Amenorrhea Flashcards
(10 cards)
Define primary amenorrhea.
No menses by age 14 in absence of growth/development of secondary sexual characteristics
No menarche by age 16 with normal growth and secondary sexual characteristics
Define secondary amenorrhea.
- Cessation of menses for 6 months after menarche if regular periods
- Cessation of menses for 3 cycles if irregular periods
How do you diagnose primary amenorrhea?
Primary amenorhea
History- Ask about pubertal development, family history (including mental retardation), neonatal/child health (for congenital adrenal hyperplasia), galactorrhea, headaches, visual field defects, polyuria/polydipsia stress/weight change/exercise, sexual activity, and current medications, including contraceptive method
Exam-
Check height/weight/BMI, look for signs of androgen excess (clitoral enlargement, hirsutism, acne, deepening voice), Tanner staging of breasts and pubic hair growth, presence of galactorrhea, neck webbing suggestive of Turner’s syndrome, bimanual exam to evaluate for presence of uterus, speculum exam to evaluate for cervicovaginal anomalies.
Which investigation would you do for primary amenorrhea and why?
Pelvic USS to determine if uterus is present or absent and to evaluate ovaries
What would be the approach if the uterus is absent?
The evaluation process for patients with amenorrhea involves checking breast and pubic hair growth and serum testosterone levels, with the following outcomes:
Elevated female testosterone level:
No signs of virilisation: Likely Complete Androgen Insensitivity (46,XY), characterized by breast development, sparse/absent pubic and axillary hair, and a blind vaginal pouch.
Signs of virilisation present: Likely 5α-reductase deficiency or Partial Androgen Insensitivity (both 46,XY), characterized by no breast development and possibly a blind vaginal pouch.
Normal female testosterone level:
Likely Uterine Agenesis (46,XX), characterized by normal breast and pubic hair development and a blind vaginal pouch.
What would be the approach if the uterus is present?
- Check UPT to rule out pregnancy.
- Check for signs of androgen excess:
a. If present → Likely PCOS, CAH, or androgen-producing tumor
- >25 follicles/ovary → PCOS
- CT scan → Adrenal tumor
- Testosterone → PCOS/tumor
- AM 17-OH progesterone → CAH
b. If absent → Do progesterone withdrawal test + check FSH, TSH, PRL
i. No withdrawal bleed → Consider:
- Gonadal dysgenesis
- Hypothalamic amenorrhea
- Pituitary/CNS tumor
- Chronic disease
- Workup:
- Trial CHC 1–3 mo (for hypothalamic causes)
- Neuro exam ± brain CT/MRI
- TSH↑ → Hypothyroid
- PRL↑ → Pregnancy, drugs, prolactinoma, etc. → Fasting PRL ± MRI
- FSH:
* ↑FSH → Gonadal dysgenesis/POI/autoimmune → Karyotype/autoAb
* Normal → PCOS or hypothalamic/chronic
* ↓FSH → Hypothalamic, anorexia, chronic
ii. Withdrawal bleed present → Likely PCOS, hypothalamic amenorrhea, or chronic disease
How is the Progesterone withdrawal test carried out?
Give Medroxyprogesterone or Norethindrone 10 mg orally once a day for 5 or 10 days.
Expected result:
If the patient has an estrogen-primed endometrium and is not pregnant, she will have a withdrawal bleed (i.e., period) 3 to 10 days after the last progesterone tablet, if estradiol > 50 pg/mL.
Which 2 conditions should be considered in secondary amenorrhea?
Asherman’s syndrome and Pituitary Insufficiency due to Sheehan’s syndrome
Name 5 drugs that cause hyperprolactinemia.
Common drugs that can increase prolactin levels include benzodiazepines, Haldol, risperidone, metoclopramide, amitriptyline, phenothiazines, reserpine, methyldopa, prostaglandins, cimetidine, and cocaine.
How should amenorrhea due to hypothyroidism be treated?
Start on Levothyroxine 1.6 mcg/kg/day.
Recheck TSH in 6 weeks.
Titrate dose by 12–25 mcg/day as needed,
Recheck TSH every 6 weeks until TSH level is normal.
