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Amenorrhea Causes and Treatment for USMLE Step 2

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Amenorrhea

Amenorrhea Causes and Treatment for USMLE Step 2 : Amenorrhea is a medical condition that refers to the absence of menstrual period in women of reproductive age. It can either be primary or secondary amenorrhea. The first one refers to the fact that menstrual period hasn’t yet occurred in women aged 16 or more. The secondary amenorrhea is defined as absence of the menstrual period for three or more consecutive moths. A woman does not have period at puberty age, at menopause and while she is pregnant and breast feeding. Each amenorrhea case should start with eliminating the possibility of being pregnant. If this is not the cause, it means that other problems have triggered lack of menstrual cycles.

Amenorrhea causes are multiple and range between ovary problems and anorexia. Anovulation is a main cause of amenorrhea as well as other problems like tumors, cysts or fibroids. Endocrinal problems are also very frequent causes of amenorrhea. These problems can be of a multitude of types. Lack of menstrual periods can also be determined by problems like bulimia, anorexia, excessively low body weight, anxiety, depression, stress. Women who practice sports or who have constant intense physical activity might suffer of amenorrhea. There can be many other factors that determine amenorrhea, but the bottom line is that absence of menstrual period is not a disease in itself, but a signal that something else is wrong in the body. Once the real cause of amenorrhea is discovered and solved, the menstrual periods will become regular again.

Sometimes amenorrhea requires treatment and other times all it takes is to eliminate the cause. In women who suffer of bulimia or anorexia, menstrual periods will come to normal once these problems are solved. In many cases patients might need counseling in order to overcome such problems. Women who practice sports can get back to normal if they slow down for a while and so on. Endocrinal and ovarian problems need to be diagnosed by a doctor and need to be addressed. Treating them implicitly ends amenorrhea also. There are prescribed pills that cause disorders in the occurrence of menstrual cycle and once the woman stops taking them, everything gets back to normal.

It is difficult to establish the correct treatment in amenorrhea cases because it depends on correctly identifying the root causes. Nevertheless, a healthy life style and a proper diet provide a bunch of different benefits, including normalization of the menstrual periods. Regular exercise and avoidance of nicotine, caffeine and alcohol are also helpful.

Amenorrhea Causes and Treatment for USMLE Step 2 : Amenorrhea, a simple, handwritten explanation and full lecture of causes and treatment of amenorrhea for medical students taking USMLE. Discussing Amenorrhea signs and symptoms as well as treatment for amenorrhea.

Amenorrhea can be dividing into to categories. The first is primary amenorrhea and the other is second amenorrhea. In primary amenorrhea, the period has never occurred and the patient has no history of ovulation. However, in secondary amenorrhoea they did have a previous history of menses or period but now they are complaining that they are missing their period and ovulation, but now they haven’t had it. In primary the definition is that they are 14 without sexual characteristics and 16 with secondary sexual characteristics. Definition of secondary amenorrhea is defined as 3 months of no menses if regular, and irregular would be 6 months of no menses.

Primary amenorrhea can be categorized based on the presence of other secondary characteristics such as ovulation. If there is no uterus, then it might be mulerian agenesis or androgen insensitivity. Mullerian Agenesis will be in a female (XX) and Androgen Insensitivity (XY). They will have normal breast growth and hair growth. Mullerian tubes is responsible for building of the upper vagina, cervix, uterus and the fallopian tube. Ovaries are unaffected so they will produce normal estrogen and the secondary characteristics will be normal and the FSH and LH levels will be normal. However the patient can’t ovulate because there is no fallopian tube. This is treated by creating a vagina and IVF with a surrogate. Patient secretes androgens, however, receptors are deficient. Wollfian duct atrophys without testosterone, Mullerian Inhibiting Factor will not be activated and so the genitalia will be female. Patient will grow up as girls, secondary sexual characteristics however, they have an XY chromosome. They will have normal secondary sexual characteristics because testes will produce estrogen. This is treated by removing testes and estrogen.

Patients with no breast and primary amenorrhea means they are not producing any estrogen and therefore ovulation will not occur. Causes include Turner Syndrome (XO) and any problem with Hypothalamic Pituitary Axis (HPA). Streatk gonads means no gonads are produced and there will be an increase FSH. If problem with pituitary there is a lack of FSH and therefore no follicles are stimulated and then no estrogen is produced. Primary cause is Kallman syndrome (anosmia) or secondary causes such as anorexia, exercise, stress, craniopharyngioma. Treatment consists of giving exogenous estrogen and progesterone to develop the normal secondary characteristics.

If both uterus and breasts are present than the problem will be associated with anatomic problems. Vaginal Agenesis or septa and imperforate hymen. These patients are generally ovulating normally.

Secondary Amenorrhea is divided into three categories depending on gonadatropin level. In Eugonodatropin the level of LH and FSH is normal. The primary cause is pregnancy. Also anovulation can also lead to eugonadotropic where there will be no corpus luteum and therefore no progesterone. This can be due to PCOS, thyroid abnormalities, pituitary abnormalities, and anti-psychotic and anti-depressants.

Hypergonadtropic is due to low estrogen. Here it is due to premature ovarian failure. This can also be due to mumps, SLE, adrenal insufficiency, radiotherapy and even chemotherapy. In order to diagnosis you need to get 2 FSH levels 1 month apart to rule out early menopause.

if there is low T3/T4 which will increase TRH activates TSH and Prolactin which can go on to activate gonadotropin. Also check prolactin levels which can be raised due to anti-psychotics and anti-depressants. Tumors may also cause it so it requries CT Scan/MRI or it maybe an idiopathic increase in Prolactin. If everything is normal then a Progesterone Challenge Test (PCT) should be performed. Patient is given progesterone with single IM Dose or MPA for 7 days. After sudden stop there is bleeding than this means that the estrogen did prime the endometrium, but there was no ovulation for progesterone to come out and withdraw. So anovulation is the cause. Treat with clomiphene. If there is no bleeding then there is a problem with either estrogen or there is an outflow obstruction. If there is no bleeding then perform the Estrogen-Progesterone Challenge Test (EPCT). In this case patient receives 21 days of estrogen and followed with 7 days of Methylprogesterone acetate. If there is bleeding then there is no estrogen. If the FSH is high then there is ovarian failure, and if the FSH is low than there is an issue with hypothalamic pituitary axis. If there is no bleeding, the the problem is from obstruciton, endometrium or imperforate hymen.

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