Amenorrhea ppt

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Questions and Answers

What defines primary amenorrhea?

Absence of menarche by age 15 (correct)

Menstrual cycles shorter than 24 days

Regular menstrual cycles occurring every 28 days

Absence of menses for over 3 months

Which of the following conditions is classified as ovarian dysfunction causing primary amenorrhea?

Transverse vaginal septum

Turner’s Syndrome (correct)

Anorexia nervosa

Functional hypothalamic amenorrhea

What is considered heavy menstrual bleeding?

Changing pads or tampons once a night

Soaking through one or more tampons every three hours

Needing to wear one pad at a time

Flow with clots the size of a quarter or larger (correct)

Which type of amenorrhea occurs in women who have previously menstruated?

Secondary amenorrhea Signup and view all the answers

Which of the following can be a cause of dysfunctional uterine bleeding (DUB)?

Anovulation Signup and view all the answers

What is the term for menstrual cycles that have intervals greater than 35 days?

Oligomenorrhea Signup and view all the answers

Which of the following scenarios indicates absence of menstruation by the age of 15?

Primary amenorrhea in a teenager Signup and view all the answers

What physiological issue might contribute to functional hypothalamic amenorrhea?

Hormonal imbalances due to chronic stress Signup and view all the answers

What is the pathophysiological abnormality primarily associated with Turner Syndrome?

Chromosomal abnormality Signup and view all the answers

Which hormonal condition is associated with Androgen Insensitivity Syndrome?

Elevated estrogen levels and absence of testosterone receptors Signup and view all the answers

What is the most common structural cause of primary amenorrhea linked to Mullerian anomalies?

Imperforate hymen Signup and view all the answers

In Turner Syndrome, what typically replaces the ovaries?

Fibrous tissue (streak gonads) Signup and view all the answers

What laboratory tests are indicated if a patient presents with primary amenorrhea and an absent uterus?

Karyotype and serum testosterone Signup and view all the answers

Which of the following is a common consequence of functional hypothalamic amenorrhea?

Risk of osteoporosis due to low estrogen Signup and view all the answers

What distinguishes the clinical presentation of Complete Androgen Insensitivity from Turner Syndrome?

Typical Tanner staging for breast growth Signup and view all the answers

Which management is typically indicated for individuals with Turner Syndrome to address estrogen deficiency?

Hormonal replacement therapy Signup and view all the answers

What is the most common cause of secondary amenorrhea?

Pregnancy Signup and view all the answers

Which statement is true regarding the ovarian function in Androgen Insensitivity Syndrome?

Ovaries are not formed due to absence of testosterone receptors Signup and view all the answers

What is a potential cause of primary ovarian insufficiency in women under the age of 40?

Genetic factors Signup and view all the answers

What condition is characterized by scarring of the endometrial lining and is commonly associated with D&C procedures?

Asherman’s Syndrome Signup and view all the answers

Which symptom is NOT typically associated with secondary amenorrhea in cases of the Female Athlete Triad?

Increased energy levels Signup and view all the answers

Dropping from very high to very low estrogen levels is likely to occur in which of the following conditions?

Primary ovarian insufficiency Signup and view all the answers

Which of the following aspects is NOT part of the hypothalamus-pituitary-ovarian axis affected by stressors?

Galactorrhea Signup and view all the answers

Which of the following is a uterine etiology that can cause secondary amenorrhea?

Asherman’s Syndrome Signup and view all the answers

Identify two common ovarian etiologies associated with secondary amenorrhea.

PCOS and Primary Ovarian Insufficiency Signup and view all the answers

Which laboratory test would you specifically order to assess for primary ovarian insufficiency?

FSH Signup and view all the answers

Which medication is known to cause secondary amenorrhea by leading to hyperprolactinemia?

Antipsychotic drugs Signup and view all the answers

What outcome is expected if a patient responds positively to a Progestin Withdrawal Test?

Estrogen is present and uterine lining is functioning Signup and view all the answers

Which of the following is a well-established pituitary etiology that contributes to secondary amenorrhea?

Prolactinoma Signup and view all the answers

What would be the result of a Progestin Withdrawal Test if the endometrium is not growing due to lack of estrogen?

Endometrium is scarred due to Asherman’s syndrome Signup and view all the answers

Which of these medications alters thyroid function potentially leading to secondary amenorrhea?

Thyroid medications Signup and view all the answers

Study Notes

Defining “Abnormal” Menstrual Bleeding

Primary amenorrhea: lack of menstruation by age 15
Secondary amenorrhea: absence of menstruation for 3 months or more in a woman who previously had regular cycles
Oligomenorrhea: Cycles that are greater than 35 days apart
Polymenorrhea: Cycles that are less than 24 days apart
Menorrhagia: Blood loss greater than 80 ml (~3 ounces)
Abnormal Uterine Bleeding: Any uterine bleeding that strays from the normal ranges
Dysfunctional uterine bleeding (DUB): Abnormal bleeding not caused by an anatomical abnormality; usually caused by anovulation

Common Causes of Primary Amenorrhea

Gonadal Dysgenesis/ Turner’s Syndrome (43%):
- Ovarian cause due to lack of normal ovarian tissue
- Absence of endometrial stimulation is the direct reason for amenorrhea, leading to no lining to shed
- Ovaries are replaced by fibrous tissue (“streak gonads”)
- Little or no estrogen production
- Elevated FSH levels similar to menopause
- Normal uterus and vagina are typically present
- Pregnancy is possible with a donated egg and IVF
Mullerian Dysgenesis/ Agenesis incl.R-K-H Syndrome (15%):
- Uterine/Vaginal cause due to absent or malformed uterus and fallopian tubes
- Often presents with cyclic pelvic pain and possible pelvic mass if functional endometrium is still present
- A pelvic ultrasound or MRI can confirm the diagnosis
Physiologic Delay (Constitutional delay)(14%):
- Hypothalamic cause due to a delay in the onset of puberty
Polycystic Ovarian Syndrome (7%):
- Ovarian cause due to hormonal imbalances and multiple cysts on the ovaries
Functional hypothalamic amenorrhea (2-3%):
- Hypothalamic cause due to inadequate stimulation or suppression of the hypothalamic-pituitary-ovarian (HPO) axis
- Often associated with anorexia nervosa, low body weight, low body fat, excessive exercise, emotional stress, and acute severe illness
- Can lead to a significant risk of osteoporosis due to low estrogen levels
Outflow tract obstruction incl.transverse vaginal septum:
- Uterine/Vaginal cause due to a physical blockage preventing menstrual flow
Hypopituitarism of any cause:
- Pituitary cause due to dysfunction of the pituitary gland
Hypogonadotropic hypogonadism (Kallman syndrome):
- Hypothalamic cause due to genetic disorders affecting the development of the hypothalamus

Androgen Insensitivity Syndrome (AIS)

Occurs when an XY fetus has testes and produces testosterone, but lacks testosterone receptors
Testes still produce MIS preventing the development of Mullerian structures (uterus, tubes, upper vagina)
Testes still produce testosterone, some of which is aromatized into estrogens
Absence of testosterone receptors results in typical female-bodied external genitalia, breast development, and a partial vagina
Due to the aromatization of testosterone into estrogens, estrogen receptors bind to these estrogens, leading to breast tissue and other secondary sexual characteristics (labial growth and hair)

Transverse Vaginal Septum and Imperforate Hymen

Transverse vaginal septum:
- Occurs due to abnormal apoptosis of the vaginal plate
- Can occur at multiple levels, often involving both Mullerian and Urogenital tissues
- Can lead to the buildup of old menstrual blood that has no external site of exit (hematocolpos)
** Imperforate Hymen**:
- Absence of appropriate apoptosis of the cells of the hymenal membrane
- More common than Mullerian abnormalities
- Can be partial or complete

Primary Amenorrhea Diagnosis Labs

If uterus and vagina are present:
- B-HCG, FSH, karyotype if FSH is elevated, TSH, prolactin
If the uterus is absent:
- Karyotype, serum testosterone

The most common cause of secondary amenorrhea is PREGNANCY

Secondary Amenorrhea Etiologies

Uterine (5%):
- Asherman's Syndrome: Uterine adhesions or scarring.
- Iatrogenic: Due to endometrial ablation (procedure to stop heavy bleeding).

Ovarian Etiologies (40%)

Polycystic Ovarian Syndrome (PCOS): Irregular periods, anovulation, fertility issues, increased ovarian cancer risk.
Primary Ovarian Insufficiency: Depletion of functional oocytes before age 40.
- Causes: Genetic, autoimmune, chemo/radiation, unknown.
- Test with FSH.
- Increased risk of osteoporosis.

Pituitary Etiologies (15%)

Prolactinoma: Benign tumor that produces prolactin.
Other Pituitary Tumors: Can affect hormone production.

Hypothalamic Etiologies (40%)

Hypothalamic Amenorrhea: Stress, weight loss, exercise can disrupt the hypothalamus's control over the menstrual cycle.
Infiltrative Lesions: Damage to the hypothalamus by disease.
Chronic Disease: Can affect hormone regulation.

Medications Causing Secondary Amenorrhea

Hormonal Contraceptives and Medicated IUDs: Thin endometrium and disrupt hormonal cycling.
Thyroid Medications and Lithium: Alter thyroid function, affecting hormone balance.
Metoclopramide (Reglan) & Antipsychotic Drugs (e.g., Thorazine, Haldol, Risperdal): Cause hyperprolactinemia.

Secondary Amenorrhea Workup

Initial Lab: HCG (Human Chorionic Gonadotropin).
Thyroid and Pituitary Assessment: TSH (thyroid stimulating hormone) and prolactin.
Primary Ovarian Insufficiency Assessment: FSH (follicle-stimulating hormone).
PCOS Assessment: Testosterone, 17-OHP (androgen effects), and Serum Progesterone (ovulation).
Uterine and Ovarian Function Assessment: Progesterone withdrawal test.

Progestin Withdrawal Test

Step 1: Give Progestin daily for several days, then stop.
- Positive: A period occurs, indicating estrogen is present and the uterine lining is functional.
- Negative: No period, indicating either:
  - Scarring of endometrium (Asherman's Syndrome).
  - Lack of estrogen to stimulate the endometrium (POF).
Step 2: If negative in step 1:
- Supplement with estrogen for a few weeks and repeat progestin withdrawal test.
- Positive: Endometrium is fine but ovaries are not producing estrogen (likely POF).
- Negative: Endometrium is scarred (likely Asherman's Syndrome).

Primary Ovarian Insufficiency (Premature Menopause)

Causes: Genetic, autoimmune, cancer treatment, unknown.
Test: FSH.
Management: Osteoporosis management and testing for other autoimmune conditions.
Contraception: Necessary unless pregnancy desired, as ovaries may regain function.

Asherman's Syndrome

Causes: Acquired scarring of the endometrial lining due to prior surgery or infection.
Risk Factors: D&C after advanced miscarriage or term delivery, with rapid estrogen level drop.
Presentation: Difficulty getting pregnant.

Secondary Amenorrhea - The Female Athlete Triad

Characteristics:
- Low Energy Availability: With or without disordered eating.
- Menstrual Dysfunction.
- Low Bone density.
Pathogenesis: Energy deficiency leads to impaired bone health and mental dysfunction.
Management: High index of suspicion, pre-participation screening.

Secondary Amenorrhea History Questions

Stressors: Hypothalamus.
Weight Loss/Changes in Diet: Hypothalamus.
Exercise: Hypothalamus.
Acne, Hirsutism, Voice Changes: Ovaries, PCOS.
Headaches, Vision Changes: Pituitary.
Hot Flashes, Vaginal Dryness, Disturbed Sleep: Ovaries, Primary Ovarian Insufficiency.
Galactorrhea: Pituitary.
History of Uterine Surgery or Infection: Uterine.
Medications: Review any medications for potential hormonal effects.

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Description

This quiz explores the definitions and causes of abnormal menstrual bleeding, including primary and secondary amenorrhea, oligomenorrhea, and menorrhagia. Gain insights into the various types and underlying issues affecting menstrual health.