Table of contents
.. beginning of document
- Bottom Line:
- If LH + FSH is high = primary gonadal failure
- If LH + FSH is low
- either gonadal hyperproduction and LH/FSH inhibition (estrogen present)
- or gonads are normal and pituitary not producing LH/FSH (estrogen absent)
- Test for estrogen with progesterone challenge test. (if withdrawal bleed = estrogen present)
- Can also do estrogen + progesterone challenge test to see if uterus able to produce menses.
EXCELLENT AAFP article on amenorrhea:
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Another way to think about this.... (My old diagram)
Premenopausal
Primary Amenorrhea
Some Causes:
- Mullerian agenesis (congenital, failure of mullerian ducts to develop: missing uterus+fallopian tubes, variable malformed vagina)
- Androgen Insensitivity (Normal breast, absent uterus; Androgen resistance (mutation in receptor), so phenotypical male 46XY appears as a female. Testicles secrete anti-mullerian hormone presents development of mullerian duct, thus upper vagina and uterus do not develop. Ectopic testes must be removed to avoid neoplasm and hormones HRT required).
- Vaginal Septum
- Imperforate Hymen
- Constitutional Delay
- Polycystic Ovarian Syndrome (PCOS)
- Gonada Dysgenesis
- Turner's Syndrome - Abnormal sex chromosomes (Turner's 45X)
- Gonadal Failure - Normal Sex chromosomes (46XX or 46 XY) --- Most common
Secondary Amenorrhea
Approach:
1. Pregnant? B-HCG
2. TSH/Prolactin? Is this a TSH or prolactin thing? (treat thyroidism or MRI for prolactin tumor (other sx headache, vision changes, galactorrhea).
3. Progestin challenge: Are the hormones normal? (withdrawal bleed then hormones normal - normogonadotropic)
4. Check LH+FSH: If normones abnormal (no withdrawal bleed) then check LH + FSH to see if it's hypogonadotropic or hypergonadotropic
Abnormal Uterine Bleeding
AUB in Menarche
Causes:
Dysfunctional Uterine Bleeding (DUB)
- Dx of exclusion'
- Anovulatory heavy irregular bleeding
- Either at menarche or at perimenopause
- Must exclude other causes:
Hematologic Causes
- Coagulopathy (vWD)
- Iron def??
- Platelet abnormalities
- Leukemia
Endocrine Disorders
- PCOS
- Adrenal: CAH, Cushings Syndrome
- Hypothalamic/Pituitary Dysfunction - eating disorder, excessive exercise, stress, idiopathic
- Thyroid Disorders: hypothyroidism
- Ovarian Tumors: secreting estrogens or androgens (very rare)
Pregnancy
- Threatened, missed, incomplete abortion
- Ectopic pregnancy
- Molar pregnancy
Local Lesions
- Endometrial Polyps
Incorrect Use of OCP
Dx:
- CBC
- BhCG?
- TSH, Prolacting
- Free testosterone, 17-hydroxy progesterone and DHEA (r/o PCOS, CAH0
- Coag profile +/- vWF activity assay
Tx:
- ABCs
- ESTROGEN (premarin 25mg iv q4h x24hrs) - causes nausea (use gravol)
OR
- OCP (monophasic prep) - ont tablet po tid x3-4d then bid for 3-4d, then od x21d.
Need to keep on OCP until HPA axis matures.
AUB in Perimenopausal
Causes:
Benign Conditions
- Pregnancy
- Leiomyomas (40% over 40 have them)
- Adenomyosis -
- Endometriosis
- PID
Pre-malignant conditions
- Cervix - Dysplasia, squamous cell ca., adenocarcinoma
- Endometrium - Endometrial hyperplasia +/- atypia; endometrial adenocarcinoma
Systemic
- Coagulation vWB (10-15% due to vWB not detected in youth)
- Thrombocytopenia (ITP)
- Leukemia
- Liver-disease - estrogen not metabolized
Endocrine
- Hypothalamic - prolactinomas, sstress, wt loss
- Hypothyroidism
- Adrenal - Cushing's, CAH
- Ovarian - hormone secreting tumors (rare), PCOS
Iatrogenic
- Forgotten IUD
- OCP/HRT incorrect
- Neuroleptics - Dopamine and prolactin
- Tubal ligation is NOT a cause. Usually people get TL in perimenopause, which is around the time of AUB
Dysfunctional Uterine Bleeding (DUB)
- Dx of exclusion
- No organic causes, anovulation
Dx
- Labs: CBC, ferritin, TSH, PRL, BhCG, coag profile if vWD suspected
- Sonohysterogram: polyps/fibroids
- U/S 0.5-1cm normal? 1.4cm if about to menstruate
- Hysteroscopy: done under GA, not commonly used
Tx:
Medical
| Drug | Mechanism | % decr flow | other benefits |
| NSAID | inhibits COX | 20-50 | decr dysmen |
| Cyclokapron | anti-fibrinolytic | 40 | |
| Danazol | inh. steroidogenesis, testosterone derivative | up to 80 | 15% amenorrhea, good tx for endometriosis |
| Progestin | Decidualizes endometrium | 50 | regulates cycle |
| OCP | inh steroidogenesis | 50 | decr. dysmen |
| Mirena IUD | decidualizes endometrium | up to 80 | treats endom. hyperp. |
Surgical
- Hysteroscopic resection: fibroids and polyps
- Hysteroscopic endometrial ablation: treats 80% over 5y, but comes back due to tubal origin?
- Hysterectomy
Congenital Adrenal Hyperplasia (CAH)
- Over 95 percent of cases of congenital adrenal hyperplasia (CAH) are due to 21-hydroxylase due to CYP21A2 mutations. It is one of the most common known autosomal recessive disorders.
- Can present as:
- Virilizing form
- Salt wasting form (adrenal crisis - hypotension, hyponatremia, hyperkalemia)
- Females
- Born with ambiguous genitalia
- Males
- Appear unaffected at birth, but later
- Both
- Early onset puberty
- Rapid growth + premature completion of growth (short stature) if not treated early
- Milder forms can present in adulthood
- Adults
- Early puberty and fertility problems
- Females can have excessive body hair, irregular menses, or acne.
Comments