qr code excel SECONDARY AMENORRHEA & MENOPAUSE in Objective-C

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SECONDARY AMENORRHEA & MENOPAUSE
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Secondary amenorrhea is defined as the absence of menses for 3 consecutive months in women who have passed menarche Menopause is defined as the terminal episode of naturally occurring menses; it is a retrospective diagnosis, usually made after 6 months of amenorrhea
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D Uterine Causes (with Normal FSH)
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Infection of the uterus commonly occurs following delivery or D&C but may occur spontaneously Endometritis due to tuberculosis or schistosomiasis should be suspected in endemic areas Endometrial scarring may result, causing amenorrhea (Asherman s syndrome) Such women typically continue to have monthly premenstrual symptoms The vaginal estrogen effect is normal
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Etiology
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The causes of secondary amenorrhea include pregnancy, hypothalamic-pituitary causes, hyperandrogenism, uterine causes, premature ovarian failure, and menopause
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A Pregnancy (High hCG)
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Pregnancy is the most common cause for secondary amenorrhea in women of childbearing age The differential diagnosis includes rare ectopic secretion of hCG by a choriocarcinoma or bronchogenic carcinoma
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E Premature Ovarian Failure (with High FSH)
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This refers to primary hypogonadism that occurs before age 40 years It affects about 1% of women About 30% of such cases are due to autoimmunity against the ovary About 8% of cases are due to X chromosome mosaicism Other causes include surgical bilateral oophorectomy, radiation therapy for pelvic malignancy, and chemotherapy Women who have undergone hysterectomy are prone to premature ovarian failure even though the ovaries were left intact Myotonic dystrophy, galactosemia, and mumps oophoritis are additional causes Other cases may be familial or idiopathic Ovarian failure is usually irreversible
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B Hypothalamic-Pituitary Causes (with Low or Normal FSH)
The hypothalamus must release GnRH in a pulsatile manner for the pituitary to secrete gonadotropins GnRH pulses occurring more than once per hour favor LH secretion, while less frequent pulses favor FSH secretion In normal ovulatory cycles, GnRH pulses in the follicular phase are rapid and favor LH synthesis and ovulation; ovarian luteal progesterone is then secreted that slows GnRH pulses, causing FSH secretion during the luteal phase Most women with hypothalamic amenorrhea have a persistently low frequency of GnRH pulses Secondary hypothalamic amenorrhea may be caused by stressful life events such as school examinations or leaving home Such women usually have a history of normal sexual development and irregular menses since menarche Amenorrhea may also be the result of strict dieting, vigorous exercise, organic illness, or anorexia nervosa Intrathecal infusion of opioids causes amenorrhea in most women These conditions should not be assumed to account for amenorrhea without a full physical and endocrinologic evaluation Young women in whom the results of evaluation and progestin withdrawal test
F Menopause (with High FSH)
Climacteric is defined as the period of natural physiologic decline in ovarian function, generally occurring over about 10 years By about age 40 years, the remaining ovarian follicles are those that are the least sensitive to gonadotropins Increasing titers of FSH are required to stimulate estradiol secretion Estradiol levels may actually rise during early climacteric The normal age for menopause in the United States ranges between 48 and 55 years, with an average of about 515 years Serum estradiol levels fall and the remaining estrogen after menopause is estrone, derived mainly from peripheral aromatization of adrenal androstenedione Such peripheral production of estrone is enhanced by obesity and liver disease Individual differences in estrone levels partly explain why the
Endocrine Disorders
symptoms noted above may be minimal in some women but severe in others
CMDT 2008
Clinical Findings
A Symptoms and Signs
All women with amenorrhea require a complete history and physical examination Nausea and breast engorgement are typical signs of early pregnancy Headache or visual field abnormalities are seen with pituitary or hypothalamic tumors Complaints of thirst and polyuria require evaluation; diabetes insipidus implicates a hypothalamic lesion Goiter may be due to hyperthyroidism Weight loss, diarrhea, or skin darkening may indicate adrenal insufficiency Weight loss with a distorted body image implicates anorexia nervosa The breasts are examined carefully for galactorrhea, a common sign of hyperprolactinemia Hirsutism or virilization may be a sign of hyperandrogenism Manifestations of hypercortisolism (eg, weakness, psychiatric changes, hypertension, central obesity, hirsutism, thin skin, ecchymoses) may indicate alcoholism or Cushing s syndrome Signs of acromegaly or gigantism may also indicate a pituitary tumor Signs of systemic illness (eg, cirrhosis, renal failure) should be appreciated Various drugs may elevate PRL and cause amenorrhea (see section on Hyperprolactinemia) Needle tracks may indicate heroin or amphetamine abuse Psychological symptoms of climacteric may include depression and irritability Women may experience fatigue, insomnia, headache, diminished libido, or rheumatologic symptoms Vasomotor instability (hot flushes) is experienced by 80% of women, lasting seconds to many minutes Hot flushes with drenching sweats may be most severe at night or may be triggered by emotional stress Some women continue to menstruate for many months despite symptoms of estrogen deficiency The acute symptoms of estrogen deficiency noted above tend to decline in severity within several years after menopause However, about 35% of women have symptoms for more than 5 years The late manifestations of estrogen deficiency include urogenital atrophy with vaginal dryness and dyspareunia; dysuria, frequency, and incontinence may occur Increased bone osteoclastic activity increases the risk for osteoporosis and fractures The skin becomes more wrinkled Increases in the LDL:HDL cholesterol ratio cause an increased risk for arteriosclerosis A careful pelvic examination is always required to check for uterine or adnexal enlargement and to obtain a Papanicolaou smear and a vaginal smear for assessment of estrogen effect Various life stresses, vigorous exercise, and crash dieting all predispose to amenorrhea; however, such factors should not be assumed to account for amenorrhea without a complete workup to screen for other causes
elevated hCG receive further laboratory evaluation including serum PRL, FSH, LH, TSH, and plasma potassium Hyperprolactinemia or hypopituitarism (without obvious cause; see section on Hypopituitarism) should prompt an MRI study of the pituitary region Routine testing for renal and hepatic function (eg, BUN, serum creatinine, bilirubin, alkaline phosphatase, and alanine aminotransferase) is also performed A serum testosterone level is obtained in hirsute or virilized women Patients with manifestations of hypercortisolism receive a 1-mg overnight dexamethasone suppression test for initial screening (see section on Cushing s syndrome) Nonpregnant women without any laboratory abnormality may receive a 10-day course of a progestin (eg, medroxyprogesterone acetate, 10 mg/d); absence of withdrawal menses typically indicates a lack of estrogen or a uterine abnormality
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