11 Amenorrhea (Secondary)
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
