Secondary amenorrhea
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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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Secondary amenorrhea

Secondary Amenorrhea


Case 1 large flying birds delivering gifts

Case 1: Large Flying Birds Delivering Gifts


Case 1

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 11

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?


Case 12

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?


Case 13

Case 1:

  • Frequency of causes:

    • Chronic anovulation (ex: PCOS) – 39%

    • Hypothyroid/Hyperprolactin – 20%

    • Weight Loss/Anorexia – 16%


Case 14

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.


Secondary amenorrhea

  • 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?


Case 15

Case 1:

  • Physical

    • BMI?

    • Galactorrhea?

    • Vagina/uterus?

    • Etc.


Secondary amenorrhea

  • 2) PREGNANCY TEST!!!!!


Secondary amenorrhea

  • 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…


Secondary amenorrhea

  • 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.


Case 16

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…


Secondary amenorrhea

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


Case 17

Case 1:

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


Case 2 she s back

Case 2:She’s back


Case 2

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?


Case 21

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.


Case 22

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.


Case 3 5 years later

Case 3:5 years later…


Case 3

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.


Case 31

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?


Case 32

Case 3:

  • Post-pill amenorrhea

    • Not that common

      • ~1 % of women.

    • Shouldn’t last more than 6 mo. (12mo for depo)


Case 33

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.


Case 34

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.


Case 35

Case 3:

  • What are you worried about based on this history?

    • Asherman?

    • Sheehan?

    • Chronic Kidney Failure?!?!?!?!

  • Investigations?

    • (Cr is normal)


Secondary amenorrhea

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


Case 36

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?


Case 37

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


Case 4 just to be ridiculous

Case 4: Just to be ridiculous…


Case 4

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


Case 41

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.


Case 42

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.


Case 43

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?


Secondary amenorrhea

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


Case 44

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…


Secondary amenorrhea

Rimonabant

(endocannabinoids)

Exogenous cannabinoids/THC


Case 45

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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