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Primary Amenorrhea
- Lack of menstruation by age 16 accompanied by normal body hair pattern and normal breast development
- Pregnancy must be ruled out
- 50% chromosome abnormality:
o gonadal dysgenesis
- 15% anatomic abnormality of the uterus, vagina, or cervix
- One of the most common causes: Tuner Syndrome:
o Short stature
o Loss of all X chromosome
o Amenorrhea
o Ovarian insufficiency
o Dx karyotype
- Dx turner syndrome critical affected patients have cardiovascular disease, metabolic syndrome, thyroid
dysfunction
Secondary Amenorrhea
- The absence of a menstrual cycle for three cycles or 6 months in previously menstruating women
- Pregnancy is the most common cause
- Uterine or outflow tract disorder (Asherman syndrome) must be considered
- Asherman syndrome:
o Due to endometrial scarring after uterine procedure
o Should be considered in women with amenorrhea and past exposure to uterine instrumentation
- After pregnancy is excluded 40% of secondary amenorrhea will be due to ovarian causes such as
polycystic ovarian syndrome (PCOS)
- Additional causes:
o Hypothalamic functional amenorrhea 18-40 years (dx of exclusion)
RF:
Low body weight and fat percentage
Eating disorders
Excessive exercise
Severe emotional stress
Nutritional deficits
FSH and LH really low, but FSH is higher than LH
o Hyperprolactinemia
Because it inhibits GnRH secretion
o Thyroid disease (hypo and hyper)
Hypothyroidism increased levels of TRH which stimulates prolactin secretion
inhibits GnRH inhibits ovulation
Hyperthyroidism fast weight loss
o Primary ovarian insufficiency
Amenorrhea before 40 y.o with two elevated FSH levels
Secondary causes: turner, fragile X permutation status, autoimmune oophoritis, effects of
quimio and radiotherapy
FEMALE INFERTILITY
- Infertility: inability to conceive in 1 year with regular unprotected sexual intercourse
- If female partner is older than 35 years then infertility is defined as the inability to conceive within 6 months
- Exams:
o TSH
o Prolactin
- If initial testings are normal referral to reproductive endocrinologist is indicated
o Evaluation will continue with semen analysis of the partnet
o Confirmation of ovulatory function with mid-luteal progesterone level measurement
o Ovarian reserve testing by measuring FSH level on day 3 of menstrual cycle
o Hysterosalpingography 6-10 days in menstrual cycle to evaluate for any uterine or tubal
abnormalities
- If there is no abnormalities
o Clomiphene
o Gonadotropins