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    Amenorrhea PDF

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    Heden Collado
    This document provides information on the evaluation and causes of amenorrhea. It discusses the diagnostic approach which involves considering disorders in four compartments: I) outflow tract, II) ovary, III) anterior pituitary, and IV) hypothalamus. Common causes of primary and secondary amenorrhea are outlined for each compartment, including mullerian anomalies, gonadal dysgenesis, pituitary tumors, and stress-related hypothalamic disorders. Laboratory tests such as FSH, prolactin, and progesterone challenges are recommended to localize the cause.

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    Amenorrhea PDF

    Uploaded by

    Heden Collado
    153 views5 pages
    This document provides information on the evaluation and causes of amenorrhea. It discusses the diagnostic approach which involves considering disorders in four compartments: I) outflow tract, II) ovary, III) anterior pituitary, and IV) hypothalamus. Common causes of primary and secondary amenorrhea are outlined for each compartment, including mullerian anomalies, gonadal dysgenesis, pituitary tumors, and stress-related hypothalamic disorders. Laboratory tests such as FSH, prolactin, and progesterone challenges are recommended to localize the cause.

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    This document provides information on the evaluation and causes of amenorrhea. It discusses the diagnostic approach which involves considering disorders in four compartments: I) outflow tract, II) ovary, III) anterior pituitary, and IV) hypothalamus. Common causes of primary and secondary amenorrhea are outlined for each compartment, including mullerian anomalies, gonadal dysgenesis, pituitary tumors, and stress-related hypothalamic disorders. Laboratory tests such as FSH, prolactin, and progesterone challenges are recommended to localize the cause.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    153 views5 pages

    Amenorrhea PDF

    Uploaded by

    Heden Collado
    This document provides information on the evaluation and causes of amenorrhea. It discusses the diagnostic approach which involves considering disorders in four compartments: I) outflow tract, II) ovary, III) anterior pituitary, and IV) hypothalamus. Common causes of primary and secondary amenorrhea are outlined for each compartment, including mullerian anomalies, gonadal dysgenesis, pituitary tumors, and stress-related hypothalamic disorders. Laboratory tests such as FSH, prolactin, and progesterone challenges are recommended to localize the cause.

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    of 5

    Page 1 of 5

    Amenorrhea
    Criseline D. Tolentino, MD, DPOGS, FPSSTD

    Step 1

    TSH, Prolactin
    Prog challenge

    TSH

    Hypothyroidism

    PRIMARY AMENORRHEA

    Absence of menses (IN WOMEN) by 16 years of age in the presence of


    normal secondary sexual characteristics.
    Absence of menses (IN WOMEN) by 14 years of age when there is no visible
    secondary sexual characteristics.

    SECONDARY AMENORRHEA

    Absence of menstruation for three normal menstrual cycles of six months


    after menarche.

    COMPARTMENTAL SYSTEMS

    Compartment Idisorders of the outflow tract


    Compartment IIdisorders of the ovary
    Compartment IIIdisorders of the anterior pituitary
    Compartment IVdisorders of the CNS (hypothalamic factors)

    DIAGNOSTIC EVALUATION
    History and PE:
    Evidence of psychological dysfunction or emotional stress
    Family hx of apparent genetic anomalies
    Nutritional status
    Abnormal G&D
    Presence of a normal reproductive tract
    Evidence of CNS disease
    -

    Genital examination: blind or absent vagina with breast development:


    mullerian agenesis, transverse vaginal septum or AIS
    UTZ: useful to confirm the presence of uterus

    +withdrawal
    challenge

    N prolactin
    N TSH

    anovulation

    Step 2
    No withdrawal bleeding
    The target organ outflow tract is inoperative or preliminary estrogen
    proliferation of the endometrium has not occurred
    Treatment: estrogen 2.25mg CEE or 2mg EE ODx21 days + progesterone
    10mg OD for the last 5 days (necessary to achieve withdrawal)
    If still without withdrawal: end organ problem
    Step 3
    Designed to determined whether the lack of estrogen is due to a fault in the
    follicle (compartment II) or in the CNS (compartment II & IV)
    Normal adult female FSH and LH: 5-20 IU/L with the ovulatory midcycle
    peak about 2x the base level
    Suggested diagram aiding in the evaluation of women with amenorrhea
    1. History and PE
    FSH (-)
    2. R/O pregnancy
    Autoimmune defect
    3. FSH & PRL
    (Mullerian dysgenesis)
    FSH, or (-)
    Chronic anovulation
    (PCD) Functional
    Hypothalamic amenorrhea
    PRL
    Radiographic evaluation (Prolactinoma)
    FSH
    Gonadal failure (Gonadal dysgenesis?)

    Page 2 of 5
    II.

    Common causes of primary amenorrhea


    Category
    Breast development
    Mullerian agenesus
    Androgen insensitivity
    Vaginal septum
    Imperforate hymen
    Constitutional delay
    No breast development: high FSH
    46 XX
    46 XY
    No breast development: low FSH
    Constitutional delay
    Prolactinomas
    Kallman syndrome
    Other CNS
    Stress, weight loss, anorexia
    PCOS
    Congenital adrenal hyperplasia
    Others

    Approximate
    frequency (%)
    30
    10
    9
    2
    1
    8
    40
    15
    5
    30
    10
    5
    2
    3
    3
    3
    3
    1

    Classification of amenorrhea

    Primary Hypogonadism
    A. Gonadal karyotype
    1. Abnormal karyotype
    Turner syndrome 45,X
    mosaicism
    2. normal karyotype
    pure gonadal dysgenesis
    i. 46, XX
    ii. 46, XY (Swyer syndrome)
    B. gonadal digenesis
    C. enzymatic deficiency
    1. 17a-hydroxylase deficiency
    2. 17, 20-lyase deficiency
    3. Aromatase deficiency
    D. Premature ovarian failure
    1. Idiopathic
    2. Injury
    Chemotherapy
    Radiation
    Mumps
    Oophoritis
    3. Resistant ovary (idiopathic)

    (Not including disorders of congenital sexual ambiguity)


    I.

    Anatomic Defects (outflow tract)


    A. Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)
    B. Complete androgen resistance (testicular feminization)
    C. Intrauterine synechiae (Asherman syndrome)
    D. Imperforate hymen
    E. Transverse vaginal septum
    F. Cervical agenesisisolated
    G. Cervical stenosisiatrogenic
    H. Vaginal agenesis---isolated
    I. Endometrial hypoplasia or aplasiacongenital

    III. Hypothalamic causes


    A. Dysfunctional
    1. Stress
    2. Exercise
    3. Nutrition-related
    Weight loss, diet, malnutrition
    Eating disorders (anorexia nervosa, bulimia)
    4. Pseudocyesis
    B. other disorders
    1. isolated gonadotropin deficiency
    Kallman syndrome
    Idiopathic hypogonadotropic hypogonadism
    2. infectionTB

    Page 3 of 5

    COMPARTMENT I:
    Disorders of the outflow tract or uterus

    Mullerian anomalies
    Imperforate hymen
    Transverse vaginal septum
    Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser Syndrome)
    Androgen Insensitivity
    Asherman syndrome

    *Imperforate Hymen

    The hymen itself is formed from the proliferation of the sinovaginal bulbs,
    becoming perforate before or shortly after birth
    Results when this sheet of tissue fails to completely canalize
    Translucent thin membrane just inferior to the urethral meatus that
    bulges with valsalva maneuver

    Karyotype 46, XY
    Male range testosterone level
    Tx: gonadectomy after puberty + HRT

    Difference between Mulalrian Agenesis and AI


    Mullerian
    Androgen
    Agenesis
    Insensitivity
    Karyotype
    46, XX
    46, XY
    Heredity
    Not known
    Maternal X-linked
    recessive, 25% risk of
    affected child, 25%
    risk of carrier
    Sexual hair
    Normal female Absent to sparse
    Testosterone
    Normal female Normal to slightly
    elevated male
    Other anomalies
    Frequent
    Rare
    Gonadal neoplasia Normal
    5% incidence of
    incidence
    malignant tumors

    *Transverse Vaginal Septum

    Horizontal wall of tissue that has formed during embryologic


    development and essentially creates a blockage in the vagina
    Occurs between the upper one-third and lower two-thirds of the vaginal
    canal
    Resection of septum

    *Mayer-Rokitansky-Kuster-Hauser Syndrome
    (Utero-vaginal Agenesis)

    15% of primary amenorrhea


    Normal secondary development and external female genitalia
    Normal female range testosterone level
    Absent uterus and upper vagina and normal ovaries
    Karyotype: 46, XX
    15-30% renal, skeletal, and middle ear anomalies

    *Androgen Insensitivity

    Normal breasts but no sexual hair


    Normal looking female external genitalia
    Absent uterus and upper vagina

    COMPARTMENT II:
    Disorders of the Ovary

    Gonadal Dysgenesis
    a. Chromosomally abnormal
    Classic Turner Syndrome (45XO)
    Turner variants (45XO/46XX), (46X-abnormal X)
    Mixed Gonadal Dysgenesis (45XO/46XY)
    b. Chromosomally normal
    46 XX (Pure Gonadal Dysgenesis
    46 XY (Swyers Syndrome)

    *Typical features of Turner Syndrome

    Page 4 of 5

    Multiple cell lines of varying sex chromosome composition


    Appear normal, attaining normal stature before premature menopause is
    experienced (accelerated atresia)
    Patients are short

    *Gonadal Agenesis

    No c omplicated clinical problems accompany the gonadal failure due to


    agenesis
    Viral and metabolic influences in early gestation or undiscovered genetic
    mutations are suspected
    Surgical removal of the gonadal streaks is necessary to avoid the
    possibility of neoplasia

    *Premature Ovarian Failure

    *Gonadal Dysgenesis

    Gonadal dysgenesis associated with a normal karyotype is also linked to


    neurosensory deafness (Perrault syndrome)
    Pure gonadal dysgenesis indicates the presence of bilateral streak
    gonads, regardless of karyotype
    Mixed gonadal digenesis indicates testicular tissue on one side and a
    streak gonad on the other

    *XY Gonadal Dysgenesis (Swyers Syndrome)

    Female patient with XY karyotype


    Palpable mullerian syndrome
    Normal female testosterone level
    Lack of sexual development

    *Mosaicism

    Early depletion of ovarian follicles before the age of 40


    Etiology: unknown but maybe due to genetic disorder with an increased
    rate of follicle disappearance
    Most common abnormalities: 45X and 47XXY, followed by mosaicism
    Hormonal therapy recommended

    *Radiation

    Ovarian dose

    Sterilization effect

    6 rads
    150 rads
    250-500 rads
    500-800 rads
    Over 800 rads

    No effect
    Smoke risk over age 40
    Ages 15-40 , 60% srterilized
    Ages 15-40, 60-70% sterilized
    100% permanently sterilized

    *Chemotherapy
    Alkylating agentsvery toxic to the gonads
    Inverse relationship between the dose required for ovarian failure and
    age at the start of therapy

    Page 5 of 5

    COMPARTMENT III:
    Disorders of the Anterior Pituitary

    Diagnostic approach to secondary amenorrhea

    Hypogonadism and delayed puberty warrant brain evaluation by MRI


    Obtain Beta hCG
    Non-functioningadenoma: microadenoma
    Pituitary prolactin secreting adenomas
    Sheehans syndrome
    Positive
    Negative
    Acute infarction and necrosis of the pituitary gland due to postpartum
    hemorrhage and shock
    Failure of lactation and loss of pubic and axillary hair
    ObtainWeight/height, PRL, FSH and
    Pregnancy
    if indicated, testosterone or TSH
    Hypothalamic amenorrhea (hypogonadotropic hypogonadism)
    Deficiency in GnRH pulsatile secretion
    Frequently associated with stress
    Abnormal
    Elevated
    Elevated
    Elevated
    Higher proportion of underweight women and previous menstrual
    ht/wt
    PRL
    FSH
    testosterone
    irregularity
    Displays the endocrine, metabolic and psychological characteristics
    suggesting the presence of a subclinical eating disorder
    Chronic hypothalamic anovulation
    Evaluate
    Ovarian
    <200
    >200
    Excessively
    Obese
    Stress
    hypothyroidism,
    failure
    mg/dl
    mg/dl
    thin
    drugs, renal failure
    Increased exercise levels
    Anorexia nervosa
    Examine for possible
    MRI scan of
    Estrogen/
    Ovarian hyperPelvis
    Head trauma
    dietary/nutritional
    hypothalamus
    progestin
    androgenism
    UTZ and
    Space-occupying lesions
    manipulations, evaluate
    and pituitary
    replacement
    adrenal

    *High serum FSH

    Indicates the presence of ovarian failure


    This test should be repeated monthly on three occasions to confirm
    persistent elevation
    A karyotype should be considered in most women of secondary
    amenorrhea age 30 years or younger to rule out complete or partial
    deletion of the X chromosome, or presence of any Y chromosome
    material

    for adrenal
    hyperandrogenism

    CT
    Treat with
    dopamine agonist

    Suppress ovarian
    androgen
    secretion with OCs

    History of D&C
    preceding amenorrhea,
    normal PRL and FSH

    Ashermann
    syndrome

    Hysteroscopy and
    hysterosalpingogram

    Trial of
    estrogen/progestin to
    stimulate withdrawal
    bleeding

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