Dr. Whitworth – Amenorrhea – 3.1.10
Definitions
Amenorrhea
Primary amenorrhea
Secondary amenorrhea:
Oligomenorrhea
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absence of menstruation – Sx not Dx
no spontaneous uterine bleeding by age 14 in the absence of secondary sexual characteristics OR by age 16
with otherwise normal development
the absence of menstrual bleeding for six months in a woman with prior regular menses or for 12 months in a
woman with previous oligomenorrhea
Decreased frequency of menstruation more than 40 days but less than 6 months
Normal Menstrual Cycle
-The normal cycle is an integration of the hypothalamus, pituitary, ovary and the
responsiveness of the uterus to these hormones
-For the cycle to proceed normally a woman must have an intact uterus with responsive
endometrium, a patent outflow tract, and a functioning endocrine system and feedback
loops, (functioning ovaries and pituitary); disruption at any level can cause amenorrhea
-GnRH from the hypothalamus acts on the pituitary to secrete FSH/LH
-FSH acts on the ovary to stimulate follicular thecal cells
-These cells produce androgens which are converted to estrogens-decreasing FSH
-One follicle is maintained,up regulation of FSH receptors
-LH levels inc-positive feedback of estradiol—causing ovulation in 24-48 hrs.-Granulosa cells of the follicle increase progesterone production
-Estrogen on the endometrium--increased thickness and vascularity
-Progesterone-increased glandular secretion and tortuosity
Causes of Amenorrhea
-Physiologic
-Primary Amenorrhea: Pregnancy and Constitutional delay of puberty
-Secondary Amenorrhea: Pregnancy, Lactation, Menopause
Causes:
Compartment
Definition
Differnetial Dx.
Compartment One
disorder of uterus or outflow tract
-Imperforate hymen
-Ashermans Syndrome--destruction of endometrium. (after D/C)
-Mullerian Anomolies
-Mullerian Agenesis
-Mayer-Rokitansky-Kuster-Hauser Syndrome
-Testicular Feminization (Androgen Insensitivity)
Compartment Two
disorders of ovary
-Turners Syndrome 46XO
-Mosaicism (blend of 46 XO & 46 XX)
-Gonadal agenesis/dysgenesis
-Resistant ovary syndrome (rare)
-Premature (before age 40) ovarian failure
-Radiation/chemotherapy (can have norm cycles later & be fertile)
-n17 a hydroxylase defeciency
Compartment Three
disorder of anterior pituitary
-Pituitary Adenoma (hyperprolactinemia)
-Empty Sella Syndrome
-Sheehans Syndrome – acute necrosis of ant pit post trauma
-Hypopituitarism
-Hypothyroid – high TSH  acts as FSH & LH – fools the pit
-Infiltrative (Sarcoidosis/hemochromostosis)
-(medications) neg feedback on ant pit
Compartment Four
disorder of the CNS/hypothalamus
-Tumors
-Craniopharyngioma, harmartoma
nHypothalamic amenorrhea- decrease in pulsitile GnRH secretion
-Eating disorder, weight loss (or gain), excessive exercise
-Kallmanns Syndrome
-disease-JRA,syphillis, TB
-psychosocial stress
-Anovulation
Evaluation of Amenorrhea
Obtain a History
-Menstrual history: Age of onset of menses, previous pattern
-Reproductive history: Use of BCP’s, previous ob/gyn procedures, development,pregnancy
-General medical history: Endocrine/metobolic disorders, medications, illnesses
-Family history- sister/mother
-Social history is patient a med student?,marathon runner? Nutritional or emotional stressors?
-Physical Exam
-In a complete physical look for normal anatomy and development
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Dr. Whitworth – Amenorrhea – 3.1.10
-Look for signs of androgen excess, estrogen deficiency or estrogen excess
-Labs: goal is to identify a problem in the hypothalamic-pituitary-ovarian axis
-GET A PRGENANCY TEST! If negative use the below flow chart.
Treatment: Need clear diagnosis
-Hypothyroid-- thyroid replacement
-Ovarian Failure-- estrogen replacement
-Pituitary Tumor--medication or surgery
-Hypothalamic --change lifestyle, cyclical hormones
Consequences of Amenorrhea:
-Psychological: Dx of genetic abnormality,
- Altered self image, Impaired fertility
-Stress the normalcy of it & find out if
something abnorm is going on
-Physiological
-Decreased Estrogen
-Vasomotor symptoms
-Vaginal dryness
-Decreased libido
-Osteoporosis
-? Increase cardiac risk factors
Questions:
1. What is the difference between primary and secondary amenorrhea?
2. What are the causes of primary and secondary amenorrhea?
3. Identify which compartment the following disorders belong to:
a. Disorder of ovary
b. Disorder of CNS/hypothalamus
c. Disorder of uterus out flow
d. Disorder of anterior pituitary
Answers:
1. Definition
no spontaneous uterine bleeding by age 14 in the absence of
secondary sexual characteristics OR by age 16 with
otherwise normal development
Secondary
the absence of menstrual bleeding for six months in a
amenorrhea:
woman with prior regular menses or for 12 months in a
woman with previous oligomenorrhea
3. A = II, B = IV, C = I, D = III
Primary
amenorrhea
2. Cause
Pregnancy and Constitutional delay of puberty
Pregnancy, Lactation, Menopause