D A V I D A G R A I N G E R M D , M P H

Amenorrhea

Conflicts

Speakers Bureau - Abbvie

Objectives

Definitions of amenorrhea

Types of amenorrhea

Primary

Secondary

Why Estrogen Status is a KEY feature

Making the correct diagnosis

Who wants a period? Why treatment is necessary

Amenorrhea - Definitions

Primary

No menses by age 13 without breast development

No menses by age 16 with breast development

Secondary

No menses for 6 months

No menses for the equivalent of 3 “normal” cycles

Menstrual Cycle: Anti-HomeostasisDaily Incremental Changes in All Hormone Levels

Amenorrhea: Homeostasis (with some exceptions)

Categories of Amenorrhea

Pregnancy, of course

Amenorrhea = anovulation (most common)

Estrogen Status?

Amenorrhea in ovulating women (the exception)

OUTFLOW TRACT

Amenorrhea With Ovulation (Primary)

Primary Amenorrhea: Imperforate hymen Transverse vaginal septum Mullerian agenesis (partial or complete) Androgen Insensitivity Syndrome

Diagnosis Symptoms Physical exam Serum Testosterone/Karyotype

Treatment Surgical for imperforate hymen/transverse septum Dilators for blind ending vagina IVF with gestational carrier for MA Gonadectomy after puberty for AI patients (seminomas, not

gonadoblastomas)

Amenorrhea With Ovulation (Secondary)

Secondary Amenorrhea Asherman’s Syndrome

Cervical Stenosis

Hysterectomy/Endometrial Ablation

Diagnosis History – multiple LEEP/cone; or

pregnancy + instrumentation + infection

Physical exam

HSG/hysteroscopy

Treatment Surgical – lysis of intrauterine adhesions

Amenorrhea Without Ovulation

Estrogen Status – Never present, Low, Normal

Primary: Breast development?

If normal, there is/has been estrogen exposure and you can wait till age 15-16 before further evaluation

Secondary: Progesterone withdrawal bleed

+bleed = anovulation

Endometrial lining thickness on TVS

Estrogen level/FSH level

Estrogen…

Low Estrogen

Cannot make it! (AKA no eggs) Primary Amenorrhea

Gonadal dysgenesis - 46 XX, 46 XY (Swyer’s syndrome), others

Secondary Amenorrhea

Gonadectomy

Premature ovarian insufficiency

Radiation, chemotherapy, ovarian surgery

Menopause

Evaluation?

SERUM FSH WILL BE HIGH

Karyotype (All patients under 40? Looking for SRY)

FMR1 testing (Fragile X )

Low Estrogen – Cannot Make EstrogenHypergonadotropic Hypogonadism

Low Estrogen

No Signal to Make Estrogen (Hypothalamic Amenorrhea) Primary

Constitutional delay? Midline brain tumors – craniopharyngioma, hamartoma Eating disorders/Over-exercise Kallman’s Syndrome

Secondary Midline tumors Hyperprolactinemia (hypothyroidism) Eating disorders/Female Athlete Triad

Evaluation MRI Counseling regarding eating disorders/Female Athlete Triad Testing for anosmia TSH/PRL

Low Estrogen – No SignalHypogonadotropic Hypogonadism

Amenorrhea With NORMAL Estrogen

Anovulation Most common diagnosis after pregnancy

Likely to be PCOS

Evaluation TVS – endometrium and ovarian morphology

Labs: FSH, LH, E2, T, DHEAS, 17-OHP, ?AMH

Virilization? T>200ng/ml, DHEAS > 700ng/Dl, look for tumors

Progesterone withdrawal will be positive (unless very hyperandrogenic with thin endometrium)

Treatment COH if wanting pregnancy

OCP’s/Spironolactone/metformin/Diet/Exercise

Anovulation

Treatment:I really don’t want to have a period…

Low Estrogen

ALL the risks of hypoestrogenism

Vaginal/Urogenital Atrophy

Osteoporosis

Heart disease

Address the underlying cause

Replace estrogen – if uterus present, need to replace progesterone also

Treatment:I really don’t want to have a period…

Normal estrogen

PCOS patients with anovulation

Have UNOPPOSED estrogen production

Have a risk of endometrial hyperplasia/endometrial cancer

Need either to ovulate (if seeking pregnancy) or take OCP’s

Benefits of OCP’s

Progesterone protection for endometrial hyperplasia

Estrogen – increased SHBG, decreased Free T; suppresses LH, decreasing total T

Summary - Amenorrhea

Definition – no menses by age 13 without or 15 with breast development; 6 months or 3 cycle lengths for secondary amenorrhea

Rule out pregnancy

Establish outflow tract patency/presence

Determine estrogen status (breast development or withdrawal bleed)

Low estrogen? Can’t make it, or no signal to make it? (FSH levels are helpful)

Quiz

51 year old presents with one year of amenorrhea. Evaluation and diagnosis?

A 9 year old patients mother calls and is worried that her daughter hasn’t started her period. Evaluation and diagnosis?

A 19 year old patient presents with 8 months of amenorrhea, and normal secondary sex characteristics. Evaluation and diagnosis?

Quiz

A 15 year old patient presents (for the 3rd time) to the ER with increasing cyclical pelvic pain. Evaluation and diagnosis?

A 28 year old patient presents with one year of amenorrhea. She just completed an Iron Man in Hawaii. Evaluation and diagnosis?

A 35 year old patient presents with 8 months of amenorrhea, also complains of a breast discharge for the last 3 months. Evaluation and diagnosis?