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D A V I D A G R A I N G E R M D , M P H
Amenorrhea
Conflicts
Speakers Bureau - Abbvie
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
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
Menstrual Cycle: Anti-HomeostasisDaily Incremental Changes in All Hormone Levels
Amenorrhea: Homeostasis (with some exceptions)
Categories of Amenorrhea
Pregnancy, of course
Amenorrhea = anovulation (most common)
Estrogen Status?
Amenorrhea in ovulating women (the exception)
OUTFLOW TRACT
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)
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
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
Estrogen…
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 )
Low Estrogen – Cannot Make EstrogenHypergonadotropic Hypogonadism
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
Low Estrogen – No SignalHypogonadotropic Hypogonadism
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
Anovulation
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
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
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)
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?
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?