Download AMENORRHEA

AMENORRHEA
Paul Beck, MD, FACOG, FACS
Incidence of Primary Amenorrhea
Less than .1%
Puberty
Breast:
Pubic Hair:
Menarche
10.8 +/- 1.10 yrs.
11.0 +/- 1.21 yrs.
12.9 +/- 1.2 yrs.
Onset of Puberty and
Menstruation
Ratio of fat to both total body weight and
lean body weight
Moderate obesity (20 – 30 % above ideal
body weight) = earlier menarch
Malnutrition (anorexia nervosa, starvation)
= delay
Prepubertal strenuous exercise (less total
body fat) = delay e.g. ballet dancers,
swimmers, runners
Diagnostic Evaluation by
Compartments
I
Outflow Tract (uterus – vagina)
II
Ovary
III Anterior Pituitary
IV CNS – Hypothalamus (environment
and
psyche)
Evaluation
History/Physical
Psychiatric, family history-genetic
abnormalities, nutritional status,
growth/development
Secondary sexual characteristics
Presence of breasts – normal reproductive
tract (uterus, vagina)
Evaluation Categories
Breast Absent – Uterus Present
Breast Present – Uterus Present
Breast Present – Uterus Absent
Breast Absent – Uterus Absent
Initial Tests for Amenorrhea
Progesterone challenge
TSH
Prolactin
TSH elevated – hypothyroid
Prolactin elevated (MRI – 100 ng/ml)
Progesterone Challenge
Positive withdrawal bleed
Normal prolactin
Normal TSH
Diagnosis = annovulation
Treatment: monthly progesterone/O.C.
Progesterone
Negative Withdrawal
FSH/LH
FSH/LH normal – estrogen/progesterone
cycle
If negative = end organ defect
If FSH/LH high = ovarian failure
Estrogen – positive withdrawal, FSH
normal or low, MRI sella = no path
Diagnosis: hypothalamic amenorrhea
Chromosome Evaluation for
Ovarian Failure
If the patient is under age 30 – karyotype
Y chromosome/excision of gonadal area
Problem – gonadal tumor – malignant
30% do not develop virilization, therefore
even normal appearing female needs
karyotype to exclude Y
After age 30 = premature menopause
Selected Blood Test for
Autoimmune Disease
Calcium, phosphorus
Fasting blood sugar
A.M. cortisol
Free T4 – TSH
Thyroid antibodies
CBC – ESR – CRP
Total protein A/G ratio
Rheumatoid factor
Antinuclear antibody
Specific Disorders
I Outflow - imperforate hymen, ashermans
mullerian agenesis, androgen insensitivity syndrome
II Ovary - can be primary or secondary amenorrhea
40% of primary amenorrhea have gonadal streaks
Of the 40%, 50% = 45,X
25% = mosaics
25% = 46 XX
Secondary amenorrhea patients have many
karyotypes
Specific Disorders
(continued)
Turner syndrome
Gonadal dysgenesis
Gonadal agenesis
Savage syndrome
Premature ovarian failure
Radiation therapy
Alkylating agents
Compartment III
Anterior pituitary disorders
Tumors – large bitemperal hemianopsia
Small tumors – visual defects- rare
Craniopharyngioma – calcification x-ray may
produce blurring of vision
Acromegaly
Cushings
Pituitary prolactin adenomas (micro/macro)
Sheehan’s syndrome
Compartment IV
CNS disorders
Hypothalamic amenorrhea – problem is a
GNRH pulsatile secretion
Anorexia/Bulemia/weight loss – 25%
(onset – 10 – 30 years)
Exercise
Etiology of Amenorrhea
Breast – Absent
Uterus Absent
Uterus Present
17, 20 desmolase
deficiency
1. Gonadal failure
turner 45X
17 a hydroxylase
deficiency 46xy
Gonadal dysgenisis
Agonadism
17 a hydroxylase
deficiency with
46XX
2. Hypothalamic
failure
3. Pituitary failure
Breast – Present
AIS (T.F.)
Mullerianagenesis
Hypothalamic,
pituitary, ovarian pt
uterine etiology