Presentation on theme: "Obstetrics and Gynecology Clerkship Case Based Seminar Series"— Presentation transcript:
1 Obstetrics and Gynecology Clerkship Case Based Seminar Series AmenorrheaUNC School of MedicineObstetrics and Gynecology ClerkshipCase Based Seminar Series
2 Objectives for Amenorrhea Define amenorrhea and oligomenorrheaExplain the pathophysiology and identify the etiologies of amenorrhea and oligomenorrheaDescribe the symptoms and physical examination findings of amenorrhea and oligomenorrheaDiscuss the steps in the evaluation and management of amenorrhea and oligomenorrheaDescribe the consequences of untreated amenorrhea and oligomenorrhea
3 Definition Amenorrhea – absence of menses Primary amenorrhea – absence of menarcheAbsence of menarche by age 14 without secondary sexual characteristicsAbsence of menarche by age 16 with secondary sexual characteristicsSecondary amenorrhea – absence of menses in a previously menstruating womanAbsence of menses for > 6 months or duration of 3 menstrual cyclesOligomenorrhea – reduction in frequency of mensesCycle lengths > 35 days, but < 6 months
5 Primary Amenorrhea: Etiology Most common etiologies:Chromosomal abnormalities causing gonadal dysgenesis – 50%Hypothalamic hypogonadism – 20%Absence of the uterus, cervix, or vagina – 15%Transverse vaginal septum or imperforate hymen – 5%Pituitary disease – 5%
6 Primary Amenorrhea: History FindingsAssociationCompletion of stages of puberty? Development of axillary and pubic hair? Breast development?Ovarian or pituitary failureChromosomal abnormalityFamily history of delayed or absent puberty?Familial disorderConstitutional delay of pubertyHeight relative to family members?Turner’s syndromeSymptoms of virilization?PCOSOvarian or adrenal tumorPresence of Y chromosomeRecent stress? Change in weight, diet, or exercise?Functional hypothalamic amenorrheaMedications (i.e. antidepressants, antipsychotics)?HyperprolactinemiaGalactorrhea?Headaches, visual field defects, fatigue, polyuria or polydipsia?Hypothalamic-pituitary disease
7 Primary Amenorrhea: Physical Exam Evaluation of pubertal development (height, weight) and growth chartBreast development (Tanner staging)Evaluation for features of Turner’s syndromeWebbed neck, low hair line, shield chest, widely spaced nipplesExamine skin for hirsutism, acne, striae, increased pigmentation, and vitiligoPelvic examClitoral sizeIntactness of hymenDepth of vaginaPresence of vaginal septumPresence of cervix, uterus, and ovaries
8 Tanner StagesStage 1: Prepubertal, no palpable breast tissue or pubic hair.Stage 2: Development of breast bud; sparse, straight pubic hair.Stage 3: Enlargement of breast; pubic hair darker, coarser, and curlier.Stage 4: Areola and papilla project above the breast; pubic hair adult-like in appearance.Stage 5: Recession of areola to match contour of breast; pubic hair extends to thigh.Figure from: Roede, MJ, van Wieringen, JC. Growth diagrams 1980: Netherlands third nation-wide survey. Tijdschr Soc Gezondheids 1985; 63:1. Reproduced with permission from the author.
9 Primary Amenorrhea: Evaluation Secondary sexual characteristics present?NoYesMeasure FSHPerform ultrasound of uterusFSH < 5FSH > 20Uterus absent or abnormalUterus present or normalHypogonadotropichypogonadismHypergonadotropichypogonadismKaryotype analysisOutflow obstructionHypothalamic amenorrheaConstitutional delay of pubertyKallman syndromeCNS tumorKaryotype analysis46,XY46,XXNoYes46,XX45,XOMüllerian agenesisEvaluate for2° amenorrheaAndrogen insensitivity syndromeImperforate hymenTransverse vaginal septumPrematureovarian failureTurner’ssyndromePCOSCushing’s
12 Secondary Amenorrhea/Oligomenorrhea: History FindingsAssociationRecent stress? Change in weight, diet, or exercise?Functional hypothalamic amenorrheaDevelopment of acne, hirsutism, striae, central obesity, increased skin pigmentation or deepening voice?PCOSCushing’s diseaseOvarian or adrenal tumorMedications (i.e. antidepressants, antipsychotics)?HyperprolactinemiaChronic illness?Headaches, visual field defects, fatigue, polyuria or polydipsia?Hypothalamic-pituitary diseaseSymptoms of estrogen deficiency (hot flashes, vaginal dryness, decreased libido, or poor sleep)?Premature ovarian failurePostmenopausal ovarian failureGalactorrhea?History of obstetrical catastrophe, severe bleeding, D&C, endometritis, or other infection?Sheehan’s syndromeAsherman’s syndrome
13 Secondary Amenorrhea/Oligomenorrhea: Physical Exam GeneralEvaluation of height, weight, and BMIExamine skin for hirsutism, acne, striae, acanthosis nigricans, thickness or thinness, and easy bruisabilityThyroid examBreast examExpress for galactorrheaPelvic examAtrophyVaginal dryness
14 Secondary Amenorrhea/Oligomenorrhea: Evaluation Negative urine pregnancy testProgestin challenge testNegative MRIConsider other causesNo withdrawal bleedProlactin < 100 ng/mLProlactin > 100 ng/mLCheck FSHEstrogen/progestinChallenge testNormogonadotropichypogonadismHypergonadotrpoic hypogonadismWithdrawal bleedFSH > 20 IU/LOutflow obstructionMedicationMRI to evaluate for pituitary tumorNormal MRIHypogonadotropic hypogonadismMRI to evaluate for prolactinomaBoth normalNormal TSH, Abnormal prolactinHyperandrogenic anovulationPCOSCushing’sCheck TSH and prolactinNormal prolactin,Abnormal TSHThyroid diseaseFSH < 5IU/LAsherman’sCervical stenosisOvarian failureHypothalamic amenorrheaChronic illness
15 Secondary Amenorrhea/Oligomenorrhea: Evaluation Progestin challenge testMedroxyprogesterone acetate 10 mg daily for 10 daysIF withdrawal bleed occurs – Not outflow tract obstructionIF no withdrawal bleed occurs – Estrogen/Progestin challenge testEstrogen/Progestin challenge testOral conjugated estrogen – 2.5 mg daily for 35 daysMedroxyprogesterone acetate 10 mg daily for daysIF no withdrawal bleed occurs – Endometrial scarringHysterosalpingogram or Hysteroscopy to evaluate endometrial cavity
16 Secondary Amenorrhea/Oligomenorrhea: Evaluation Evaluation of hyperandrogenismSymptoms: hirsutism, acne, alopecia, masculinization, and virilizationDifferential diagnosis:Adrenal disorders: Atypical congenital adrenal hyperplasia (CAH), Cushing’s syndrome, Adrenal neoplasmOvarian disorders: PCOS, Ovarian neoplasmsLab: Testosterone, DHEA-S, 17α-hydroxyprogesteroneHormoneLevelIndicationTestosterone< 200 ng/dLPCOS> 200 ng/dLEvaluate for adrenal or ovarian tumorDHEA-S< 700 ng/dL> 700 ng/dL17α-hydroxyprogesterone> 4 ng/mLConsider ACTH stimulation test to diagnose CAH
17 Amenorrhea/Oligomenorrhea: Management Treatment should be directed at…Correcting the underlying pathologyHelping woman to achieve fertility (IF desired)Preventing the complications of disease processConsequences of untreated amenorrhea/oligomenorrhea:Hypoestrogenism – Osteoporosis, InfertilityHyperestrogenism – Heart disease, Stroke, Diabetes Mellitus, Breast cancer (controversial), Endometrial hyperplasia and Endometrial cancer
18 Amenorrhea/Oligomenorrhea: Management DiagnosisManagementOvarian insufficiencyPremature ovarian failurePostmenopausal ovarian failureHormone replacement therapy (HRT)*Congenital anatomic lesionsSurgical correction*Presence of Y chromosome (i.e. AIS)Gonadectomy*Gonadal dysgenesis (i.e. Turner syndrome)Estrogen + progestin, growth hormoneIVF (IF pregnancy desired)HyperprolactinemiaDopamine agonist (Bromocriptine, Cabergoline)Functional hypothalamic amenorrheaIncrease caloric intake > energy expenditureHypothalamic or pituitary dysfunction(non-reversible)OCP’s, pulsatile GnRH or exogenous gonadotropinsCNS tumorCraniopharyngiomaProlactinomaSurgical resectionMicroadenoma (< 10mm) – Dopamine agonistMacroadenoma (>10mm) – Trans-sphenoidal resectionPCOSOCP’s, weight loss, and metforminAsherman’s syndromeHysteroscopic lysis of adhesions*Causes of primary amenorrhea only
19 Bottom Line ConceptsA thorough history and physical examination as well as laboratory testing can help narrow the diagnosis of amenorrhea.In patients with primary amenorrhea, the presence or absence of sexual development should direct evaluation.Constitutional delay of puberty is a diagnosis of exclusion.The definitive method to identify hypothalamic-pituitary dysfunction is to measure FSH and prolactin levels.If the patient has abnormal uterine development, a karyotype analysis should be performed to diagnose müllerian agenesis versus chromosomal abnormalities.In a patient with secondary amenorrhea, pregnancy should be ruled out prior to further workup.Treatment goals of amennorrhea and oligomenorrhea include prevention of complications such as osteoporosis, endometrial hyperplasia and heart disease; preservation of fertility; and in primary amenorrhea, progression of normal pubertal development.
20 References and Resources APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 43 (p92-93).Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 35 (p ).Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 32 (p ).Master-Hunter T, Helman DL. Amenorrhea: evaluation and treatment. Am Fam Physician Apr 15; 73(8):
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