus, and kidneys
-failure of vaginal vault to form in embryonic life
-1:4000-5000 pts
-often due to mullerian tract anomaly type 1:
-uterus is also absent or is hypoplastic
-transverse vaginal septum
dx and tx of vaginal agenesis
-Dx:
-Absent vaginal introitus and vault on PE
-US is confirmatory- Rudimentary structures may be visible
-May also reveal anomalies of kidneys or ureters
-Tx:
-Creation of neovagina, if desired-
-use of dilators or via neovaginoplasty
-No other tx is necessary if functional ovaries
-Otherwise, treat with hormone therapy
androgen insensitivity syndrome
-genotypically 46,XY
-insensitive to endogenous testosterone
-Due to loss-of-function gene in long arm of X chromosome
-1:20,000 liveborn genotypic males worldwide
-Complete:
-No male genitals develop
-Gonads remain in abdominal cavity or in inguinal region
-Female genitalia develop instead- Vagina is usually shorter than normal
-No female upper genital tract organs develop
-Increased risk of testicular CA
-Primary amenorrhea
-Possible labial swelling or inguinal mass (descended testicle)
-Scanty axillary and pubic hair
-Tall stature
-Partial:
-genitalia -> virilized female or undervirilized male
dx and tx of androgen insensitivity syndrome
-Dx:
-Increased LH
-Increased testosterone
-Increased serum anti-Müllerian hormone
-US- no evidence of uterus, tubes or upper vagina
-46, XY karyotype
-Tx:
-Gonadectomy at 16-18yo due to the risk of gonadal malignancy (5-10%) to permit completion of puberty
-Discussion with parents and/or patient
-Estrogen replacement
-Referral for counseling
-Vaginal lengthening if and when the patient is interested and is old enough to consider benefits
-Sequelae:
-osteoporosis
-issues w/ gender identity
primary amenorrhea work up
secondary amenorrhea
-amenorrhea occurring at some point after menarche
-MC dx is pregnancy
other common dx of secondary amenorrhea
-Menopause
-Premature ovarian insufficiency
-Prolactinoma
-Hyperthyroidism
-Post-pill amenorrhea
-Anorexia nervosa
-Medication effects
-Outlet obstruction
-Polycystic ovarian syndrome
signs and sx of menopause or premature ovarian insufficiency
-amenorrhea
-vasomotor instability
-vulvovaginal atrophy or dyspareunia
->40yo - any age with premature ovarian failure
-no reason to obtain FSH if the pt is >45yo
-FSH >30 is indicative of menopause
tx of menopause/premature ovarian insufficiency
-Menopause:
-No tx needed
-may choose to take HRT if no CI exist
-See text and menopause lecture handout for more details
-Premature ovarian insufficiency:
-Must replace estrogens to prevent:
-Osteoporosis
-Vulvovaginal atrophy
-See text and menopause lecture handout for more details
prolactinoma
-A benign prolactin-secreting tumor of the anterior pituitary
-May be asymptomatic
-May cause:
-Amenorrhea
-Galactorrhea
-Possible visual field cuts due to compression of the optic chiasm
-Infertility (due to amenorrhea)
-Headaches
-Osteopenia or osteoporosis
-Dx:
-Suspect with evidence of hyperprolactinemia
-Avoid breast exam prior to drawing prolactin
-If hyperprolactinemia -> MRI of brain w/ contrast to r/o prolactinoma
-Hyperprolactinemia: prolactin >25 ng/ml
-Tx:
-Microadenoma: <1 cm on MRI
-Tx: dopamine agonists
-Bromocriptine
-Cabergoline
-Macroadenoma: >1 cm on MRI
-Requires resection
-Refer to Neurosurgery
-Refer to ophthalmology or neuro-ophthalmology for formal visual field studies
-Consider contraception in patients who do not desire fertility
hyperthyroidism
-low TSH: obtain T4
-high T4: hyperthyroidism
-low T4: pituitary (secondary) hypothyroidism
-treat accordingly or refer to endo
post-pill amenorrhea
-while or after stopping hormonal contraception due to atrophic endometrium
-negative pregnancy test
-Dx- hx and negative UCG
-Tx:
-reassure; no other tx necessary
anorexia nervosa
Amenorrhea is often but not always present due to low body fat and low estrogen stores
medication effect
-Many medications may cause amenorrhea
-Most are hormones
-Estrogens
-Combined estrogens and progestins
-Testosterone
-Other steroid hormones
-Psychiatric medications may also cause amenorrhea
-Changes in secretion of prolactin
outlet obstruction
-hx of cervical surgery may have scarring of endocervical canal or endometrial cavity, impeding flow of menses
-C/O cyclical crampy abdominal pain, breast tenderness, etc. w/o vaginal bleeding
-Attempt passage of instrument into uterine cavity (endometrial bx catheter, etc.)
-Tx:
-cervical dilation after administration of vaginal misoprostol at home
-May be accomplished in office but is painful
Asherman’s syndrome
-Synechiae of the uterus form after uterine instrumentation
-Results in diminished menstrual flow or amenorrhea
-MC occurs after uterine instrumentation following pregnancy
-Dx:
-Hysterosalpingography
-Sonohysterography
-Hysteroscopy
-Tx: hysteroscopic resection
PCOS
-4-12% of all patients
-insulin resistance and high circulating insulin levels
-amenorrhea, hyperandrogenism and may cause menometrorrhagia
-hirsutism and obesity
-No ovulation -> thickened proliferative EM (exposed to estrogen but not to progesterone)
-Eventually, patients will bleed heavily
-Pathophysiology:
-produce relatively more LH than FSH
-Theca cells of ovary produce more androgens than estrogens
-lower FSH levels make it difficult for androgens to aromatize to estrogen
-Anovulation results
PCOS sx
-hirsutism (NOT virilization)
-obesity
-acanthosis nigricans
-PE:
-Usually overweight or obese
-Obtain waist circumference (significant if >34”)
-hyperandrogenism
-Acne
-Acanthosis
-Hirsutism
-Dx:
-UCG or bHCG
-Testosterone
-Sex hormone-binding globulin
-TSH
-Prolactin
-FSH/LH
-Random glucose >200 mg/dL, or Hgb A1c
-Imaging:
-US of pelvis- At least 12 follicles 2 mm in diameter or increased ovarian volume
-Evaluate endometrial stripe for possible endometrial hyperplasia
-May demonstrate enlarged ovaries with or w/o the “string of pearls” sign
-≥12 follicles in one or both ovaries
-pic- 13 follicles are seen
-Possible endometrial hyperplasia -EM stripe >1 cm, within normal limits
PCOS diff dx
Androgen secreting tumor of adrenals or ovaries
Exogenous androgens
Cushing’s syndrome or disease
Congenital adrenal hyperplasia
Acromegaly
Hypothalamic amenorrhea
Primary ovarian insufficiency
Thyroid disease
Hyperprolactinemia
PCOS dx criteria
-Rotterdam criteria for dx of PCOS:
-at least 2 of the following:
-Androgen excess
-Ovulatory dysfunction
-Polycystic ovaries seen on US
-(dont need to know) NIH criteria: must have both:
-hyperandrogenism
-oligomenorrhea or amenorrhea
