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AMENORRHEA

AMENORRHEA. Paul Beck, MD, FACOG, FACS. 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

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AMENORRHEA

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  1. AMENORRHEA Paul Beck, MD, FACOG, FACS

  2. 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.

  3. 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

  4. Diagnostic Evaluation by Compartments I Outflow Tract (uterus – vagina) II Ovary III Anterior Pituitary IV CNS – Hypothalamus (environment and psyche)

  5. Evaluation • History/Physical • Psychiatric, family history-genetic abnormalities, nutritional status, growth/development • Secondary sexual characteristics • Presence of breasts – normal reproductive tract (uterus, vagina)

  6. Evaluation Categories • Breast Absent – Uterus Present • Breast Present – Uterus Present • Breast Present – Uterus Absent • Breast Absent – Uterus Absent

  7. Initial Tests for Amenorrhea • Progesterone challenge • TSH • Prolactin TSH elevated – hypothyroid Prolactin elevated (MRI – 100 ng/ml)

  8. Progesterone Challenge • Positive withdrawal bleed • Normal prolactin • Normal TSH • Diagnosis = annovulation • Treatment: monthly progesterone/O.C.

  9. 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

  10. 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

  11. Selected Blood Test forAutoimmune 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

  12. 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

  13. Specific Disorders(continued) • Turner syndrome • Gonadal dysgenesis • Gonadal agenesis • Savage syndrome • Premature ovarian failure • Radiation therapy • Alkylating agents

  14. 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

  15. Compartment IV CNS disorders • Hypothalamic amenorrhea – problem is a GNRH pulsatile secretion • Anorexia/Bulemia/weight loss – 25% (onset – 10 – 30 years) • Exercise

  16. Etiology of Amenorrhea Breast – Absent Breast – Present

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