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Beck - Amenorrhea

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					AMENORRHEA

Dr, Walaa Ahmed, MD,
 Incidence of Primary Amenorrhea

Less than .1%

Puberty
  Breast:       10.8 +/- 1.10 yrs.
  Pubic Hair:   11.0 +/- 1.21 yrs.
  Menarche      12.9 +/- 1.2 yrs.
Onset of Puberty and    Menstruation
Ratio of fat to both total body weight and
lean body weight
Moderate obesity (20 – 30 % above ideal
body weight) = earlier menarch
Malnutrition (anorexia nervosa, starvation)
= delay
Prepubertal strenuous exercise (less total
body fat) = delay e.g. ballet dancers,
swimmers, runners
      Diagnostic Evaluation by
          Compartments
I     Outflow Tract (uterus – vagina)
II    Ovary
III Anterior Pituitary
IV CNS – Hypothalamus (environment
   and     psyche)
            Evaluation
History/Physical
Psychiatric, family history-genetic
abnormalities, nutritional status,
growth/development
Secondary sexual characteristics
Presence of breasts – normal reproductive
tract (uterus, vagina)
 Evaluation Categories

Breast Absent – Uterus Present
Breast Present – Uterus Present
Breast Present – Uterus Absent
Breast Absent – Uterus Absent
 Initial Tests for Amenorrhea

Progesterone challenge
TSH
Prolactin
   TSH elevated – hypothyroid
   Prolactin elevated (MRI – 100 ng/ml)
   Progesterone Challenge

Positive withdrawal bleed
Normal prolactin
Normal TSH
Diagnosis = annovulation
Treatment: monthly progesterone/O.C.
         Progesterone
      Negative Withdrawal
FSH/LH
FSH/LH normal – estrogen/progesterone
cycle
If negative = end organ defect
If FSH/LH high = ovarian failure
Estrogen – positive withdrawal, FSH
normal or low, MRI sella = no path
Diagnosis: hypothalamic amenorrhea
   Chromosome Evaluation for
        Ovarian Failure
If the patient is under age 30 – karyotype
Y chromosome/excision of gonadal area
Problem – gonadal tumor – malignant
30% do not develop virilization, therefore
even normal appearing female needs
karyotype to exclude Y
After age 30 = premature menopause
      Selected Blood Test for
       Autoimmune Disease
Calcium, phosphorus
Fasting blood sugar
A.M. cortisol
Free T4 – TSH
Thyroid antibodies
CBC – ESR – CRP
Total protein A/G ratio
Rheumatoid factor
Antinuclear antibody
            Specific Disorders
I Outflow - imperforate hymen, ashermans
   mullerian agenesis, androgen insensitivity syndrome
II Ovary - can be primary or secondary amenorrhea
   40% of primary amenorrhea have gonadal streaks
       Of the 40%, 50% = 45,X
                     25% = mosaics
                     25% = 46 XX
       Secondary amenorrhea patients have many
       karyotypes
        Specific Disorders
           (continued)
Turner syndrome
Gonadal dysgenesis
Gonadal agenesis
Savage syndrome
Premature ovarian failure
Radiation therapy
Alkylating agents
          Compartment III
Anterior pituitary disorders
Tumors – large bitemperal hemianopsia
Small tumors – visual defects- rare
Craniopharyngioma – calcification x-ray may
produce blurring of vision
Acromegaly
Cushings
Pituitary prolactin adenomas (micro/macro)
Sheehan’s syndrome
         Compartment IV

CNS disorders
 Hypothalamic amenorrhea – problem is a
 GNRH pulsatile secretion
 Anorexia/Bulemia/weight loss – 25%
 (onset – 10 – 30 years)
 Exercise
        Etiology of Amenorrhea
                   Uterus Absent       Uterus Present

Breast – Absent    17, 20 desmolase    1. Gonadal failure
                   deficiency          turner 45X
                   17 a hydroxylase    Gonadal dysgenisis
                   deficiency 46xy
                   Agonadism           17 a hydroxylase
                                       deficiency with
                                       46XX
                                       2. Hypothalamic
                                       failure
                                       3. Pituitary failure

Breast – Present   AIS (T.F.)          Hypothalamic,
                                       pituitary, ovarian pt
                                       uterine etiology
                   Mullerianagenesis

				
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Description: Beck, AMENORRHEA AMENORRHEA Paul MD, FACOG, FACS Incidence of Primary Amenorrhea Incidence Less than .1% Puberty Breast: Breast: Pubic Hair: ...