This document discusses amenorrhea, including definitions, pathophysiology, diagnostic approach, and management. Primary amenorrhea is defined as the absence of menarche by age 16 with pubertal development or by age 14 without pubertal development. Secondary amenorrhea is the absence of menstruation for 3 or more months in a previously menstruating woman. The diagnostic approach involves obtaining a thorough history, physical exam, and ultrasound to rule out pregnancy and cryptomenorrhea before classifying the patient based on endocrine abnormalities. Management aims to restore ovulatory cycles if possible or replace estrogen when deficient, with periodic progestogen to protect the endometrium.
AMENORRHEA
Ludmila Barbakadze
Ivane Javakhishvili Tbilisi State University Assistant Professor Medical Doctor at Archil Khomassuridze Institute of Reproductology ,Tbilisi , Georgia.
AMENORRHEA
Ludmila Barbakadze
Ivane Javakhishvili Tbilisi State University Assistant Professor Medical Doctor at Archil Khomassuridze Institute of Reproductology ,Tbilisi , Georgia.
Abnormal uterine bleeding can occur when a woman experiences a change in menstrual loss, or the degree of loss or vaginal bleeding pattern differs from that experienced by the age-matched general female population
AUB is not restricted to menstrual bleeding that is abnormally heavy, but includes bleeding that is abnormal in TIMING
Abnormal uterine bleeding can occur when a woman experiences a change in menstrual loss, or the degree of loss or vaginal bleeding pattern differs from that experienced by the age-matched general female population
AUB is not restricted to menstrual bleeding that is abnormally heavy, but includes bleeding that is abnormal in TIMING
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
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2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
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This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
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STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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2. Definitions
Primary amenorrhea
Failure of menarche to occur when expected in
relation to the onset of pubertal development.
No menarche by age 16 years with signs of pubertal
development.
No onset of pubertal development by age 14 years.
Secondary amenorrhea
Absence of menstruation for 3 or more months in a
previously menstruating women of reproductive
age.
11. Once Pregnancy and cryptomenorrhea are
excluded:
The patient is a bioassay for
Endocrine abnormalities
Four categories of patients are identified
1. Amenorrhea with absent or poor
secondary sex Characters
2. Amenorrhea with normal 2ry
sex characters
3. Amenorrhea with signs of
androgen excess
4. Amenorrhea with absent uterus
and vagina
12. FSH Serum level
Low / normal High
Hypogonadotropic
hypogonadim
Gonadal
dysgenesis
AMENORRHEA
Absent or poor secondary sex
Characteristics
13. AMENORRHEA
Normal secondary sex
Characteristics
- FSH, LH, Prolactin, TSH
- Provera 10 mg PO daily
x 5 days
+ Bleeding No bleeing
Prolactin
TSH
Further
Work-up
(Endocrinologist)
- Mild hypothalamic
dysfunction
- PCO (LH/FSH) Review FSH result
And history (next slide)
16. Normal FSH, LH; -ve bleeding
history is suggestive of amenorrhea
trumatica
Asherman’s syndrome
• History of pregnancy associated D&C
• Rarely after CS , myomectomy T.B
endometritis, bilharzia
• Diagnosis : HSG or hysterescopy
• Treatment : lysis of adhesions; D&C or
hysterescopy + estrogen therapy ( ? IUCD or
catheter)
Some will prescribe a cycle of Estrogen and
Progesterone challenge Before HSG or Hysterescopy
22. Turner’s syndrome
• Sexual infantilism and short stature.
• Associated abnormalities, webbed
neck,coarctation of the aorta,high-arched
pallate, cubitus valgus, broad shield-like chest
with wildely spaced nipples, low hairline on the
neck, short metacarpal bones and renal
anomalies.
• High FSH and LH levels.
• Bilateral streaked gonads.
• Karyotype - 80 % 45, X0
- 20% mosaic forms (46XX/45X0)
• Treatment: HRT
26. Premature ovarian failure
• Serum estradiol < 50 pg/ml and FSH > 40
IU/ml on repeated occasions
• 10% of secondary amenorrhea
• Few cases reported, where high dose estrogen
or HMG therapy resulted in ovulation
• Sometimes immuno therapy may reverse
autoimmue ovarian failure
• Rarely spont. ovulation (resistant ovaries)
• Treatment: HRT (osteoporosis, atherogenesis)
27. Polycystic ovary syndrome
• The most common cause of chronic anovulation
• Hyperandrogenism ; LH/FSH ratio
• Insulin resitance is a major biochemical feature
( blood insulin level hyperandrogenism )
• Long term risks: Obesity, hirsutism, infertility,
type 2 diabetes, dyslipidemia, cardiovasular
risks, endometrial hyperplassia and cancer
• Treatment depends on the needs of the patient
and preventing long term health problems
28.
29. Hypogonadotrophic
Hypogonadism
• Normal hight
• Normal external and internal
genital organs (infantile)
• Low FSH and LH
• MRI to R/O intra-cranial pathology.
• 30-40% anosmia (kallmann’s
syndrome)
• Sometimes constitutional delay
• Treat according to the cause (HRT),
potentially fertile.
30. Constitutional pubertal delay
• Common cause (20%)
• Under stature and delayed
bone age
( X-ray Wrist joint)
• Positive family history
• Diagnosis by exclusion and
follow up
• Prognosis is good
(late developer)
• No drug therapy is required –
Reassurance (? HRT)
31. Sheehan’s syndrome
• Pituitary inability to secrete gonadotropins
• Pituitary necrosis following massive obstetric
hemorrhage is most common cause in women
• Diagnosis : History and E2,FSH,LH
+ other pituitary deficiencies (MPS test)
• Treatment :
Replacement of deficient hormones
32. Weight-related amenorrhoea
Anorexia Nervosa
• 1o or 2o Amenorrhea is often first sign
• A body mass index (BMI) <17 kg/m²
menstrual irregularity and amenorrhea
• Hypothalamic suppression
• Abnormal body image, intense fear of
weight gain, often strenuous exercise
• Mean age onset 13-14 yrs (range 10-21 yrs)
• Low estradiol risk of osteoporosis
• Bulemics less commonly have amenorrhea
due to fluctuations in body wt, but any
disordered eating pattern (crash diets) can
cause menstrual irregularity.
• Treatment : body wt. (Psychiatrist referral)
33. Exercise-associated
amenorrhoea
• Common in women who participate
in sports (e.g. competitive athletes,
ballet dancers)
• Eating disorders have a higher
prevalence in female athletes than
non-athletes
• Hypothalamic disorder caused by
abnormal gonadotrophin-releasing
hormone pulsatility, resulting in
impaired gonadotrophin levels,
particularly LH, and subsequently
low oestrogen levels
34. Contraception related
amenorrhea
• Post-pill amenorrhea is not an entity
• Depot medroxyprogesterone acetate
Up to 80 % of women will have amenorrhea
after 1 year of use. It is reversible
(oestrogen deficiency)
• A minority of women taking the progestogen-
only pill may have reversible long term
amenorrhoea due to complete suppression of
ovulation
35. • Autosomal recessive trait
• Most common form is due to 21-
hydroxylase deficiency
• Mild forms Closely resemble PCO
• Severe forms show Signs of
severe androgen excess
• High 17-OH-progesterone blood
level
• Treatment : cortisol replacement
and ? Corrective surgery
Late onset congenital adrenal
hyperplasia
36. Cushing’s syndrome
• Clinical suspicion : Hirsutism,
truncal obesity, purple striae, BP
• If Suspicion is high :
dexamethasone suppression test
(1 mg PO 11 pm ) and obtaine
serum cortisol level at 8 am :
< 5 µg/ dl excludes cushing’s
• 24 hours total urine free cortisol
level to confirm diagnosis
• 2 forms ; adrenal tumour or ACTH
hypersecretion (pituitary or ectopic
site)
37. Utero-vaginal Agenisis
Mayer-Rokitansky-Kuster-Hauser syndrome
• 15% of 1ry amenorrhea
• Normal breasts and Sexual Hair
development & Normal looking external
female genitalia
• Normal female range testosterone level
• Absent uterus and upper vagina & Normal
ovaries
• Karyotype 46-XX
• 15-30% renal, skeletal and middle ear
anomalies
• Treatment : STERILE ? Vaginal creation
( Dilatation VS Vaginoplasty)
38. Androgen insensitivity
Testicular feminization syndrome
• X-linked trait
• Absent cytosol receptors
• Normal breasts but no sexual hair
• Normal looking female external
genitalia
• Absent uterus and upper vagina
• Karyotype 46, XY
• Male range testosterone level
• Treatment : gonadectomy after
puberty + HRT
• ? Vaginal creation (dilatation VS
Vaginoplasty )
39. General Principles of management
of Amenorrhea
. Attempts to restore ovulatory function
. If this is not possible HRT (oestrogen and
progesterone) is given to hypo-estrogenic
amenorrheic women (to prevent osteoporosis; atherogenesis)
. Periodic progestogen should be taken by euestrogenic
amenorrheic women (to avoid endometrial cancer)
. If Y chromosome is present gonadectomy is indicated
. Many cases require frequent re-evaluation
40. Hormonal treatment
Primary Amenorrhea with absent
secondary sexual characteristics
To achieve pubertal development
Premarin 5mg D1-D25 + provera 10mg D15-D25
X 3 months; 2.5mg premarin X 3 months and
1.25mg premarin X 3 months
Maintenance therapy
0.625mg premarin + provera OR ready HRT
preparation OR 30µg oral contraceptive pill
41. Summary
• Although the work-up of amenorrhea may seem to be
complex, a carefully conducted physical examination with the
history, and Looking to the patient as a bioassay for
endocrine abnormalities, should permit the clinician to narrow
the diagnostic possibilities and an accurate diagnosis can be
obtained quickly.
• Management aims at restoring ovulatory cycles if possible,
replacing estrogen when deficient and Progestogegen to
protect endometrium from unopposed estrogen.
• Frequent re-evaluation and reassurance of the patient.