oligomenorrhea + amenorrhea Flashcards

1
Q

primary amenorrhea definition

A
  • no menses ever
  • by age 14 if no sex dev
  • by age 16 if breast + pubic hair dev
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2
Q

secondary amenorrhea

A
  • period stops, non for 6 mo if reg, none for 12 mo if irreg
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3
Q

oligomenorrhea

A

light or infreq (>35 days, 4-9x/year)

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4
Q

anovulatory bleed

A

noncyclic, from endometrium, due to hormones, no anatomic lesion

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5
Q

differential diagnosis of amenorrhea

A
/w sex dev:
anatomic:
- mullerian agenesis
- imperforate hymen
- mullerian agenesis
- androgen insensitivity syndrome

Hypergonadotropic hypogonadism - no sex dev

  • turner’s syndrome
  • primary ovarian insufficiency
  • gonadal dysgenesis

hypogonadotropic hypogonadism

  • constitutional delay
  • PCOS
  • hypothyroid
  • hyperprolactinemia
  • congenital CNS abnormalities, hypopituarism, or GnRH def, kallmans
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6
Q

common differential for secondary amennorhea

A

hypogonadotropic

  • weight loss
  • hypothalamic “stress”
  • PCOS / anovulation
  • hypothyroidism
  • cushings
  • hyperprolactinemia
  • pituitary tumor, empty sella, sheehan syndrome (pituitary necrosis)

hypergonadotropic

  • POI
  • abnormal karyotype

Anatomic
- ashermans

hyperandrogens

  • ovarian tumour
  • CAH
  • undiagnosed
  • (PCOS)
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7
Q

work-up for primary amenorrhia

A
  • history
  • physical exam for sex dev + androgens, BMI
  • BHCG, TSH, PRL, FSH, pelvic US if second dev, if virulization do testosterone + DHEAS (tumor)
  • FSH low + all else normal: brain MRI, if normal = constitutional, hypothalamic, or pituitary dysfunction
  • FSH high: karyotype (POI or turners)
  • US no uterus: karyotype (XY + AIS or XX + mullerian agenesis)
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8
Q

work-up for secondary amenorrha

A
  • HCG, FSH, BMI, PRL, TSH, fasting glucose, testosterone, LH if suspect PCOS
  • FSH high - POI - karyotype if under 30, can check estrogen /w prog challenge test
  • FSH low - hypothalamic (+low androgens
  • PCOS: high BMI, high androgens, high LH:FSH
  • r/o adrenal tumour + NACH: DHEAS (rapid) + 17-hydroxyprogesteron
  • PRL high: brain MRI or drugs or hypothyroidism, or renal failure
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9
Q

work-up + tx for elevated prolactin

A
  • drug hx, r/o hypothyroidism
  • if no meds, brain MRI
  • tx: bromocriptine (dopamine agonist)
  • ## alt = transphenoidal excision, only if mass effects or med failure
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10
Q

PCOS dx

A
  • BP
  • BMI, waist-hip
  • signs of hyperandrogenism + insulin resitance
  • pelvic exam (enlarged ovaries)

labs

  • total +/- free testosterone
  • DHEAS if rapid virulization
  • 17-hydroxyprogesterone (CAH)
  • TSH, prolactin - exclude
  • consider acromegally (GH)
  • HbA1c, 2 hr OGTT, fasting lipid + lipoproteins

optional

  • ovary US (for fertility, rapid virulization)
  • fasting insulin
  • LH + FSH
  • 24 hr urine for cortisol (late onset or looks like cushings)
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11
Q

diagnostic criteria for PCOS

A
  • two of:

- clinical or biochem hyperandrogenism, ovulatory dysfunction, or PCOs on US

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12
Q

management of PCOS

A

not TTC:

  • OCP: cycle reg, dec androgens, red endometrial Ca
  • progestins: alt to OCP
  • insulin sensitizers = 2nd line, decrease androgens, improve ovulation, and glucose tests

TTC

  • exercise, weight loss
  • letrozole for ovulation induction
  • 2nd line: clomiphene citrate (alone or in combo) for ovulation
  • 3rd line: gonadotropins
  • metformin - alone or in combo, other insulin sentizers
  • 3rd line = ovarian drilling
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13
Q

premature ovarian failure management

A
  • if before age 30, karyotype for sex chromosome translocation, deletions, or occult Y (remove gonads!)
  • prog challenge test for E
  • obtain fam Hx for autosomal disorders, genetics counselling
  • autoimmune thyroiditis common
  • tx: E + P until age 51, if adolescent mimic puberty by increasing E slowly and add P when breast mound developed
  • note: rare spont ovulation possible
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