Amenorrhea and Dysfunctional Uterine Bleeding

1
Amenorrhea (and Dysfunctional Uterine Bleeding)

• Elizabeth Mandell, MD

2
Amenorrhea absence of menses

• Normal cycle is 28 days
• This occurs in 15 of cycles
• 98 have cycles between 24-35 days
• Average duration 4-6 days (2-8 normal)
• Average blood loss per cycle 30 ml.
• gt 80 ml. Leads to risk for anemia

3
PRIMARY AMENORRHEA

• Patient has never menstruated
• No period by age 14 with no secondary sexual
  characteristics
• No period by age 16 regardless of secondary
  sexual characteristics

4
SECONDARY AMENORRHEA

• Previously established cycles cease

5
ALWAYS RULE OUT PREGNANCY

• Then evaluate the four parts of the system

6
(No Transcript)
7
(No Transcript)
8
REASONS FOR AMENORRHEA

• Pregnancy
• Menopause
• Thyroid/Prolactin Disorders
• Anovulation
• Outflow obstruction
• CNS/hypothalamic dysfunction
• Drugs/Stress/Nutrition
• Chromosomal/Abnormal Sexual Differentiation

9
ALWAYS RULE OUT PREGNANCY!!!!!!!

• No matter WHAT!!!

10
STEP ONE will diagnose pregnancy, thyroid
disorder, hypoprolactinemia and anovulation

• LABS
• Beta hcg
• TSH
• Prolactin
• MEDS
• Progestin challenge
• If galactorrhea, obtain MRI of pituitary/sella
  turcica

11
STEP TWO will diagnose outflow tract obstruction

• Give estrogen priming, followed by progestin
• Estrogen x 21 days
• Add progesterone for the last 5 days

12
STEP 3- will determine if lack of estrogen is due
to ovarian failure vs. altered CNS/pituitary axis

• FSH
• (LH)

13
(No Transcript)
14
I. UTERUS VAGINA OUTFLOW TRACT

• Ashermans secondary amenorrhea
• Imperforate hymen primary amenorrhea
• Vaginal septum primary amenorrhea
• Agenesis primary amenorrhea
• Testicular feminization primary amenorrhea

15
(No Transcript)
16
II. OVARY

• Chromosomes Normal-
• Menopause
• Radiation/Chemo
• Autoimmune Disorder
• Infection
• Chromosomes Abnormal-
• Primary Amenorrhea
• Premature Menopause

17
(No Transcript)
18
III. ANTERIOR PITUITARY

• Prolactin Secreting Tumors
• Sheehans Syndrome

19
IV. CNS / HYPOTHALAMUS

• Weight loss, anorexia, stress, intense exercise
• Hypothyroidism TRH/drugs which affect dopamine
• Anovulation
• Hypothalamic Suppression

20
ALWAYS, ALWAYS, ALWAYS

• RULE OUT PREGNANCY

21
CASE STUDY

• 17 year old female with primary amenorrhea. She
  is of normal weight and has mature secondary
  sexual characteristics.

22
CASE STUDY

• 15 year old with three months of secondary
  amenorrhea. She underwent normal pubertal
  development and had menarche at age 12 with
  regular cycles for three years. She is on the
  track team.

23
CASE STUDY

• 42 year old G3P3 with 5 months amenorrhea.
  Normal weight. Has been experiencing hot flashes.

24
CASE STUDY

• 28 year old G2P2 with 8 months of amenorrhea.
  Has been gaining weight lately, feels cold all of
  the time, and complains of constipation and
  fatigue.

25
CASE STUDY

• 35 year old G0 with amenorrhea for 9 months.
  Overweight. Slightly hirsute.