amenorrhea.ppt

amenorrhoea

1. Click to add text
Amenorrhea

2. Definitions and Epidemiology
Primary amenorrhea
–absence of normal menstruation in a
patient without previously established
cycles
–no periods by age 14 with no secondary
sex changes
–absence of menarche by age 16
regardless of secondary sex changes
–no periods by 2 years after the start of
secondary sex changes
–< 0.1-2.5% of reproductive age women

3. Definitions and Epidemiology
Secondary amenorrhea
–absence of menses for 3 cycle lengths in
oligomenorrhea, or for 6 months after
having regular menses
–1-5% of the population

4. Clinical Presentation
History
–milestones, development, diet, exercise, wt
change
–drug use (antipsychotics, hormones, narcs, anti-
HTN’s
–systemic disease (hypothyroidism, adrenal insuff.,
GH excess)
–past surgery, glactorrhea, hirsutism
–gyn/ob hx (hemorrhage, D&C, infection)
–genetic history

5. Clinical Presentation
Physical
–ht, wt, vitals
–signs of thyroid dz (protuberant eyes, enlarged
gland, puffy face, heat/cold intolerance)
–secondary sex changes
•thelarche (breast devel): avg. age 10.8 yrs;
indication of estrogen exposure
•adrenarche (pubic/axillary hair development):
avg. age 11 and indicates ovarian and adrenal
androgen production and end organ response
–decreased breast size or vaginal dryness
indication decreasing estrogen exposure (or
increasing androgens)
–presence of a cervix (confirms presence of a
uterus)

6. Etiology
Primary amenorrhea
–gonadal failure is most common cause
–uterovaginal agenesis is second most
common cause
Anorexia nervosa is the most common cause of
amenorrhea overall in teens
Secondary amenorrhea
–pregnancy is most common cause
–49-62% have hypothalamic disorders,
including PCO
–7-16% have pituitary disorders
–10% have ovarian disorders
–7% have Ashermans syndrome

7. DDx and Tx in Primary Amenorrhea:
2nd sex changes absent, cervix present
–50% of patients
–primary ovarian disorders
•Turner’s sd; pure gonadal dysgenesis; chromosomal
mosaics; structural abnormalities of the sex
chromosomes
–CNS, hypothalamic, or pituitary failure
•anatomic lesions; Kallman’s sd; anorexia nervosa or
bulimia; exercise induced; constitutional delay;
hyperprolactinemia
–Endocrinopathies (17 alpha hydroxylase
deficiency)

8. DDx and Tx in Primary Amenorrhea:
2nd sex changes absent, cervix present
Work up includes measuring FSH
–if >40 and less than 30 yrs
•do karyotype
–if Y chromosome exists, excise gonads
–if 46XX, r/o 17a-hydroxylase deficiency
•replace estrogen/progesterone, and if 17a-
hydroxylase deficient, replace steroids also
–if low, then a problem with the CNS, hypothalamic, or
pituitary exists
•measure serum prolactin
•consider CT
•no karyotype needed (all are 46XX)
•replace estrogen/progesterone
•consider GH
•fertility requires assistance

9. DDx and Tx in Primary Amenorrhea:
2nd sex changes present, cervix present
May present w/ primary or secondary amenorrhea
CNS or hypothalamic causes
•anatomic lesions (can appear with or without secondary
sex changes
•drugs affecting prolactin levels (stimulators and
inhibitors)
•stress, exercise, and eating disorders
•PCOS
•functional hypothalamic amenorrhea
Pituitary causes
Ovarian causes (elevated gonadotropin and low estrogen)
–radiation and chemo; premature ovarian failure; ovarian
resistance sd; PCOS; infection; vascular injury; cystetomy
Uterine causes (only group in this category who will show
normal endocrine findings

10. DDx and Tx in Primary Amenorrhea:
2nd sex changes present, cervix present
Work up
–r/o pregnancy
–r/o hyperprolactinemia
–if prolactin level elevated, evaluate thyroid
function
–measure FSH and LH
–measure 17a-hydroxylase progesterone and
progesterone
–do a progesterone challenge test
Treatment
–dopamine agonist therapy
–combination OCP therapy
–estrogen replacement

11. DDx and Tx in Primary Amenorrhea:
2nd sex changes present, cervix absent
androgen insensitivity (testicular feminization sd)
mullerian anomalies or agenesis
work up
–karyotype and testosterone level
–if nl body hair and female testosterone levels,
uterine agenesis is present and pt is sterile
•karyotype is to r/o male pseudohermaphrodism
•IVP should be done to r/o renal anomalies
•may need reconstructive surgery
–pts with AI are usually raised as girls (XY)
•remove gonads after breast development and
epiphyseal closure
•replace estrogen

12. DDx and Tx in Primary Amenorrhea:
2nd sex changes absent, cervix absent
<1% of primary amenorrhea
–pts are 46XY, but have abnormality in
testosterone synthesis
–mullerian inhibiting factor causes internal female
organs to regress
DDx
–17a-hydroxylase deficiency
–17,20 desmolase deficiency
–agonadism
Lab: elevated gonadotropins and low-normal
female testosterone levels
Tx: remove testicles and replace estrogen; no
need for progesterone

13. Secondary Amenorrhea
Differential
–similar to that of primary amenorrhea with cervix and
secondary sex changes present
Work up
–r/o pregnancy
–r/o hyperprolactinemia
–if prolactin level elevated, evaluate thyroid function
–measure FSH and LH
–measure 17a-hydroxylase progesterone and
progesterone
–do a progesterone challenge test
Treatment
–dopamine agonist therapy
–combination OCP therapy
–estrogen replacement