Learning Objectives: I - A. Menstrual Cycle

3.08
Amenorrhea
Dr. Carmencita B. Tongco, 4/19/18
I. MENSTRUATION
A. Menstrual Cycle
II. AMENORRHEA
A. Types of Amenorrhea
1. Why treat Amenorrhea?
B. Primary Amenorrhea
C. Secondary Amenorrhea
D. Categories of Amenorrhea
III. PRIMARY AMENORRHEA
A. Turner Syndrome
B. Swyer Syndrome
C. Imperforate Hymen
D. Androgen Insensitivity Syndrome
E. Mayer-‐Rokitansky-‐Kuster-‐Hauser Syndrome
IV. SECONDARY AMENORRHEA
A. Polycystic Ovarian Syndrome
B. Functional Hypothalamic Amenorrhea
C. Hyperprolactinemia due to Pituitary Adenoma
D. Primary Ovarian Insufficiency Figure 1. Hypothalamic-‐Pituitary-‐Ovarian Axis.
V. CAUSES OF AMENORRHEA
The secretion of the hormones should follow a certain pattern.
A. Anatomic Defects
GnRH should be secreted not in a continuous fashion but in
1. Tips in Amenorrhea workup pulsatile fashion.
VI. TIPS IN AMENORRHEA WORKUP If the secretion is pulsatile the response of the pituitary
A. History specifically the FSH and LH secretion will also be good.
B. Physical Examination If the secretion is continuous, we call it tonic, and the response
VII. PRIMARY AMENORRHEA: THE WORK-‐UP of the pituitary the gonadotropins (FSH, LH) go down.
VIII. SECONDARY AMENORRHEA: THE W ORK-‐UP
IX. WAYS TO DETERMINE ESTROGEN STATUS I-‐A. MENSTRUAL CYCLE
X. TREATMENT OF AMENORRHEA: G UIDELINES
LEARNING OBJECTIVES
At the end of the lecture, the student must be able to:
• Define amenorrhea
• Enumerate and define types of amenorrhea
• Enumerate the different causes of amenorrhea and their
clinical features
• Explain the importance of diagnosis and treatment of
amenorrhea
• Explain the workup for primary and secondary amenorrhea
• Discuss the rationale for the laboratory tests
• Discuss treatment guidelines
I. MENSTRUATION
• The presence of menstruation means a normal or intact:

o Hypothalamic-‐Pituitary-‐Ovarian connection
o Outflow tract (uterus, cervix, vagina)

Figure 2. Menstrual Cycle.
FSH and LH have a role in the development of the follicle. As

the follicle grows, it secretes the hormones (estrogen,
progesterone) and these two hormones are responsible for
changing the endometrium, into a proliferative and secretory
phase.
1 of 10 | Amenorrhea (Manalac, Marcial, Martin, Masorong, Mendoza) | Editor: Tarabi

3.08 Amenorrhea [Dr. Carmencita B. Tongco]
Withdrawal of progesterone leads to menstruation. The most frequent cause of secondary amenorrhea is
hypothalamic dysfunction.
II. AMENORRHEA
II-‐D. CATEGORIES OF AMENORRHEA
• It is the absence of menses
• It could be a sign of abnormality in the: Table 1. Categories of Amenorrhea based on Gonadotropin and
o Hypothalamic-‐Pituitary-‐Ovarian connection Estrogen levels
o Outflow tract (uterus, cervix, vagina) Type of LH/FSH Estrogen Primary
The most important and probably most common cause of Hypogonadism Defect
amenorrhea in adolescent girls is anorexia nervosa Hypergonadotropic High Low Ovary
Hypogonadotropic Low Low Hypothalamus/
II-‐A. TYPES OF AMENORRHEA Pituitary
Eugonadotropic Normal Normal Varied
• 2 types:

o Physiologic – pregnancy & lactation, menopause

o Pathologic – 2 types:
• Primary
No menses ever
• Secondary
A woman has been previously
menstruating and then suddenly stops
menstruating
II-‐A-‐1. WHY TREAT AMENORRHEA (PATHOLOGIC)
• Incidence of pathologic amenorrhea: in 3-‐4% of women

• May be a sign/symptom of a more serious underlying disease
• Failure to treat may lead to serious medical and surgical
complications (pituitary tumor)
• Results in physical, mental, emotional, social, and even legal
consequences
Figure 4. HPO Axis.
II-‐B. PRIMARY AMENORRHEA
III. PRIMARY AMENORRHEA
It is defined as the absence of menses in a woman who has
never menstruated by the age of 16.5 years. III-‐A. TURNER SYNDROME
Another definition: girls who have not menstruated within 5
years of breast development. Breast development should occur CASE 1
by age 13 or otherwise requires evaluation. Linda Hunt, 70 years old, Hollywood actress
• Age of 15 years old, no menses, yet with secondary sexual • Turner Syndrome – 45 XO
characteristics • Infantile characteristics
• Age of 13 years old, no menses, no secondary sexual • Small / short stature
characteristics • could have received growth hormone to improve height
Gonadal failure is the most common cause of primary
amenorrhea, accounting for almost 50% of patients with this • Most common cause of primary amenorrhea
disorder. Have a distinct physical appearance
Have a very small uterus. It has not been stimulated with
estrogen
• 45XO or mosaic -‐ streak gonads, small stature
Two X’s is needed for normal height development, if
there is a problem with one of your X, you will be under 5
feet
You also need two X for the full development of the ovary
• Hypergonadotropic hypogonadism = LOW Estrogen
• History: Lacks pubertal development, incomplete development
of ovaries normal intelligence
Figure 3. Normal Puberty in Girls/Women. Normal Puberty:
• Physical Examination: Less than 5 feet, low set ears, webbed
Thelarche > Growth spurt > Adrenarche > Menarche
neck, broad chest, infantile breasts, no axillary nor pubic hair,
reproductive tract is female but uterus is infantile
II-‐C. SECONDARY AMENORRHEA
• Concerns: Appearance, height, fertility
• Absent menses in a previously menstruating woman • Diagnosis: FSH elevated, estrogen low (feedback is not
o > / = 3 months, if with regular cycles working), karyotyping
o > / = 6 months, if with irregular cycles

• Treatment: Hormones to promote secondary sexual

development, growth hormone, oocyte donation & IVF

Figure 5. Turner Syndrome Karyotype

Figure 7. Swyer Syndrome.
III-‐C. IMPERFORATE HYMEN
CASE 2
nd
IH, 13 years old, 2 year HS
• No menarche
• Felt very insecure with friends
• Cyclic hypogastric pain and a mass
• Imperforate hymen with hematocolopos and
hematometra
• Hymenotomy done
• Menses came regular, monthly

• Failure of degeneration of epithelial cells of hymen

• Normal pubertal development
Figure 6. Turner Syndrome Clinical presentation • Cyclic pain +/-‐ mass
• PE: Bulging bluish mass on introitus
III-‐B. SWYER SYNDROME
• Treatment: Hymenotomy
• Complications: infection, endometriosis, acute abdomen
• Pure gonadal dysgenesis
• Obstruction causes the blood to get trapped in the vagina
• 46 XX or mosaic – streak gonads, small stature
and if it is so full it can get to the uterus and it can also
• 46 XY (problem is in the gonads, Mullerian-‐inhibiting substance
regurgitate to the abdominal cavity, so it is the cause of
is absent = organ looks like for females)
the pain and mass.
• Hypergonadotropic hypogonadism = LOW Estrogen

• History: lacks pubertal development, normal intelligence
• PE: less than 5 feet, infantile breasts, no axillary nor pubic hair,
reproductive tract is female but uterus is infantile
• Concerns: appearance, height, fertility
• Diagnosis: FSH elevated, estrogen low, karyotyping
• Treatment: hormones to promote secondary sexual
development, growth hormone, oocyte donation & IVF
Figure 8. Imperforate Hymen Before and After Surgery. It’s a
Swyer and Turner belong under gonadal dysgenesis, their
bulging and bluish hymen (sign of an imperforate hymen). After
difference lies under karyotyping: karyotype of Turner (45XO =
being perforated, what came out was something like melted
abnormal), karyotype of Swyer could be normal
chocolate syrup – that’s old blood. Then they try to tie the edges of
If you do a karyotype in Turner and Swyer and you see a Y, that
the hymen to keep it open, to make an open vagina.
predisposes the patient to malignant degeneration of the
streak gonad, so you have to remove/operate on it
It is important to do a workup on these patients


III-‐D. ANDROGEN INSENSITIVITY SYNDROME • Make sure to check skeletal (spine), kidneys (develop at the
same time with your reproductive organs), and hearing loss
CASE 3
A.I. 28 year old, newly married
• With breasts but no pubic/axillary hair
• No uterus, no vagina
• Androgen insensitivity syndrome
• 46XY, male testosterone levels
• Gender?
Figure 10. Mayer-‐Rokitansky-‐Kuster-‐Hausen Syndrome with
• X-‐linked recessive disorder – 46XY congenital absence of uterus.
• Defect in androgen receptors, but testes are normal (inguinal
area) IV. SECONDARY AMENORRHEA
• Female phenotype: (+) breasts, no hair, external genitalia but
no vagina and uterus and with enlarged clitoris IV-‐A. POLYCYSTIC OVARIAN SYNDROME
• Diagnosis:
o UTZ – absent uterus/vagina and ovaries CASE 5
o Serum testosterone – normal male level PCOS, 34-‐years old with infertility
o Karyotype: 46 XY • Polycystic ovarian syndrome
• Treatment: gonadectomy, gender reversal (?), neovagina • Irregular menses, acne and hirsutism, polycystic ovaries
The testes of individuals with androgen resistance have on ultrasound
approximately a 20% chance of becoming malignant after the • Obese
age of 20 years. • No treatment
• At 36 years old, diabetic, MI, endometrial carcinoma

• 20% of amenorrhea

• State of hyerinsulinemia and insulin resistance which stimulates
androgen production in the ovary
• May also have lifelong health concerns
o Heart disease
o DM
o Liver disease
o Endometrial cancer
o Infertility
o Poor pregnancy outcome
• Diagnosis: amenorrhea hyperandrogenism, polycystic ovaries

Figure 9. Androgen Insensitivity syndrome (UTZ) (Rotterdam Criteria for PCOS)
o Testosterone increased
III-‐E. MAYER-‐ROKITANSKY-‐KUSTER-‐HAUSER SYNDROME o +/-‐ obesity
o Check 2 hr 75gm OGTT, Lipids, liver function
CASE 4 • Treatment:
M.R.K.H.S. 42 years old, married for 1 year o Prevent endometrial hyperplasia (COC/ progesterone)
• Unsatisfactory sex o Prevent metabolic complications (weight loss –
• 46XX Metformin)
• No uterus, 1 cm vaginal dimple o Treat acne and hirsutism with antiandrogens/ cyproterone
• Congenital absence of uterus acetate
• Neovagina reconstruction o Ovulation induction for fertility

• Mullerian agenesis or congenital absence of uterus

• Failure of mullerian duct development
• Normal ovaries5
• 1 in 4000-‐5000 of female births; 15% of primary amenorrhea
nd
(2 most common cause of primary amenorrhea)
• Normal height, thelarche, adrenarche
• PE: (+) breast and pubic hair, female external genitalia; no
vagina, no uterus
• Diagnosis: UTZ, karyotype 46XX, normal E2 levels
Figure 11. PCOS. Left: Typical PCOS patient, Right: polycystic
• Treatment: vaginal dilators, neovagina, surrogacy
ovaries on ultrasound. See appendix for bigger picture
• Check: Skeletal, kidneys, hearing loss

Lifted from 2018A:
• May have rudiments of uterus but still no vagina

IV-‐B. FUNCTIONAL HYPOTHALAMIC AMENORRHEA § Treatment: microadenomas are treated with Bromocriptine
(an ergot-‐derived dopamine agonist, which inhibits prolactin
CASE 6 release); bigger tumors need surgery
Karen Carpenter, died at 32 years old
• Anorexia nervosa IV-‐D. PRIMARY OVARIAN INSUFFICIENCY
• Hypoestrogenic and amenorrhea: functional amenorrhea
• Osteoporosis CASE 8
POI, 27 y/o, soon-‐to-‐be bride

• Absence of organic pathology

• Irregular menses for 2 years
o May lead to osteoporosis if anorexia persists
• Hot flashes
• Associated with abnormal GnRH pusles/LH pulses • Primary ovarian insufficiency due to an autoimmune
• Causes: condition
o Sudden and excessive weight loss (anorexia • Elevated FSH
nervosa/bulimia) or weight gain • Fertility
o Excessive exercise
• Premature ovarian failure

o Stress
o Chronic illness • Menopause before age 40 (allowable age to have
o Malnutrition menopause)
• Loss of ovarian follicles
• Check estrogen levels: hypothalamic dysfunction vs.
• Causes: trauma (surgery), chemotherapy, radiation,
hypothalamic failure
autoimmune oophoritis, or mutations
• Treat if hypoestrogenic – risk of osteoporosis • Diagnosis: ANA, antithyroid antibodies, TSH; karyotype if <25
o Give estrogen supplementation y/o
• Concerns: fertility, consequences of estrogen deficiency (e.g.
vasomotor symptoms, genitourinary symptoms,
osteoporosis, heart disease, cognitive decline, colon CA)
o For fertility, she could still get pregnant (be a
surrogate mother) but she would require donor
oocytes.
• Treatment: Treat underlying cause, HRT, oocyte donation
V. CAUSES OF AMENORRHEA
Note: The table below was lifted from 2018B. The contents are the
same as the ones in the lecturer’s PowerPoint, albeit a change in
format.
HPO AXIS
§ Trauma § Surgery

Figure 12. Functional Hypothalamic Amenorrhea § Drugs § Anoxia
Pathophysiology § Chemotherapy § Tumors
§ Radiation § Infection
IV-‐C. HYPERPROLACTINEMIA DUE TO PITUITARY ADENOMA
HYPOTHALAMUS
CASE 7 § GnRH Deficiency (Kallman Syndrome)
PA, 28 y/o § Functional Hypothalamic amenorrhea: weight loss, eating
• Irregular and scanty menses disorders, excessive exercise, stress, prolonged illness
• Milky nipple discharge § Hypothalamic dysfunction, Hypothalamic failure
• Headache, blurred vision § Other syndromes: Prader-‐Willi, Lawrence-‐Moon-‐Biedl, Leptin
• Elevated serum prolactin Mutations
• CT scan: pituitary tumor
• Bromocriptine (dopamine agonist – inhibit prolactin) à HYPOTHALAMIC HYPOTHALAMIC FAILURE
Decrease in tumor size, regular menses DYSFUNCTION
§ Normal estrogen levels § Low estrogen and FSH
• Amenorrhea + Galactorrhea = Hyperprolactinemia § No CNS organic pathology § No CNS organic pathology
§ Abnormality in GNRH and § Risk of osteoporosis
• Causes: pituitary adenoma secreting prolactin; high levels of
LH pulses § Treatment: hormone
prolactin inhibiting GnRH secretion
§ Treatment: cycle replacement therapy
• Diagnosis:
regulation, ovulation
o Symptoms: amenorrhea, milky nipple discharge,
induction agents
headache, blurring of vision
It is important to specify if it a dysfunction or a failure. Because
o Laboratory: Prolactin elevated
which of them do we treat, dysfunction or failure? Of course, it’s
o CT/MRI scan of pituitary: (+) tumor
failure because there is low estrogen which puts them at risk for

CVD, cognitive decline, osteoporosis Alzheimer’s, colon cancer, V-‐A-‐1. TIPS IN AMENORRHEA WORKUP
etc.
PITUITARY GLAND • #1 Rule out PREGNANCY
In the pituitary, the most common reason would be TUMORS! • Determine if Primary or Secondary
§ Empty sella syndrome – pituitary resides in the sella turcica. If o REMEMBER! Primary if patient never had any menarche;
this compartment is filled with CSF, and the pituitary cannot be while secondary, patient was previously menstruating and
seen there – this is what you called an empty sella. Where is it? there was cessation of menses.
It may have been pushed or flattened, and so this patient • If PRIMARY, think GENETIC (Chromosomal or enzyme
cannot secrete the hormones that are released by this gland – deficiencies) or ANATOMIC (congenital).
FSH, LH, Prolactin, ACTH, Growth Hormone, Oxytocin, etc. • If SECONDARY, think ENDOCRINE or ANATOMIC (acquired)
§ Genetic causes of hypopituitarism disorders.
§ Others: hypothyroidism, hyperthyroidism, PCOS, diabetes • Identify level of abnormality: Hypothalamus, Pituitary,
§ Sheehan’s / Simmonds disease – these are insults to the Ovarian, Uterine/Outflow tract
pituitary. Sheehan’s is when there is hemorrhage during • Go by frequency of occurrence
pregnancy, patient becomes anoxic and the pituitary suffers.
Simmonds is the same but occurs in nonpregnant patients.
OVARY
§ Absent gonads – very rare; no gonads but appear female. Why
do they appear female? Because it‘s the default setting if there
are no gonads.
§ Dysgenetic gonads (Turner/Swyer syndrome)
§ Enzyme disorders
§ Autoimmune disorders
OUTFLOW TRACT
(Uterus, Cervix, Vagina) Figure 14. Causes of Primary Amenorrhea: Incidence. Take note of
Abnormal Mullerian § Androgen Insensitivity the most common one which Is Gonadal Dysgenesis, followed by
Development Syndrome Mullerian Agenesis and This Trans will be using two additional
(Congenital) § Mayer-‐Rokitasky-‐Kuster-‐Hauser bullets for organization and to determine where the information
Syndrome came from.
§ Cervical Agenesis

Trauma/Infection § Cervical Stenosis
§ Intrauterine adhesions
o Tuberculosis
o Asherman’s syndrome –
excessive curettage of the
endometrium leads to
scarring, no endometrium
develops, no reaction to
estrogen and progesterone
à no more menstruation.

Congenital Defects of § Transverse Vaginal Septum
the Urogenital Sinus § Imperforate Hymen Figure 15. Causes of Secondary Amenorrhea

V-‐A. ANATOMIC DEFECTS VI. TIPS IN AMENORRHEA WORKUP
VI-‐A. HISTORY
• Signs and symptoms of pregnancy

• Pubertal development
• Family history
• Illnesses
• Surgery
• Drug use
• Chemo/radiotherapy
• Headache, visual changes, seizures
• Masses
• Cyclic hypogastric pain
• Exercise
Figure 13. Anatomical Defects

• Stress o Androgen Insensitivity presents with no pubic hair and

male testosterone levels
• Weight loss
o MRKH Syndrome will have pubic hair and low
• Vasomotor symptoms (hot flashes) testosterone levels
VI-‐B. PHYSICAL EXAMINATION o Both conditions will have an absent vagina
• Height/weight (BMI)
• Tanner stage: Breast/axillary/pubic hair
• Physical signs
• Nipple discharge
• Hirsutism/acne
• Abdominal masses
• Pelvic exam:
o External genitalia
o Clitoris
o Vagina
o Cervix
o Uterus
o Adnexa
• Inguinal masses Figure 18. Breast (-‐) Uterus (+)
• Skin changes • Breast (-‐) Uterus (+)
o Workups: Karyotyping & Brain CT/MRI
VII. PRIMARY AMENORRHEA: THE WORK-‐UP o Karyotyping can reveal Gonadal Failure seen in Turner
Syndrome 45 XO
• Patients can vary into any of the following permutations: o Those with Hypothalamic Failure due to a tumor will have
a positive brain MRI seen in Kallman Syndrome (presents
with anosmia)
o Brain CT scan can also reveal Pituitary Failure from
pituitary tumors, empty sella, or mumps encephalitis

Figure 16. Work-‐up for Primary Amenorrhea

Figure 19. Breast (-‐) Uterus (-‐)
• Breast (-‐) Uterus (-‐)

o Workups: Karyotyping & Testosterone
o Very rare condition!
o Might actually be a male:
o Agonadism
o VanishingTestesSyndrome
o Don’t develop breasts
Figure 17. Breast (+) Uterus (-‐)
o No maturation of Mullerian system
• Breasts (+) Uterus (-‐) o Could be due to Enzyme Abnormalities
o Workups: Karyotyping & Testosterone. Karyotyping will o Gonadectomy is recommended
distinguish Androgen Insensitivity 46 XY from MRKH
Syndrome 46XX

IX. WAYS TO DETERMINE ESTROGEN STATUS
• Ultrasound:
o Mid cycle endometrial stripe
o Thickness should measure: >4mm
• PAP smear: Cytohormonal index (predominance of superficial
cells)
o Pink superficial cells: estrogen effect
o Blue cells: progesterone effect
o Small cells (neither blue nor pink): no estrogen effect
• Progesterone challenge test
Figure 20. Breast (+) Uterus (+)
o 10mg of progesterone daily for 5 days
• Breast (+) Uterus (+) o Positive:
o Workup as Secondary Amenorrhea § Bleeding within 1-‐4 days from last tablet
§ Positive estrogen effect on uterus
VIII. SECONDARY AMENORRHEA: THE WORK-‐UP • Negative:
§ No bleeding
§ Negative estrogen or non-‐responsive endometrium
• Serum estradiol
• >40pg/mL
X. TREATMENT OF AMENORRHEA: GUIDELINES
• Goals:
o Treat the underlying cause, if possible
o Improve fertility
o Menstruation, if desired
o Prevent the complications of the disease
• Counseling
• Lifestyle change, ideal weight
• Surgery
o Gonadal excision: if with Y chromosome (risk of
gonadoblastoma)
o Vaginal reconstruction
o Excision of vaginal septum/hymenotomy
• Medical
o Oral contraceptive pills, progesterone for cycle regulation
o Hormone replacement:
Figure 21. Secondary Amenorrhea Workup. See appendix for
bigger picture § To enhance secondary sex characteristics
§ To treat effects of hypoestrogenism
• First rule out pregnancy with a pregnancy test and check for • Fertility: ovulation induction agents/gonadotropins
outflow tract to see if intact and normal
• Check for hormones SUMMARY
o Prolactin
§ Hyperprolactinemia • Amenorrhea (pathologic) may be primary or secondary
§ Check for tumor in pituitary • Primary amenorrhea (no menarche) is due to genetic or
o Estrogen congenital anatomic abnormalities
§ 40pg/ml required for menstruation • Secondary amenorrhea is due to endocrine disorder or
§ If >30-‐40 pg/mL: has estrogen, either has: acquired anatomic abnormalities
- PCOS • Diagnosis and treatment are important because it may be a
- Hypothalamic dysfunction sign of a more serious condition and the consequences of
- Pelvic ultrasound will differentiate two amenorrhea may be life-‐threatening
§ If <30-‐40pg/ml: hypoestrogenic, check FSH • Pregnancy should be ruled out
- If FSH is HIGH: premature menopause, primary • Diagnostic process is step-‐wise and logical (minimum of tests):
ovarian insufficiency involves an investigation of the hypothalamic-‐pituitary-‐ovarian
- If FSH is NORMAL or LOW: hypothalamic or axis and the outflow tract
pituitary dysfunction giving rise to • Goals of treatment: treat the underlying cause, enhance
hypoestrogenemia fertility, prevent the consequences of the condition
- Rule out tumor first with brain CT/MRI • In all individuals with amenorrhea and having a Y chromosome,
gonadectomy is recommended to reduce the risk of
gonadoblastoma

• The approach to an amenorrheic patient requires a caring and 6. A 30 y/o G1P1 who delivered 10 months ago and currently
understanding physician who is able to empathize with the breastfeeding complains of amenorrhea since her delivery. What
patient’s plight and is able to devote time for counseling is most likely diagnosis?
a. Hypothalamic dysfunction
REFERENCES b. Hyperprolactinemia
c. Pregnancy
Dr. Tongco’s Lecture d. Sheehan’s syndrome
2018A Trans
th
Comprehensive Gynecology 7 Edition 7. A 13 y/o w/o menarche complains of cyclic pelvic pain. Breast
and pubic hair are tanner 3. A 10cm cystic hypogastric mass was
REVIEW QUESTIONS palpated. Hymen is intact. What is the most likely diagnosis?
a. Delayed puberty
From 2018A: (Same Lecturer)
b. Ovarian New Growth

c. Pelvic Endometriosis
1. In which of these patients with amenorrhea is gonadectomy
d. Transverse vaginal septum
recommended?

a. Androgen Insensitivity Syndrome
8. In which of these syndromes w/ amenorrhea is
b. Empty Sella syndrome
hypoestrogenemia present?
c. Mullerian Agenesis
a. Asherman’s
d. Turner syndrome
b. Mayer-‐Rokitansky-‐Kuster-‐Hauser

c. Polycystic Ovarian
2. What is the best treatment for a 26 y/o gymnast w/
d. Swyer
amenorrhea of 8 months and a serum estradiol of 20pg/mL?

a. Bromocriptine
9. A 32 year old G0 w/ amenorrhea for 1 year has hot flashes and
b. Estrogen + Progesterone
night sweats. FSH level is elevated. Cytohormonal index showed
c. Gonadotropins.
predominance of parabasal cells. She wants to experience
d. Thyroid hormone
monthly periods. What is the best treatment?

a. Estrogen
3. A 23 y/o had her LMP 9 months ago. She had no withdrawal
b. Estrogen and progesterone
bleeding after a progesterone challenge test. FSH level is
c. Recombinant FSH
elevated. What is the most likely diagnosis?
d. GnRH
a. Anovulation

b. Craniopharyngioma
10. What is the best treatment for a 31 year old with milky nipple
c. Pituitary adenoma
discharge, elevated prolactin levels, and a 0.8cm pituitary
d. Primary Ovarian Insufficiency
adenoma?

a. Dopamine agonist
4. A 14 y/o w/ secondary sexual characteristics complains of
b. Oral contraceptive pills
absence of menarche. What is the best test to request at this
c. Surgical extirpation
point?
d. Thyroid hormone
a. Estradiol

b. FSH
11. What is the most common cause of primary amenorrhea?
c. HCG
a. Delayed puberty
d. TSH
b. Gonadal dysgenesis

c. Mullerian agenesis
5. Which test will differentiate Androgen Insensitivity from
d. Outflow tract disorders
Congenital Absence of the uterus?

a. Estradiol
b. FSH Answers: ABDCD CDDBA B
c. Prolactin
d. Testosterone


3.08
Amenorrhea
Dr. Carmencita B. Tongco, 4/19/18
APPENDIX

Secondary Amenorrhea Workup

Typical PCOS patient presentation


Learning Objectives: I - A. Menstrual Cycle

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Learning Objectives: I - A. Menstrual Cycle

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• The presence of menstruation means a normal or intact:

FSH and LH have a role in the development of the follicle. As

o Physiologic – pregnancy & lactation, menopause

II-‐A-‐1. WHY TREAT AMENORRHEA (PATHOLOGIC)

• Incidence of pathologic amenorrhea: in 3-‐4% of women

• Treatment: Hormones to promote secondary sexual

III-‐C. IMPERFORATE HYMEN

• Failure of degeneration of epithelial cells of hymen

• 20% of amenorrhea

• Mullerian agenesis or congenital absence of uterus

• Absence of organic pathology

• Premature ovarian failure

V. CAUSES OF AMENORRHEA

V-‐A. ANATOMIC DEFECTS VI. TIPS IN AMENORRHEA WORKUP

• Signs and symptoms of pregnancy

• Stress o Androgen Insensitivity presents with no pubic hair and

• Breast (-‐) Uterus (-‐)

IX. WAYS TO DETERMINE ESTROGEN STATUS

X. TREATMENT OF AMENORRHEA: GUIDELINES

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Learning Objectives: I - A. Menstrual Cycle

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Learning Objectives: I - A. Menstrual Cycle

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• The presence of menstruation means a normal or intact:

FSH and LH have a role in the development of the follicle. As

o Physiologic – pregnancy & lactation, menopause

II-­‐A-­‐1. WHY TREAT AMENORRHEA (PATHOLOGIC)

• Incidence of pathologic amenorrhea: in 3-­‐4% of women

• Treatment: Hormones to promote secondary sexual

III-­‐C. IMPERFORATE HYMEN

• Failure of degeneration of epithelial cells of hymen

• 20% of amenorrhea

• Mullerian agenesis or congenital absence of uterus

• Absence of organic pathology

• Premature ovarian failure

V. CAUSES OF AMENORRHEA

V-­‐A. ANATOMIC DEFECTS VI. TIPS IN AMENORRHEA WORKUP

• Signs and symptoms of pregnancy

• Stress o Androgen Insensitivity presents with no pubic hair and

• Breast (-­‐) Uterus (-­‐)

IX. WAYS TO DETERMINE ESTROGEN STATUS

X. TREATMENT OF AMENORRHEA: GUIDELINES

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• Incidence of pathologic amenorrhea: in 3-‐4% of women

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• Breast (-‐) Uterus (-‐)