Beck - Amenorrhea-1

Beck - Amenorrhea-1 - AMENORRHEA AMENORRHEA Paul Beck MD...

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Unformatted text preview: AMENORRHEA AMENORRHEA Paul Beck, MD, FACOG, FACS Incidence of Primary Amenorrhea Incidence Less than .1% Puberty Breast: Breast: Pubic Hair: Menarche 10.8 +/- 1.10 yrs. 10.8 11.0 +/- 1.21 yrs. 12.9 +/- 1.2 yrs. Onset of Puberty and Onset Menstruation Ratio of fat to both total body weight and Ratio lean body weight lean Moderate obesity (20 – 30 % above ideal Moderate body weight) = earlier menarch body Malnutrition (anorexia nervosa, starvation) Malnutrition = delay delay Prepubertal strenuous exercise (less total Prepubertal body fat) = delay e.g. ballet dancers, swimmers, runners swimmers, Diagnostic Evaluation by Compartments Compartments I Outflow Tract (uterus – vagina) II Ovary III Anterior Pituitary IV CNS – Hypothalamus (environment CNS and psyche) psyche) Evaluation Evaluation History/Physical Psychiatric, family history-genetic Psychiatric, abnormalities, nutritional status, growth/development growth/development Secondary sexual characteristics Presence of breasts – normal reproductive Presence tract (uterus, vagina) tract Evaluation Categories Evaluation Breast Absent – Uterus Present Breast Present – Uterus Present Breast Present – Uterus Absent Breast Absent – Uterus Absent Initial Tests for Amenorrhea Initial Progesterone challenge TSH Prolactin TSH elevated – hypothyroid Prolactin elevated (MRI – 100 ng/ml) Progesterone Challenge Progesterone Positive withdrawal bleed Normal prolactin Normal Normal TSH Normal Diagnosis = annovulation Treatment: monthly progesterone/O.C. Progesterone Negative Withdrawal Negative FSH/LH FSH/LH normal – estrogen/progesterone FSH/LH cycle cycle If negative = end organ defect If FSH/LH high = ovarian failure Estrogen – positive withdrawal, FSH Estrogen normal or low, MRI sella = no path normal Diagnosis: hypothalamic amenorrhea Chromosome Evaluation for Ovarian Failure Ovarian If the patient is under age 30 – karyotype Y chromosome/excision of gonadal area Problem – gonadal tumor – malignant 30% do not develop virilization, therefore 30% even normal appearing female needs karyotype to exclude Y karyotype After age 30 = premature menopause Selected Blood Test for Selected Autoimmune Disease Calcium, phosphorus Fasting blood sugar A.M. cortisol Free T4 – TSH TSH Thyroid antibodies CBC – ESR – CRP Total protein A/G ratio Rheumatoid factor Antinuclear antibody Specific Disorders Specific I Outflow - imperforate hymen, ashermans mullerian agenesis, androgen insensitivity syndrome II Ovary - can be primary or secondary amenorrhea Ovary 40% of primary amenorrhea have gonadal streaks 40% Of the 40%, 50% = 45,X Of 50% 25% = mosaics 25% 25% = 46 XX Secondary amenorrhea patients have many Secondary karyotypes karyotypes Specific Disorders Specific (continued) Turner syndrome Gonadal dysgenesis Gonadal agenesis Savage syndrome Premature ovarian failure Radiation therapy Alkylating agents Compartment III Compartment Anterior pituitary disorders Tumors – large bitemperal hemianopsia Tumors Small tumors – visual defects- rare Small Craniopharyngioma – calcification x-ray may Craniopharyngioma produce blurring of vision produce Acromegaly Cushings Pituitary prolactin adenomas (micro/macro) Sheehan’s syndrome Compartment IV Compartment CNS disorders Hypothalamic amenorrhea – problem is a Hypothalamic GNRH pulsatile secretion GNRH Anorexia/Bulemia/weight loss – 25% Anorexia/Bulemia/weight (onset – 10 – 30 years) (onset Exercise Etiology of Amenorrhea Etiology Uterus Absent 17, 20 desmolase 17, deficiency deficiency 1. Gonadal failure 1. turner 45X turner 17 a hydroxylase 17 deficiency 46xy deficiency Gonadal dysgenisis Gonadal Agonadism Agonadism Breast – Absent Uterus Present 17 a hydroxylase 17 deficiency with 46XX 46XX 2. Hypothalamic 2. failure failure 3. Pituitary failure Breast – Present AIS (T.F.) Mullerianagenesis Hypothalamic, Hypothalamic, pituitary, ovarian pt uterine etiology uterine ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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