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Secondary Amenorrhea

Secondary Amenorrhea. Case 1: Large Flying Birds Delivering Gifts. Case 1:. A 25 yo female presents to your clinic with the co having missed her period the past couple of months. Is this secondary amenorrhea? What is secondary amenorrhea?. Case 1:. Secondary Amenorrhea:

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Secondary Amenorrhea

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  1. Secondary Amenorrhea

  2. Case 1: Large Flying Birds Delivering Gifts

  3. Case 1: • A 25 yo female presents to your clinic with the co having missed her period the past couple of months. • Is this secondary amenorrhea? • What is secondary amenorrhea?

  4. Case 1: • Secondary Amenorrhea: • “absence of menses for more than three cycles or six months in a woman who previously had menses” • (stolen un-gratuitously from UpToDate and our notes from last year) • Does she have secondary amenorrhea?

  5. Case 1: • She has been having her period regularly since she was 14. Her cycle is normally 28 days. The last time she had her period was 90 days ago. • Is this secondary amenorrhea? • Yes. What could be causing it?

  6. Case 1: • Frequency of causes: • Chronic anovulation (ex: PCOS) – 39% • Hypothyroid/Hyperprolactin – 20% • Weight Loss/Anorexia – 16%

  7. Case 1: • Approach to amenorrhea (of any type): • Compartment 1: • Disorders of the outflow tract or uterus. • Compartment 2: • Disorders of the ovary. • Compartment 3: • Disorders of the pituitary. • Compartment 4: • Disorders of the hypothalamus.

  8. 1) History and Physical • Ask about the different compartments/common causes of secondary amenorrhea • Stress, change in weight, diet, exercise, illness? • Acne, hirsutism, deepening of voice? • Rx? • Pmhx? • Headaches, visual field defects? Fatigue, polyuria, polydypsia, etc. ? • Hot flashes, vaginal dryness, poor sleep, decreased libido? • Galactorrhea? • Obstetric hx. • Thyroid, AI disease, renal failure, genetic etc. Functional hypothalamic amenorrhea • Hypothalamus/pituitary? • Hyperprolactinemia? • Asherman? Sheehan? • Estrogen Deficiency PCOS • Danazol, OCP, anti-psychotics?

  9. Case 1: • Physical • BMI? • Galactorrhea? • Vagina/uterus? • Etc.

  10. 2) PREGNANCY TEST!!!!!

  11. 3) TSH and PRL levels • PRL (and TRH) inhibit FSH and LH • 4) Progestin Challenge • Is there withdrawal bleeding after progesterone? • Is their body making estrogen, and can they respond to it? • Positive suggests the problem is a “progesterone deficiency. “ • Ie: they are anovulatory (PCOS, Danazol, etc.) • Negative could mean any number of things. Need to narrow down…

  12. 5) FSH level • Low/normal suggests ovaries are good. • High suggests ovarian failure. • 6) Give progesterone and Estrogen. • Bleeding suggests the problem is due to the pituitary/hypothalamus • No bleeding suggests the problem is the endometrium.

  13. Case 1: • Physical and history are unremarkable… though… • Her husband and herself use condoms as their only method of contraception. • A urine test for b-HCG is positive…

  14. Physical Exam Anatomic abnormality bleeding Normal Pregnancy Test Est/prog No blood Positive Negative High Low/normal PRL and TSH Elevated Normal FSH Progestin Challenge No blood bleeding

  15. Case 1: • You recommend she use an additional method other than just condoms to avoid pregnancy in the future.

  16. Case 2:She’s back

  17. Case 2: • The same patient comes back to see you 10 months later. • Concerned as she’s 4mo pp and still no period. She’s been breast-feeding. • Is this normal? What do you tell her?

  18. Case 2: • During pregnancy, estrogen made by the placenta stimulates PRL secretion (but inhibits the effects of PRL on breast tissue) • After birth, no more placenta  decreased estrogen. • Suckling  decreased PRL-IF produced by the hypothalamus. •  Maintained elevated PRL • And therefore, decreased FSH and LH.

  19. Case 2: • Reassure her this is normal. • Luckily, she’s on Micronor (progesterone only) for birth control. • (why?) • Plans to switch to a combined OCP after finished breast-feeding. You give her a 5 yr rx for a C-OCP.

  20. Case 3:5 years later…

  21. Case 3: • The same patient comes to your office again, 5 years later, and has brought her 5 year old daughter with her. • Her husband and herself have been trying for another child, but she hasn’t been able to get pregnant since they started trying 3ma.

  22. Case 3: • She stopped her C-OCP which she had used religiously since her first pregnancy, 2 months ago. • She also hasn’t had a period since she stopped them. • Is this normal?

  23. Case 3: • Post-pill amenorrhea • Not that common • ~1 % of women. • Shouldn’t last more than 6 mo. (12mo for depo)

  24. Case 3: • You reassure her, and tell her to keep trying. • She comes back in, 7 months after having stopped the OCPs. Still not pregnant. Still no periods either.

  25. Case 3: • You get a more complete history. • In her first pregnancy, she suffered a large post-partum bleed, due to retained products of conception. • Needed to be manually removed, via D+C. • Also suffered acute kidney failure at the time due to blood loss, but has had no problems since. • Never had menses since, but thought that was because she had always been on the pill since then.

  26. Case 3: • What are you worried about based on this history? • Asherman? • Sheehan? • Chronic Kidney Failure?!?!?!?! • Investigations? • (Cr is normal)

  27. Physical Exam Anatomic abnormality bleeding Normal Pregnancy Test Est/prog No blood Positive Negative High Low/normal PRL and TSH Elevated Normal FSH Progestin Challenge No blood bleeding

  28. Case 3: • You diagnose her with Asherman Syndrome. • Because you like wasting health care resources, you also order a U/S and a hysteroscopy. • U/S showed lack of normal uterine stripe. • Hysteroscopy confirmed too. • Can she have another baby?

  29. Case 3: • Probably • Lysis of adhesions via hysteroscopy • To prevent reformation of adhesions, either • High dose estrogen for 30d followed by progesterone for 10d • Stick a Foley in for 10d • Outcome • Restoration of menstruation in 73-92% of patients • Live delivery rates in up to 76% • Lower in px with more severe adhesions. • In our patient, the surgery was successful, and she was eventually able to conceive another child

  30. Case 4: Just to be ridiculous…

  31. Case 4: • You meet your patient again, 10 years down the road, but under different circumstances. • Her past medical history is now more extensive: • GERD • Hypertension

  32. Case 4: • You also find out that after her second pregnancy, she developed post-partum psychosis, and has been on anti-psychotics since. • Over the years since, she has also been diagnosed with depression for which she is taking a TCA. • She has also been abusing cocaine.

  33. Case 4: • Her medications she takes regularly are: • Pepcid (famotidine): 20mg BID • Verapamil: 80mg TID • Risperidone: 6mg OD • Clomipramine: 100mg OD • And guess what? She has amenorrhea again.

  34. Case 4: • She had been having her menses consistently until relatively recently, when she had some of her medications adjusted. • On exam, you note that she has galactorrhea… • Pregnancy test is negative. • What’s going on? What do you do next?

  35. Physical Exam Anatomic abnormality bleeding Normal Pregnancy Test Est/prog No blood Positive Negative High Low/normal PRL and TSH Elevated Normal FSH Progestin Challenge No blood bleeding

  36. Case 4 • Hyperprolactinemia • Tends to only cause amenorrhea when elevated to > 4x normal value (> 100microg/L ) • When associated with amenorrhea, 34% will have a pituitary mass. • Can also be caused by medications, kidney failure, increased estrogen…

  37. Rimonabant (endocannabinoids) Exogenous cannabinoids/THC

  38. Case 4: • You check her PRL and it is 104 microg/L • You switch her Risperidone to Seroquil • You switch her TCA to a SSRI • You switch her Verapamil to HCTZ • You switch her Famotidine to Omeprazole. (But only because it is associated with a better prognosis for GERD) • She still abuses cocaine though. • And her amenorrhea disappears (along with the galactorrhea). • A repeat PRL is 22 microg/L

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