Evaluation of Amenorrhea

I. Is it primary or secondary?

First step to evaluating amenorrhea is to determine if it is primary or secondary (see Figure 15-2).

Workup

Positive Findings Indicate

Workup

Positive Findings Indicate

1. Examine hymen

Imperforate hymen

2. Determine presence of uterus

No uterus: Do karyotyping and consider testicular feminization, mullerian agenesis, 46,XY steroid enzyme defects

3. Determine if there is breast development

Yes: Work up as secondary amenorrhea. No: Work up as progestin-negative secondary amenorrhea (below).

II. Secondary amenorrhea workup

Once you have determined that the amenorrhea is not primary, do a secondary amenorrhea workup (see Figure 15-3). The secondary amenorrhea workup is divided into two groups: Without galactorrhea and with galactorrhea:

Patent vagina

Imperforate hymen, transverse vaginal septum, or vaginal agenesis

Breasts

Karyotype: Testicular feminization, muNerian agenesis, 46,XY steroid enzyme defects, pure gonadal dysgenesis, or anorchia

Work up as secondary amenorrhea

Work up as progestin-negative secondary amenorrhea

FIGURE 15-2. Workup for primary amenorrhea.

(Redrawn, with permission, from DeCherney AH, Pernoll, ML. Current Obstetric & Gynecologic Diagnosis- & Treatment. Norwalk, CT: Appleton & Lange, 1994: 1010.)

1. Without galactorrhea, administer Progestin Challenge: Give progestin and if menses results, ovaries are secreting estrogen.

■ If the progestin challenge results in menses, then the diagnosis is one of the following

■ Ovarian or adrenal tumor

■ Hypothalamic dysfunction

■ If progestin challenge is negative:

a) Heteroscopy to determine if Asherman's syndrome is the cause b) Check FSH level:

■ If suspect hypothalamic-pituitary failure.

2. Amenorrhea + galactorrhea:

■ Check TSH levels. If low, hypothyroidism is the cause.

■ If TSH is normal, check prolactin levels. Prolactin levels are high, perform a CT/MRI of the brain to confirm a prolactinoma.

Prolactin inhibits GnRH pulsations, and therefore inhibits ovulation.

See Figure 15-4.

Progestin challenge

Negative

Rule out Asherman's syndrome if necessary

Hirsute

Hirsute

Polycystic ovary syndrome Rule out ovarian tumor Rule out adrenal tumor

Nonhirsute

Mild hypothalamic dysfunction

Over 40 mlU/mL

Gonadal failure

Under 40 mlU/mL

Severe hypothalamic dysfunction

FIGURE 15-3. Workup for secondary amenorrhea without galactorrhea.

(Redrawn, with permission, from DeCherney AH, Pernoll ML. Current Obstetric & Gynecologic Diagnosis & Treatment. Norwalk,CT: Appleton & Lange, 1994: 1012.)

Cone view normal and prolactin 50-100 ng/mL

Repeat prolactin every 6 months Cone views every 1-2 years

Cone view abnormal or prolactin over 50-100 ng/mL or visual symptoms

CT or MRI scan

CT or MRI scan

Elevated

Treat hypothyroidism

Microadenoma, hyperplasia

Macroadenoma

FIGURE 15-4. Workup for secondary amenorrhea with galactorrhea.

(Redrawn, with permission, from DeCherney AH, Pernoll ML. Current Obstetric & Gynecologic Diagnosis & Treatment. Norwalk,CT: Appleton & Lange, 1994: 1011.)

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