Amenore - Polikistik Over -


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Amenore - Polikistik Over -

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Amenore - Polikistik Over -

  1. 1. Amenorrhea/ Polycystic Ovaries FWC
  2. 2. Definitions <ul><li>Secondary Amenorrhea - absence of menses for 6 months </li></ul><ul><li>Primary Amenorrhea- Absence of menses by age 14 with no secondary sexual characteristics or by age 16 with secondary sexual characteristics present </li></ul><ul><li>Oligomenorrhea- More than 35 day cycle length </li></ul>
  3. 3. Normal Menses Requires <ul><li>Outflow tract </li></ul><ul><li>Endometrium </li></ul><ul><li>Hormones estrogen and progesterone from the ovary </li></ul><ul><li>LH/FSH (anterior pitiutary) </li></ul><ul><li>GNRH (Hypothalmus) </li></ul><ul><li>Inhibitory and stimulatory functions </li></ul>
  4. 4. Compartment that has the dysfunction <ul><li>Outflow tract (target organs) </li></ul><ul><li>Ovarian disorders </li></ul><ul><li>Disorders of the anterior pituitary </li></ul><ul><li>Disorders of the CNS (hypothalmic) </li></ul>
  5. 5. Evaluation of Amenorrhea <ul><li>H&P- evaluate possible genetic factors, physical problems, growth and development disorders, nutritional status, evidence of CNS disease, and an abnormal reproductive tract </li></ul><ul><li>Careful drug history- thyroid meds, psychotropic meds, hormones, gnrh agonists, Chemotherapy etc. </li></ul>
  6. 6. Evaluation of Amenorrhea <ul><li>Pregnancy test, TSH, Prolactin, and progestational challenge (Medroxyprogesterone acetate 10mgX 7 days) </li></ul><ul><li>The same blood work applies to the evaluation of galactorrhea </li></ul><ul><li>If Prolactin levels elevated then add a coned down view of the sella turcica </li></ul><ul><li>Only a few patients with amenorrhea or galactorrhea will have hypothyroidism but are easily treated </li></ul>
  7. 7. Hypothyroidism <ul><li>The longer the duration of hypothyroidism the higher the polactin levels may be (usually less than 100). </li></ul><ul><li>Thyroid releasing hormone stimulates the release of prolactin </li></ul><ul><li>The pituitary gland can become hypertrophied by the constant stimulation (X-Ray shows enlargement) </li></ul>
  8. 8. Progestational Challenge <ul><li>Assesses the production of estrogen and evaluate the competence of the outlfow tract (Do not use oral contraceptives for this) </li></ul><ul><li>If the progesterone causes a withdrawal bleed and the TSH and prolactin are normal the cause of amenorrhea is anovulation </li></ul>
  9. 9. Treatment of Anovulation <ul><li>Monthly administration of progesterone (10mg MPA or 5mg norethindrone acetate) for 10 days ( usually the first 10 days of the month) </li></ul><ul><li>Oral contraceptives </li></ul><ul><li>Ovulation induction with clomiphene citrate if pregnancy is desired (start with 50mg a day starting cycle day 3-5 for five days) </li></ul>
  10. 10. Why treat anovulation? <ul><li>Decrease risk of endometrial hyperplasia with or with out atypia </li></ul><ul><li>Decrease risk of endometrial cancer </li></ul><ul><li>Anovulation, amenorrhea, or oligomenorrhea are not contraindications to BCP’s </li></ul>
  11. 11. Hyperprolactinemia <ul><li>Elevated prolactin level </li></ul><ul><li>Level of prolactin is not correlated with size of pituitary adenoma (2cm or less is microadenoma) </li></ul><ul><li>Treat microadenomas with Parlodel start with 2.5mg q day or BID or Doestenix 0.25mg twice a week </li></ul><ul><li>Coned down view of sella turcica or CT </li></ul>
  12. 12. Progesterone challenge negative <ul><li>Indicates either outflow tract dysfunction/ obstruction or lack of estrogen stimulation </li></ul><ul><li>Administer estrogen-Premarin 1.25 to 2.5mg a day for 21 days then add provera 10mg a day for the last 5-10 days </li></ul><ul><li>This should induce a withdrawal bleed if the uterus is normal and the outflow tract is normal </li></ul>
  13. 13. Negative progestational challenge <ul><li>If the patient bleeds after priming the uterus with estrogen then the ovaries, pituitary gland, or the the Hypothalmus are cause </li></ul><ul><li>If no bleeding occurs after the estrogen then there is a problem with the uterus(ashermans syndrome or congenital problem) or cervix(stenosis) </li></ul>
  14. 14. Treatment of uterine or cervical abnormality <ul><li>Usually surgery </li></ul><ul><li>Hysteroscopic resection/D&C </li></ul><ul><li>Cervical dilation with insertion of laminaria </li></ul><ul><li>If congenital defect may need uterine surgery to correct or may not be correctable </li></ul>
  15. 15. Positive response to estrogen <ul><li>Either a gonadotropin problem or ovarian problem </li></ul><ul><li>FSH/LH levels </li></ul>
  16. 16. Gonadotropin levels <ul><li>FSH-5-30 normal adults </li></ul><ul><li>FSH-less than 5 Hypogonadotropic state seen in prepubertal girls or in hypothalmic or pituitary dysfunction </li></ul><ul><li>FSH- Greater than 30-Hypergonadotropic state seen in Postmenopausal, premature ovarian failure, and castrate levels </li></ul>
  17. 17. Gonadotropin Levels <ul><li>LH- 5-20 normal levels </li></ul><ul><li>LH-Less than 5 Hypogonadotropic state seen in prepubertal, hypothalmic or pituitary dysfunction </li></ul><ul><li>LH-Greater than 40 Hypergonadotropic state seen with menopause, premature ovarian failure and castration </li></ul>
  18. 18. Gonadotropins <ul><li>Measure both FSH and LH because in the perimenopause FSH levels can be elevated and ovulation can still occur if LH is elevated usually the ovaries are depleted of follicles </li></ul>
  19. 19. Premature Ovarian Failure <ul><li>Can be due to autoimmune disease </li></ul><ul><li>Check antithyroid antibodies </li></ul><ul><li>Can be due to MS, ITP, RA, </li></ul><ul><li>Occasionally mense return with corticosteroid treatment </li></ul><ul><li>Adrenal surveillance may be warranted as ovarian failure can precede adrenal failure </li></ul>
  20. 20. Premature Ovarian Failure <ul><li>If under age 30 must do a Karyotype to rule out mosiacs, Turners syndrome, and X chromosomal deletions </li></ul><ul><li>Calcium, Phosphorus, A.M. Cortisol, Free T4, TSH, Thyroid antibodies, CBC, Sed rate, ANA, RF, Total protein/Albumin ratio </li></ul>
  21. 21. Polycystic Ovarian Syndrome <ul><li>Wide range of presentation </li></ul><ul><li>Menstral irregularities/Anovulation </li></ul><ul><li>Hirsuitism </li></ul><ul><li>Infertility </li></ul><ul><li>Insulin resistance/Hyperinulinemia </li></ul><ul><li>Obesity </li></ul>
  22. 22. PCO <ul><li>A state of persistent anovulation </li></ul><ul><li>Many causes of anovulation so many causes of PCO </li></ul><ul><li>Elevated circulating levels of testosterone, androstenedione, DHEAS, DHA, 17 hydroxyprogesterone and estrone </li></ul><ul><li>The ovary secretes normal levels of estradiol </li></ul>
  23. 23. PCO <ul><li>The ovary produces androstenedione(50%) which can be converted to estrogen or testosterone </li></ul><ul><li>The ovary produces 25% of testosterone </li></ul><ul><li>The ovary produces 10% of DHA </li></ul><ul><li>50% of testosterone comes from peripheral conversion of androstenedione </li></ul>
  24. 24. PCO <ul><li>The adrenal gland produces 100% of DHEAS, 90% of DHA, 50% of androstenedione, and about 25% of testosterone </li></ul><ul><li>Stressful events can increase adrenal production of androstenedione which is converted in the peripheral tissue to estrogen </li></ul>
  25. 25. PCO/Obesity <ul><li>High estrogen levels alter FSH secretion </li></ul><ul><li>Decreased sex hormone binding globulin from elevated androgen levels increasing the levels of free testosterone and free estradiol </li></ul><ul><li>Increased insulin levels can stimulate androgen production by the stromal cells of the ovary </li></ul>
  26. 26. PCO <ul><li>50% reduction in Sex Hormone Binding Globulin </li></ul><ul><li>Testosterone decreases SHBG </li></ul><ul><li>Estrogen and Thyroxine increase SHBG </li></ul><ul><li>LH levels are elevated and FSH is low </li></ul>
  27. 27. PCO <ul><li>High LH levels cause increased androgen production in the ovary making local concentrations of androgens elevated thus inhibiting ovulation </li></ul>
  28. 28. PCO <ul><li>Acanthosis Nigricans can be present in these pt because of the elevated insulin levels </li></ul><ul><li>Fasting blood sugar to fasting insulin ratio should be greater than 4.5 in a normal patient anything below that is considered insulin resistant </li></ul>
  29. 29. Ultrasound findings of PCO <ul><li>Multiple follicles around the periphery of the ovary (this is a finding not the cause-25% of normal women can have this fining) </li></ul><ul><li>Ultrasound is not necessary to make the diagnosis </li></ul>
  30. 30. Lab test for PCO <ul><li>Testosterone </li></ul><ul><li>Androstenedione </li></ul><ul><li>DHEAS </li></ul><ul><li>+/- 17OHP </li></ul><ul><li>Prolactin </li></ul><ul><li>TSH </li></ul><ul><li>HCG if needed- </li></ul>
  31. 31. Lab tests for PCO <ul><li>Fasting Blood sugar </li></ul><ul><li>Fasting Insulin level </li></ul><ul><li>LH/FSH </li></ul>
  32. 32. Treatment of PCO in patients not wanting to conceive <ul><li>Weight loss (decreases insulin and androgen levels) </li></ul><ul><li>Glucaphage start with 500mg BID </li></ul><ul><li>Oral contraceptives unless contraindicated </li></ul><ul><li>Spironolactone 100-200mg per day for hirsuitism </li></ul><ul><li>Progesterone if not a candidate for BCP’s </li></ul>
  33. 33. Why treat PCO <ul><li>Decrease risk of endometrial hyperplasia and cancer, possibly decrease risk of breast CA, decrease all sequella that occur with DM </li></ul><ul><li>Patients satisfaction </li></ul>
  34. 34. Treatment of patients that want to conceive <ul><li>Ovulation induction with clomid 50mg X5 days start cycle day 3-5 </li></ul><ul><li>Glucophage 500mg BID </li></ul><ul><li>May need to induce a withdrawal bleed prior to ovulation induction </li></ul>
  35. 35. Review <ul><li>Most amenorrhea is anovulatory in nature </li></ul><ul><li>Birth control pills and progesterones are the mainstay of treatment </li></ul><ul><li>If PCO metformin increases ovulation </li></ul><ul><li>If pregnancy is desired use clomid </li></ul>