Amenorrhea

2,505 views

Published on

Amenorrhea

  1. 1. Amenorrhea www.freelivedoctor.com
  2. 2. Definitions and Epidemiology <ul><li>Primary amenorrhea </li></ul><ul><ul><li>absence of normal menstruation in a patient without previously established cycles </li></ul></ul><ul><ul><li>no periods by age 14 with no secondary sex changes </li></ul></ul><ul><ul><li>absence of menarche by age 16 regardless of secondary sex changes </li></ul></ul><ul><ul><li>no periods by 2 years after the start of secondary sex changes </li></ul></ul><ul><ul><li>< 0.1-2.5% of reproductive age women </li></ul></ul>www.freelivedoctor.com
  3. 3. Definitions and Epidemiology <ul><li>Secondary amenorrhea </li></ul><ul><ul><li>absence of menses for 3 cycle lengths in oligomenorrhea, or for 6 months after having regular menses </li></ul></ul><ul><ul><li>1-5% of the population </li></ul></ul>www.freelivedoctor.com
  4. 4. Clinical Presentation <ul><li>History </li></ul><ul><ul><li>milestones, development, diet, exercise, wt change </li></ul></ul><ul><ul><li>drug use (antipsychotics, hormones, narcs, anti-HTN’s </li></ul></ul><ul><ul><li>systemic disease (hypothyroidism, adrenal insuff., GH excess) </li></ul></ul><ul><ul><li>past surgery, glactorrhea, hirsutism </li></ul></ul><ul><ul><li>gyn/ob hx (hemorrhage, D&C, infection) </li></ul></ul><ul><ul><li>genetic history </li></ul></ul>www.freelivedoctor.com
  5. 5. Clinical Presentation <ul><li>Physical </li></ul><ul><ul><li>ht, wt, vitals </li></ul></ul><ul><ul><li>signs of thyroid dz (protuberant eyes, enlarged gland, puffy face, heat/cold intolerance) </li></ul></ul><ul><ul><li>secondary sex changes </li></ul></ul><ul><ul><ul><li>thelarche (breast devel): avg. age 10.8 yrs; indication of estrogen exposure </li></ul></ul></ul><ul><ul><ul><li>adrenarche (pubic/axillary hair development): avg. age 11 and indicates ovarian and adrenal androgen production and end organ response </li></ul></ul></ul><ul><ul><li>decreased breast size or vaginal dryness indication decreasing estrogen exposure (or increasing androgens) </li></ul></ul><ul><ul><li>presence of a cervix (confirms presence of a uterus) </li></ul></ul>www.freelivedoctor.com
  6. 6. Etiology <ul><li>Primary amenorrhea </li></ul><ul><ul><li>gonadal failure is most common cause </li></ul></ul><ul><ul><li>uterovaginal agenesis is second most common cause </li></ul></ul><ul><li>Anorexia nervosa is the most common cause of amenorrhea overall in teens </li></ul><ul><li>Secondary amenorrhea </li></ul><ul><ul><li>pregnancy is most common cause </li></ul></ul><ul><ul><li>49-62% have hypothalamic disorders, including PCO </li></ul></ul><ul><ul><li>7-16% have pituitary disorders </li></ul></ul><ul><ul><li>10% have ovarian disorders </li></ul></ul><ul><ul><li>7% have Ashermans syndrome </li></ul></ul>www.freelivedoctor.com
  7. 7. DDx and Tx in Primary Amenorrhea: 2nd sex changes absent , cervix present <ul><ul><li>50% of patients </li></ul></ul><ul><ul><li>primary ovarian disorders </li></ul></ul><ul><ul><ul><li>Turner’s sd; pure gonadal dysgenesis; chromosomal mosaics; structural abnormalities of the sex chromosomes </li></ul></ul></ul><ul><ul><li>CNS, hypothalamic, or pituitary failure </li></ul></ul><ul><ul><ul><li>anatomic lesions; Kallman’s sd; anorexia nervosa or bulimia; exercise induced; constitutional delay; hyperprolactinemia </li></ul></ul></ul><ul><ul><li>Endocrinopathies (17 alpha hydroxylase deficiency) </li></ul></ul>www.freelivedoctor.com
  8. 8. DDx and Tx in Primary Amenorrhea: 2nd sex changes absent , cervix present <ul><li>Work up includes measuring FSH </li></ul><ul><ul><li>if >40 and less than 30y/o </li></ul></ul><ul><ul><ul><li>do karyotype </li></ul></ul></ul><ul><ul><ul><ul><li>if Y chromosome exists, excise gonads </li></ul></ul></ul></ul><ul><ul><ul><ul><li>if 46XX, r/o 17a-hydroxylase deficiency </li></ul></ul></ul></ul><ul><ul><ul><li>replace estrogen/progesterone, and if 17a-hydroxylase deficient, replace steroids also </li></ul></ul></ul>www.freelivedoctor.com
  9. 9. DDx and Tx in Primary Amenorrhea: 2nd sex changes absent , cervix present <ul><ul><li>if low, then a problem with the CNS, hypothalamic, or pituitary exists </li></ul></ul><ul><ul><ul><li>measure serum prolactin </li></ul></ul></ul><ul><ul><ul><li>consider CT </li></ul></ul></ul><ul><ul><ul><li>no karyotype needed (all are 46XX) </li></ul></ul></ul><ul><ul><ul><li>replace estrogen/progesterone </li></ul></ul></ul><ul><ul><ul><li>consider GH </li></ul></ul></ul><ul><ul><ul><li>fertility requires assistance </li></ul></ul></ul>www.freelivedoctor.com
  10. 10. DDx and Tx in Primary Amenorrhea: 2nd sex changes present , cervix present <ul><li>May present w/ primary or secondary amenorrhea </li></ul><ul><li>1/3 of pts with primary amenorrhea have breasts and a uterus, 1/4 of these have hyperprolactinemia </li></ul><ul><li>CNS or hypothalamic causes </li></ul><ul><ul><ul><li>anatomic lesions (can appear with or without secondary sex changes </li></ul></ul></ul><ul><ul><ul><li>drugs affecting prolactin levels (stimulators and inhibitors) </li></ul></ul></ul><ul><ul><ul><li>stress, exercise, and eating disorders </li></ul></ul></ul><ul><ul><ul><li>PCOS </li></ul></ul></ul><ul><ul><ul><li>functional hypothalamic amenorrhea </li></ul></ul></ul>www.freelivedoctor.com
  11. 11. DDx and Tx in Primary Amenorrhea: 2nd sex changes present , cervix present <ul><li>Pituitary causes </li></ul><ul><li>Ovarian causes (elevated gonadotropin and low estrogen) </li></ul><ul><ul><li>radiation and chemo; premature ovarian failure; ovarian resistance sd; PCOS; infection; vascular injury; cystetomy </li></ul></ul><ul><li>Uterine causes (only group in this category who will show normal endocrine findings </li></ul>www.freelivedoctor.com
  12. 12. DDx and Tx in Primary Amenorrhea: 2nd sex changes present , cervix present <ul><li>Work up </li></ul><ul><ul><li>r/o pregnancy </li></ul></ul><ul><ul><li>r/o hyperprolactinemia </li></ul></ul><ul><ul><li>if prolactin level elevated, evaluate thyroid function </li></ul></ul><ul><ul><li>measure FSH and LH </li></ul></ul><ul><ul><li>measure 17a-hydroxylase progesterone and progesterone </li></ul></ul><ul><ul><li>do a progesterone challenge test </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>dopamine agonist therapy </li></ul></ul><ul><ul><li>combination OCP therapy </li></ul></ul><ul><ul><li>estrogen replacement </li></ul></ul>www.freelivedoctor.com
  13. 13. DDx and Tx in Primary Amenorrhea: 2nd sex changes present , cervix absent <ul><li>androgen insensitivity (testicular feminization sd) </li></ul><ul><li>mullerian anomalies or agenesis </li></ul><ul><li>work up </li></ul><ul><ul><li>karyotype and testosterone level </li></ul></ul><ul><ul><li>if nl body hair and female testosterone levels, uterine agenesis is present and pt is sterile </li></ul></ul><ul><ul><ul><li>karyotype is to r/o male pseudohermaphrodism </li></ul></ul></ul><ul><ul><ul><li>IVP should be done to r/o renal anomalies </li></ul></ul></ul><ul><ul><ul><li>may need reconstructive surgery </li></ul></ul></ul><ul><ul><li>pts with AI are usually raised as girls (XY) </li></ul></ul><ul><ul><ul><li>remove gonads after breast development and epiphyseal closure </li></ul></ul></ul><ul><ul><ul><li>replace estrogen </li></ul></ul></ul>www.freelivedoctor.com
  14. 14. DDx and Tx in Primary Amenorrhea: 2nd sex changes present , cervix absent <ul><ul><li>if nl body hair and female testosterone levels, uterine agenesis is present and pt is sterile </li></ul></ul><ul><ul><ul><li>karyotype is to r/o male pseudohermaphrodism </li></ul></ul></ul><ul><ul><ul><li>IVP should be done to r/o renal anomalies </li></ul></ul></ul><ul><ul><ul><li>may need reconstructive surgery </li></ul></ul></ul><ul><ul><li>pts with AI are usually raised as girls (XY) </li></ul></ul><ul><ul><ul><li>remove gonads after breast development and epiphyseal closure </li></ul></ul></ul><ul><ul><ul><li>replace estr </li></ul></ul></ul>www.freelivedoctor.com
  15. 15. DDx and Tx in Primary Amenorrhea: 2nd sex changes absent , cervix absent <ul><li><1% of primary amenorrhea </li></ul><ul><ul><li>pts are 46XY, but have abnormality in testosterone synthesis </li></ul></ul><ul><ul><li>mullerian inhibiting factor causes internal female organs to regress </li></ul></ul><ul><li>DDx </li></ul><ul><ul><li>17a-hydroxylase deficiency </li></ul></ul><ul><ul><li>17,20 desmolase deficiency </li></ul></ul><ul><ul><li>agonadism </li></ul></ul>www.freelivedoctor.com
  16. 16. DDx and Tx in Primary Amenorrhea: 2nd sex changes absent , cervix absent <ul><li>Lab: elevated gonadotropins and low-normal female testosterone levels </li></ul><ul><li>Tx: remove testicles and replace estrogen; no need for progesterone </li></ul>www.freelivedoctor.com
  17. 17. Secondary Amenorrhea <ul><li>Differential </li></ul><ul><ul><li>similar to that of primary amenorrhea with cervix and secondary sex changes present </li></ul></ul><ul><li>Work up </li></ul><ul><ul><li>r/o pregnancy </li></ul></ul><ul><ul><li>r/o hyperprolactinemia </li></ul></ul><ul><ul><li>if prolactin level elevated, evaluate thyroid function </li></ul></ul><ul><ul><li>measure FSH and LH </li></ul></ul><ul><ul><li>measure 17a-hydroxylase progesterone and progesterone </li></ul></ul><ul><ul><li>do a progesterone challenge test </li></ul></ul>www.freelivedoctor.com
  18. 18. Secondary Amenorrhea <ul><li>Treatment </li></ul><ul><ul><li>dopamine agonist therapy </li></ul></ul><ul><ul><li>combination OCP therapy </li></ul></ul><ul><ul><li>estrogen replacement </li></ul></ul>www.freelivedoctor.com

×