47 terms

Primary and Secondary Amenorrhea

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Sertoli Cells
these secrete AMH causing mullerian regression

cause an increase in androgen binding protein which increases concentration of testosterone for spermatogenesis
Leydig Cells
these secrete testosterone to stimulate wolffian/mesonephric duct development

stimulate testicular descent

allow for conversion to DHT for development of external genitalia
Paramesonephric Duct
in the female, this will become the fallopian tubes, uterus, and upper vagina
Urogenital Sinus
in the male, this will become the lower 1/3 vagina
FSH
this stimulates ovarian folliclar growth, estogen and inhibin production, and increases expression of LH/FSH receptors
LH/hCG
these stimulate the corpus leuteum to secrete progresterone, stimulate theca cells to promote androgens, and cause the LH surge to resume meoisis/ovulation
Estrogen
this is made by the granulosa cells of the follicle

causes endometrium to grow
stops menstrual bleeding

feedsback on LH, GnRH, and FSH
Estrone (E1)
this is the estrogen during menopause
Estradiol (E2)
this is the estrogen during reproductive years
Estriol (E3)
this is the estrogen during pregnancy
Inhibin
this is made by the granulosa cells of the follicle and feeds back on FSH secretion
Progesterone
this is made by the corpus leuteum

stops endometrial growth
causes corpus leuteum to secrete substances necessary to support an early pregnancy
induces a secretoy state in the endometrium
feedsback on GnRH, FSH, and LH

secreted in small amounts by the growing follicle
Follicular Phase
this is the ovarian phase where FSH stimulates follicle growth and estrogen/inhibin secretion
Leuteal Phase
this is the ovariann phase where LH leutenizes the granulosa cells to become the corpus luteum and stimulates progesterone
Corpus Leuteum
this has a finite life span of 14 days unless rescued by hCG (pregnancy)

made by LH during the luteal phase
Proliferative Phase
this uterine phase has rising estrogen levels, stimulating endometrial growth around the 5th-14th day

proliferation of tubular glands and BV
stimulation of endometrial glands to produce a thick mucus
causes endometrial cells to produce receptors for progesterone

gets body ready for ovulation/pregnancy
Secretory Phase
this uterine phase has endometrial thickening with spiral arteries becoming coiled/dilated

has glycogen rich secretions

lasts about 14 days
Late Secretory/Menstrual Phase
this ovarian phase has the corpus leutum regressing about the 24th day if not fertilized

have decreased E2 and P4

spiral arteries coil/contract leading to ischemia, degeneration, and focal necrosis
necrotic endometrium is shed along with blood and other secretions
Primary Amenorrhea
this is NO period:

by age 16 with secondary sex characteristics
by age 14 without secondary sex characteritics
>3 years between onset of sexual characteristics and no menses
Secondary Amenorrhea
this is amenorrhea where the patient has had a previous period but has had >6 months with no menses
Oligomenorrhea
this is a menstrual interval >35 days and <6 months
Hypogonadotropic Hypogonadism
this can be from increased TRH, hyperprolactinemia, or Sheehan's Syndrome
Increased TRH
this causes hypogonadotropic hypogonadism

disrupts GnRH pulses leading to LOW levels of everything
will have elevated prolactin
will have secondary amenorrhea

generally caused by Hashimoto's thyroiditis

can treat with Levothyroxine
Hyperprolactinemia
this causes hypogonadotropic hypogonadism

can be from pregnancy, breastfeeding, stress, exercise, organsm, dopamine antagonists!!, metoclopramide, estrogen, or prolactinoma
Metoclopramide
this is a drug given to people trying to produce milk

can cause hyperprolactinemia
Prolactinoma
this is a prolactin secreting pituitary adenoma
#1 most common pituitary tumor

have secondary amenorrhea due to GnRH inhibition
have galactorrhea, headache, and visual disturbances

treat with dopamine agonists
treat with estrogen if pregnancy is not desired
Sheehan's Syndrome
hypogonadotropic hypogonadism

this is a postpartum hypopituitarism or postpartum pituitary necrosis

can be secondary to acute infarction or ischemic necrosis due to postpartum hemorrhage and hypovolemic shock

have loss of GH, FSH, LH, ACTH, and TRH

# 1 symptom is failure of lactation!
have secondary amenorrhea
Ovarian Dysfunction
this causes a hypergonadotropic hypogonadism

has increased GnRH with LH>FSH and increased estrogen

can be seen in PCOS
PCOS
this is a hypergonadotropic hypogonadism

found in 80-90% of women with excess androgens

have normal FSH with HIGH LH and sufficient estrogen

strongly related with insulin resistance, diabetes, and obesity

have secondary amenorrhea
have infertility
have hirsutism
have necklace sign (many follicles) on ovarian ultrasound

MUST RULE OUT ENDOMETRIAL HYPERPLASIA/CANCER IF > 35

want to reduce production of androgens, protect the endometrium, lower the risk of CV disease, and induce ovulation
Ovarian Failure
have a hypergonadotropic hypogonadism

have high GnRH with high LH/FSH and low E2/P4
Premature Ovarian Failure
this is a hypogonadotropic hypogonadism that is very rare and usually from unknown causes but is likely caused by autoimmune causes (hypothyroid, hypoparathyroid, hypoadrenal, pernicious anemia)

must prevent osteoporosis and give hormone therapy

have secondary amenorrhea
Acquired Uterovaginal Obstruction
this will have secondary amenorrhea but will levels of everything normal

includes Asherman's syndrome, cervical stenosis, and pelvic radiation
Asherman's Syndrome
this is an acquired uterovaginal obstruction that causes secondary amenorrhea where there are intrauterine adhesions

often occurs after a D&C for retained placenta

can be diagnosed by uterine sounding and treated with cervical dilation
Kallman's Syndrome
this is an X linked mutation (AR in female) with has hypogonadotropic hypogonadism

associated with anosmia because GnRH neurons originate in the oldfactory placode and migrate to the hypothalamus during embryogenesis

causes primary amenorrhea
Hypogonadotropic Hypogonadism
this can be caused by Kallman's syndrome or anorexia, stress, excess exercise, weight loss, pituitary tumor, hypothalamic tumor, or hypothyroidism

will cause primary amenorrhea
Androgen Insensitivity
this will have a 46XY genotype with partial/complete inability to respond to androgens (testosterone)

have primary amenorrhea

have androgen receptor defect

X-linked recessive

have formation of testes but NO spermatogenesis
results in female phenotype (but male genotype) with neither type of reproductive system
Complete Androgen Insensitivity
this type of patient have normal female externalgenitalia with a short vagina that ends blindly

genotypically male with female phenotype

have primary amenorrhea with large breasts, NO pubic/axillary hair, tall stature, and lack of internal genitalia

treat with gonadectomy and HRT
17 Alpha Hydroxylase Deficiency
these patients are not producing ANY sex hormones

have primary amenorrhea

have a crap ton of aldosterone with hypokalemia, hypernatremia, ovarian failure, and enlarged ovariaes

often seen with CAH and HTN
Gonadal Dysgenesis
this causes primary amenorrhea and will be from Turner's syndrome, 17 alpha hydroxylase deficiency, and Swyer's syndome

can be treated with GH for short stature, E2/P4 for secondary sexual characteristics, and gonadectomy for Y chromosome
Turner's Syndrome
these patients will have short stature, a webbed neck, coarctation of the aorta, and renal abnormalities

will have streak gonads and accelerated oocyte atresia
Swyer's Syndrome
these are genotypic males with NO AMH produced and thus uterus development

have correct sexual equipment for a woman but will have non-functional gonads and no breasts

will have primary amenorrhea
Imperforate Hymen
this is an outflow tract obstruction that causes primary amenorrhea

have a vaginal bulge that is associated with cyclic pelvic pain

have menses every month but it isn't able to come out, so have retrograde flow that can lead to endometriosis

have to treat with surgical incision and drainage --> very easy
Transverse Vaginal Septum
this is an outflow tract obstruction that causes primary amenorrhea

have cyclic pelvic pain with hematometrium but NO vaginal bulge

can use pelvic US/MRI to differentiate from imperforate hymen

cannot be easily fixed
Vaginal Agenesis (Mayer-Rokitansky-Kuster-Hauser)
this occurs in 46XX females with normal female testosterone

have failure of mullerian duct development
have normal ovaries with normal reproductive hormone and normal secondary sex characteristics (including hair) but will have primary amenorrhea!

will also have renal abnormalities and possibly have skeletal abnormalities

can create a neo-vagina with vaginal dilation or surgical correction
Decrease Gonadotropins
this is what exercise, stress, anorexia, and high CRH and ACTH will do to gonadotropins
Exercise Amenorrhea
this occurs with athletic training before menarche

can delay menses as much as 3 years
Anorexia Nervosa
this is immoderate food restriction with irrational fear of gaining weight

have high estrogen and amenorrhea