11 Amenorrhea (Secondary)

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secondary amenorrhea-absence of menses for more than __ in women who previously had regular menstrual cycles OR ___ long in women who had irregular menses

-3 mo -6 mo

sx of hypothalamic pituitary dz

-HA -visual field defects -fatigue -polyuria -polydipsia

meds to ask about in hx for secondary amenorrhea

-OCPs -danazol -high-dose progestin

ovarian causes of secondary amenorrhea

-PCOS -primary ovarian insuff/premature ovarain failure

tx of hypothalamic amenorrhea

-adequaate calorie intake, exercise moderation, nutritional counseling -manage low bone density, may need estrogen replacement therapy

PCSO characterized by:

-androgen access -ovulatory dysfunction -polycystic ovaries

tx Asherman syndrome

-consult surgeon hysteroscopic lysis of adhesions (LOA) -estrogen therapy (stimulates growth of endometrium)

labs seen with primary ovarian insuff/premature ovarian failure

-elevated FSH -low estrogen -failed progestin withdrawal test

labs seen with hyperprolactinemia

-elevated prolactin -obtain MRI

primary ovarian insuff/premature ovarian failure characterized by:

-estrogen def -endometrial atrophy -cessation of menstruation

hypothalamus causes of secondary amenorrhea

-functional hypothalamic amenorrhea

sx estrogen def

-hot flashes -vaginal dryness -poor sleep

pituitary causes of secondary amenorrhea

-hyperprolactinemia

absence of bleeding with progestin withdrawal test indicates__ or ___

-hypoestrogenism -outflow tract disorder

labs seen with thyroid disease and secondary amenorrhea

-hypothyroidism can be ass w hyperproclactinemia -TSH can be high or low

uterine causes of secondary amenorrhea

-intrauterine adhesions (Asherman syndrome) extra-thyroid dx

labs seen with PCOS

-low/normal FSH -elevated serum total testosterone

labs seen with functional hypothalamic amenorrhea

-low/normal FSH -low estrogen

labs seen with intrauterine adhesions (asherman syndrome)

-no lab abnormalities -failed progestin/estrogen stimulation test

how to do progestine/estrogen stimulation test

-oral estradiol 1 mg/day x 35 days -medroxyprogesterone 10 mg beginning on day 26 x 10 days -absence of w/drawal bleeding = outflow tract disorder

usually see functional amenorrhea in women with BMI less than __

19

__ prevents normal build-up and shedding of endometrial cells

Asherman syndrome

MOST COMMON CAUSE OF SECONDARY AMENORRHEA

PREGNANCY UNTIL PROVEN OTHERWISE

acquired scarring of the endometrial lining, postpartum hemorrhage, endometrial infection followed by D&C

asherman syndrome

tx hyperprolactinemia

dependent on etiology

asherman syndrome prevents normal build-up and shedding of ___

endometrial cells

decrease oocyts results in decrease in ___

estrogen --> cause pit to make FSH (INC)

tx primary ovarian insufficiency

estrogen therapy for bone loss

MUST order ___ on EVERY pt with secondary amenorrhea

hCG

secondary amenorrhea ass with thyroid __ and __

hypo and hyper (BOTH)

hyper or hypothyroidism ass with hyperprolactinemia

hypothyroidism

absence of withdrawal bleeding with progestin/estrogen stimulation test indicates ___

outflow tract disorder

estrogen def, endometrial atrophy, and cessation of menstruation think

primary ovarian insuff/premature ovarian failure

best way to assess estrogen status

progestin withdrawal test -medroxyprogesterone 10mg x 10 days -w/draw bleeding confirms that there has been endogenous estrogen exposure -absence of bleeding due to either hypoestrogenism or outflow tract disorder

w/u steps for secondary amneorrhea

step 1: hCG -pregnancy mc cause of 2nd amenorrhea STOP until non-preg confirmed step 2: labs -prolactin -TSH -FSH -estrogen (E2) -PRN serum total testosterone step 3: progestin w/drawal test step 4: progestin/estrogen stimulation -if all prior labs normal & hx uterine instrumention


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