david a grainger md, mph - wesley ob/gyn .pdfamenorrhea with ovulation (primary) primary amenorrhea:...
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D A V I D A G R A I N G E R M D , M P H
Amenorrhea
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Conflicts
Speakers Bureau - Abbvie
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Objectives
Definitions of amenorrhea
Types of amenorrhea
Primary
Secondary
Why Estrogen Status is a KEY feature
Making the correct diagnosis
Who wants a period? Why treatment is necessary
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Amenorrhea - Definitions
Primary
No menses by age 13 without breast development
No menses by age 16 with breast development
Secondary
No menses for 6 months
No menses for the equivalent of 3 “normal” cycles
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Menstrual Cycle: Anti-HomeostasisDaily Incremental Changes in All Hormone Levels
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Amenorrhea: Homeostasis (with some exceptions)
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Categories of Amenorrhea
Pregnancy, of course
Amenorrhea = anovulation (most common)
Estrogen Status?
Amenorrhea in ovulating women (the exception)
OUTFLOW TRACT
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Amenorrhea With Ovulation (Primary)
Primary Amenorrhea: Imperforate hymen Transverse vaginal septum Mullerian agenesis (partial or complete) Androgen Insensitivity Syndrome
Diagnosis Symptoms Physical exam Serum Testosterone/Karyotype
Treatment Surgical for imperforate hymen/transverse septum Dilators for blind ending vagina IVF with gestational carrier for MA Gonadectomy after puberty for AI patients (seminomas, not
gonadoblastomas)
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Amenorrhea With Ovulation (Secondary)
Secondary Amenorrhea Asherman’s Syndrome
Cervical Stenosis
Hysterectomy/Endometrial Ablation
Diagnosis History – multiple LEEP/cone; or
pregnancy + instrumentation + infection
Physical exam
HSG/hysteroscopy
Treatment Surgical – lysis of intrauterine adhesions
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Amenorrhea Without Ovulation
Estrogen Status – Never present, Low, Normal
Primary: Breast development?
If normal, there is/has been estrogen exposure and you can wait till age 15-16 before further evaluation
Secondary: Progesterone withdrawal bleed
+bleed = anovulation
Endometrial lining thickness on TVS
Estrogen level/FSH level
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Estrogen…
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Low Estrogen
Cannot make it! (AKA no eggs) Primary Amenorrhea
Gonadal dysgenesis - 46 XX, 46 XY (Swyer’s syndrome), others
Secondary Amenorrhea
Gonadectomy
Premature ovarian insufficiency
Radiation, chemotherapy, ovarian surgery
Menopause
Evaluation?
SERUM FSH WILL BE HIGH
Karyotype (All patients under 40? Looking for SRY)
FMR1 testing (Fragile X )
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Low Estrogen – Cannot Make EstrogenHypergonadotropic Hypogonadism
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Low Estrogen
No Signal to Make Estrogen (Hypothalamic Amenorrhea) Primary
Constitutional delay? Midline brain tumors – craniopharyngioma, hamartoma Eating disorders/Over-exercise Kallman’s Syndrome
Secondary Midline tumors Hyperprolactinemia (hypothyroidism) Eating disorders/Female Athlete Triad
Evaluation MRI Counseling regarding eating disorders/Female Athlete Triad Testing for anosmia TSH/PRL
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Low Estrogen – No SignalHypogonadotropic Hypogonadism
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Amenorrhea With NORMAL Estrogen
Anovulation Most common diagnosis after pregnancy
Likely to be PCOS
Evaluation TVS – endometrium and ovarian morphology
Labs: FSH, LH, E2, T, DHEAS, 17-OHP, ?AMH
Virilization? T>200ng/ml, DHEAS > 700ng/Dl, look for tumors
Progesterone withdrawal will be positive (unless very hyperandrogenic with thin endometrium)
Treatment COH if wanting pregnancy
OCP’s/Spironolactone/metformin/Diet/Exercise
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Anovulation
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Treatment:I really don’t want to have a period…
Low Estrogen
ALL the risks of hypoestrogenism
Vaginal/Urogenital Atrophy
Osteoporosis
Heart disease
Address the underlying cause
Replace estrogen – if uterus present, need to replace progesterone also
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Treatment:I really don’t want to have a period…
Normal estrogen
PCOS patients with anovulation
Have UNOPPOSED estrogen production
Have a risk of endometrial hyperplasia/endometrial cancer
Need either to ovulate (if seeking pregnancy) or take OCP’s
Benefits of OCP’s
Progesterone protection for endometrial hyperplasia
Estrogen – increased SHBG, decreased Free T; suppresses LH, decreasing total T
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Summary - Amenorrhea
Definition – no menses by age 13 without or 15 with breast development; 6 months or 3 cycle lengths for secondary amenorrhea
Rule out pregnancy
Establish outflow tract patency/presence
Determine estrogen status (breast development or withdrawal bleed)
Low estrogen? Can’t make it, or no signal to make it? (FSH levels are helpful)
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Quiz
51 year old presents with one year of amenorrhea. Evaluation and diagnosis?
A 9 year old patients mother calls and is worried that her daughter hasn’t started her period. Evaluation and diagnosis?
A 19 year old patient presents with 8 months of amenorrhea, and normal secondary sex characteristics. Evaluation and diagnosis?
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Quiz
A 15 year old patient presents (for the 3rd time) to the ER with increasing cyclical pelvic pain. Evaluation and diagnosis?
A 28 year old patient presents with one year of amenorrhea. She just completed an Iron Man in Hawaii. Evaluation and diagnosis?
A 35 year old patient presents with 8 months of amenorrhea, also complains of a breast discharge for the last 3 months. Evaluation and diagnosis?