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CC July 2010 Q 53-54 Secondary amenorrhea

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jikejala's version from 2015-04-17 09:58

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Question Answer
Define secondary ammenorrhea?it is the absence of menses for > 6 months in women who previously had normal menstrual cycles and are not pregnant, lactating or menopausal
** Initial evaluation includes what 2 points?1. thorough H & P 2. pregnancy test
Secondary amenorrhea often results from thyroid disease or conditions that affect prolactin (liver or renal failure, meds, pituitary adenoma). If the pregnancy test is negative, what 2 lab tests should be ordered?1. TSH 2. prolactin
What disease is suspected if the TSH is abnormal and the prolactin level is normal?thyroid disease
If the TSH is normal but the prolactin level is abnormal, what imaging should be ordered? Why?1. MRI of the brain 2. to r/o prolactinoma
Is US of the pelvis necessary in the initial workup of secondary amenorrhea?no
When both TSH and prolactin are normal, what 3 classifications of secondary amenorrhea should be considered?1. normogonadotropic hypogonadism 2. hypergonadotropic hypogonadism 3. hypogonadotropic hypogonadism
List the 2 common causes of normogonadotropic amenorrhea?1. hyperandrogenic chronic anovulation 2. outlet obstruction
When is hyperandrogenic chronic anovulation present (a cause of normogonadotropic amenorrhea)?when a protestogen challenge test results in withdrawal bleeding
What medication challenge is given to r/o hyperandrogenic chronic anovulation as a cuase of normogonadotropic amenorrhea?Medroxyprogesterone acetate (Provera) 10 mg daily x 7-10 days although other protestogens may also be used. Withdrawal bleeding usually occurs 2-7 days after this treatment.
Hyperandrogenic chronic anovulation (a cause of normogonadotropic amenorrhea) is most often due to what disease? What does this disease do to insulin? What test should be done on these patients? List the 3 treatment modalities?1. PCOS 2. insulin resistance 3. glucose intolerance testing 4. weight loss, metformin, combination oral contraceptives (COCs) or cyclic progestational agents
Outlet obstruction ( a cause of normogonadotropic amenorrhea) is diagnosed when what happens?1. NO withdrawal bleeding from progestogen challenge and combined estrogen-progestogen challenge.
What is the most common reason for outlet obstruction (a cause of normogonadotropic amenorrhea)? Explain what happens?Asherman's syndrome (results from scarring of the endometrium due to infection or overly aggressive curettage)
What other 2 causes of outlet obstruction other than the main cause?1. cervical stenosis 2. polyps
List 2 possible testing to confirm the dx of Asherman's syndrome?1. hysteroscopy 2. hysterosalpingogram (HSG)
HYPERgonadotropic hypogonadism is characterized by ovarian failure due to what 2 causes?1. menopause 2. premature ovarian failure (due to premature menopause, genetic disorders, pelvic irradiation)
List the 2 lab tests and their levels seen in hYPERgonadotropic hypogonadism?1. FSH > 20 2. LH > 40
Premature menopause may result from what 3 disorders? Many women w/ premature menopause will also develop what other disorders?1. hypothyroidism 2. Addison's disease 3. DM 4. may also develop autoimmune disorders
If a women experiences premature menopause prior to age of 30 years, what test should be done?karyotype drawn to r/o the presence of a Y chromosome
What lab test is helpful in the evaluation of Addison's disease?morning cortisol levels
HYPOgonadotropic hypogonadism is characterized by what 2 causes?1. abnormal gonadotropin-releasing hormone secretion 2. disruption of the hypothalamic-pituitary-ovarian axis
List the 3 causes of HYPOgonadotropic hypogonadism?1. vigorous exercise 2. stress 3. rapid weight loss
Women w/ excessive weight loss should be screened for what?eating disorders
The restoration of healthy body weight usually restores what?normal menses
A cause associated with HYPOgonadotropic hypogonadism is the female athlete triad. List the 3 s/s seen in this disorder?1. disordered eating 2. amenorrhea 3. osteoporosis
Algorithm for evaluation. If there is amenorrhea (> 6 months) and a negative pregnancy test, do a TSH and prolactin level. If the TSH is abnormal and prolactin is normal, what is the dx?thyroid disease
Algorithm for evaluation. If the TSH is normal and the prolactin is abnormal, list the 2 pathways that should be taken depending on the level of the prolactin?1. if the prolactin is < 100 mcg/L, consider liver failure, renal failure, antidepressants, antipsychotics, antiHTNs, opiates, cocaine H2 blockers, breast stim 2. If the prolactin is > 100 mcg/L, do an MRI to r/o emptyl sella or prolactinoma
Algorithm for evaluation. If both the TSH and prolactin are normal, what test should be done?progestogen challenge test
Algorithm for evaluation. If both the TSH and prolactin are normal and the progestogen challenge test shows NO withdrawal bleed, what next test should be done?estrogen-progestogen challenge
Algorithm for evaluation. If both the TSH and prolactin are normal and the progestogen challenge test shows NO withdrawal bleed and the estrogen-progestogen challenge test shows withdrawal bleeding, what levels should be checked and what are the two results that could occur?1. FSH / LH 2. If FSH > 20 IU/L with LH > 40 IU/L, then there is hypergonadotropic hypogonadism (caused by premature menopause, menopause or genetic disorder) 2. If the FSH and LSH is low (< 5 IU/L), then do an MRI to r/o pituitary tumor, if the MRI is normal, then there is hypogonadotropic hypogonadism (caused by excessive exercise, chronic illness, disordered eating, excessive weight loss, hypothalmic or pituitary destruction)
Algorithm for evaluation. If both the TSH and prolactin are normal and the progestogen challenge test shows NO withdrawal bleed and the estrogen-progestogen challenge test shows NO withdrawal bleeding, what is the dx?outlet obstruction
Algorithm for evaluation. If both the TSH and prolactin are normal and the progestogen challenge test shows a withdrawal bleed, what are the possible diagnosis?normogonadotropic hypogonadism causing hyperandrogenic anovulation (like Cushing's dse, PCOS, androgen-secreting tumor)
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