Endocrinology

Front 1

Polycystic ovary syndrome ?

Definition

Incidence

Aetiology

Back 1

* Definition :

- Old : Descriped by Stein & Leventhal 1935 in a group of patients showing cystic changes in their ovaries in association with :

Amenorrhea + Hirsutism + Obesity + Infertility

- Recently : Clinical syndrome characterized by 2 or more of the following :

Chronic anovulation :

2ry Oligo/Amenorrhea + Infertility

Hyperandrogenism : Hirsutism + Elevated serum LH + Increased free testosterone

Characterestic US morphology :

Increased ovarian size & volume with peripherally arranged small follicles in dense stroma = Necklace appearance

* Prevalance :

- 5-10% of women in reproductive age

- Most common ovarian cause of 2ry amenorrhea / chronic anovulation / infertility

* Aetiology :

Exact cause is unclear but presence of familial background suggests involvement of a special gene related to its development.

Front 2

Pathogenesis of PCOS ?

Back 2

Triad of

A) High LH :

- Due to :

Increased LHRH pulse & frequency = abnormally high LH/FSH ratio > 2:1

- Effect :

1- Stimulate secretion of androgens by ovarian theca cells

2- Inhibtion of aromatase responsible for conversion of ovarian androgens into estrogen
Overall = Increased ovarian androgens

B) Hyperandrogenemia :

- Due to :

1- Stimulate secretion of androgens by ovarian theca cells "By both high LH & high insulin"

2- Inhibtion of aromatase enzyme

- Effect :

1- Atresia of developing follicles = Anovulation & Amenorrhea

2- Hyperandrogenemia : High serum Free & Total androgens
3- Hirsutism

4- Acyclic increase of estrone due to peripheral conversion of excess androgen in fat into estrone leading to :

- Increased Pituitary LH & Suppression of FSH

- Unopposed Estrogen = Endometrial Hyperplasia & Carcinoma

C) Hyperinsulinemia :

- Due to : Associated Peripheral insulin resistance

- Effect :
1- Increased sensitivity of ovarian theca cells to LH : Increased LH induced androgen production by the ovaries.

2- Decreased aromatase enzyme activity

3- Decreased production of SHBG = increased serum free androgen

Front 3

Diagnosis of PCOS ?

Back 3

A) Clinical Presentation :

1- 2ry Amenorrhea "Oliguria" + Infertility

Chronic anovulation

2- Hyperandrogenism = Hirsutism

Affecting face / chest / inner thighs
3- Obesity with abnormal glucose tolerance

4- DUB in chronic anovulation due to associated endometrial hyperplasia

B) Laboratory :

1- LH/FSH ratio > 2 Eleavated LH&Normal FSH
2- Elevated E1 + Androstenidione + Free T
3- Hyperinsulinemia increased insulin resist.

C) Ultrasound :
Adam's Criteria =
1- Increased ovarian size & volume
2- Ovaries show central dense stroma surrounded by small follicles (2-10 mm) peripherally arranged = necklace appearance

3- No dominant or mature follicles = chronic anovulation

NB : Encountered in 25% otherwise normal females

D) Laparoscopic appearnce :

Oyster Shell ovary = Absence of ovulation stigma on ovarian surface :
Large ovaries / thick capsule / absent gyri

Front 4

Longterm risks for PCOS ?

Back 4

1- Increased risk for
DM + Obesity + Hyperlipidemia +
Cardiovascular disease
2- Increased risk for endometrial hyperplasia :
Increased estrogenic effect on endometrium unopposed by progesterone
3- Increased risk for endometrial carcinoma : atypical endometrial hyperplasia

Front 5

Managment of PCOs ?

Back 5

1- Weight reduction in obese females :

5-10% of body weight = decrease insulin & androgens = re-establish ovulation or improve response to thrapy

2- Insulin sensitizing drugs :

Metformin 500 mg/day/orally
Increases insulin receptor sensetivity = decrease in insulin & androgens = increase sensetivity to endogenous FSH or CC which may re-establish ovulation

3- Hormone therapy in Amenorrhea / DUB
1- Cyclic gestagens therapy "MPA 10mg daily"

for 10 days from D16-25 every cycle to induce regular 28-30 days cycle.
2- Combines OCPs from D5 - D25 to establish regular cycles in cases not requesting pregnancy.

4- Induction of ovulation for infertility :

1- CC : Oral tablets twice daily for 5 days starting D3/D4/D5 = drug of choice in PCO presenting with anovulatory infertility due to least risk of OHSS

2- HMG repeated IM injection : effective in induction with increased risk of OHSS
3- Purified HMG / Recombinant FSH IM inj :
lower risk of OHSS = minimal / absent LH

4- hCG IM injections : trigger rupture of follicles when they reach maturity

5- Hirsutism :
Cepretorone acetate / Laser depilation / electrolysis
NB : OCPs decrease LH & increase SHBG

6- Corticosteroid theapy :

Supress ACTH production in adrenal hypergonadism

7- Surgical treatment :
Laparoscopic ovarian drilling : decrease ovarian androgens production but adhesion formation in unfavourable side effect

Front 6

Luteal Phase defect ?
Definition
Incidence
Etiology

Back 6

* Definition :

Poor secretory changes in the endometrium during luteal phase of ovulatory cycles due to :

- Low progesterone levels in luteal phase

- Short luteal phase duration < 11 days interval between ovulation & menstruation

- Both

* Incidence :
- Sporadic May oocur in isolated cycles in normally ovulating women

- Recurrent May be a cause of infertility in 3-4% of cases or Recurrent 1st TM abortion

* Etiology :

1- Inadequate FSH production during follicular phase or FSH/LH ratio at time of ovulation

2- Hyperprolactinemia :

Decreased FSH & blunted LH surge
3- Prolonged use of CC for induction :

decreased endogenous FSH release

Front 7

Diagnosis of Luteal Phase defect ?

Back 7

1- BBT Chart : Biphasic with short luteal phase

2- Midluteal Serum Progesterone level :

At day 21 = 5-10 ng/ml

3- Dated PEB :

Secretory changes with lag > 2 days behind that of normal cycle

Front 8

Treatment of LPD ?

Back 8

1- Progesterone support :

Throughout luteal phase "Oral / Vaginal tablets"

2- Repeated hCG injections :
in Luteal phase = stimulate CL production of P
3- Bromocryptine / Cabergoline :
In cases with elavated serum PRL
4- Intermittent use of drugs for superovulation : CC/HMG/hCG

Front 9

Hirsutism vs Hypertrichosis vs Virilization ?

Back 9

Hirsutism :

Excessive growth of androgen dependant sexual hair = Male pattern of hair : Upper lip / chin / chest / abdomen / pubic triangle / inner thighs / proximal limbs"

Hypertrichosis :
Excessive growth of androgen independant hair as in forearm & legs

Virilization :
Hirsutism associated with other signs of hypergonadism as :
- Defeminization : loss of femal body contour
- Muscularization : increased muscle mass / clitoromegaly / temporal baldness / voice deepening
Virilization is Irreversible

Front 10

Pathophysiology & Classification of Hirsutism ?

Back 10

* Pathophysiology :

Increased Androgen levels "ovarian / adrenal" or Increased hair follicles sensetivity to normal female androgens will cause transformation of
Vellouus hair : thin non pigmented into
Terminal hair : coarse & dark
at level of androgen dependant hair follicles.
* Classification :

1- Mild

Fine pigmented hair at face / chest / abdomen / perineum

2- Moderate

Coarse pigmented hair at face / chest / abdomen / perineum

3- Severe

Coarse pigmented hair at face "Complete beard" / tip of nose / ear lobes / chest / abdomen / perineum

Front 11

Aetiology of hirsutism ?

Back 11

1- Idiopathic :

Increased hair follicles sensetivity to normal female androgen levels either due to :

1- Increased receptor activity in hair follicles

2- increased 5 alpha reductase which converts T into DHT "more potent"

2- Adrenal causes :

- CAH : AR disorder with late onset casued by partial / complete deficiency of 21 hydroxylase

which converts P into Aldosterone & 17 OH P into cortisol so all P is shifted into androgens pathway "AS & T"

- Adrenal tumors : Producing DHA / DHAS /T

3- Ovarian Causes :

- Increased ovarian androgens :

PCOS / Hperthecosis / Stromal cell hyperplasia
- Ovarian androgenic tumors :

Gonadoblastoma / Sertoli-Leydig cell tumor / Hilar cell tumor / adrenal rest tumor

4- Mixed ovarian & adrenal hyperandrogenism : ( 30%-40%)

Increased adrenal androgens production inhibit follicular maturation by premature atresia with increased ovarian androgens
5- Pituitary gland :

- Cushing : Increased ACTH

- Acromegaly : High GH = Hyperinsulinism = Increased LH induced ovarinan androgen & decreased SHBG

6- Androgenic drugs :
Long term use of Danazol for endometriosis cause hirsutism & virilization

Front 12

Investigations for Hirsutism ?

Back 12

A) Hormonal Assays :

- Testosterone :

Total (N = 0.2-0.8 ng/ml)

If > 2 ng/ml = androgen secreting tumor

If mildly elevated suspect PCOs

If normal + hirsutism = idiopathic

Free (N = 1-3% of total) Index for androgens

- DHEAS (N = 1500-2500 ng/ml)
If > 9000 ng/ml = adrenal tumor
- 17 OH Progesterone : Eleavated In CAH

B) Radiological Investigations :

- CT/MRI : Pituitary gland

- Abdominal US / IVP : Adrenal tumors

- Pelvic US : PCOS + Ovarian tumors

Front 13

Treatment of Hirsutism ?

Back 13

- Combination of : Hormonal Suppression of hair growth + Mechanical removal of hair

= Most Complete & Most effective

Because once terminal hair has been established withdrawal of androgen doesn't affect established hair pattern
1- Elimination of Specific causes :

- Drug Elimination of suspected drugs

- Tumor Surgical removal of androgen secreting ovarian & adrenal tumors

- Diseases Cushing / Hyperprolactinemia / Hyperthyroidism

2- Hair removal techniques :

- Temporary : At repeated intervals

- Shaving / Tweezing / Waxing / Depilators

- Bleaching in mild hair growth

- Permanent : Destruction of hair follicles which is reasonably effective

- Electrloysis / Laser

3- Suppression of androgens synthesis :

- OCPs :

Combined low dose E & P

Decrease ovarian androgens & Free T

Increase SHBG

Progestins Inhibit 5 alpha reductase

- Corticosteroids :
(Dexamethazone 1-5 mg daily)

Suppression of adrenal androgens production

SE : OP + DM + Avascular necrosis of hip

- Spironolactone :

K+ sparing diuretic that's aldosterone antagonist that :

Inhibit 5 alpha reductase & decrease ovarian & adrenal androgens production

- Cypretorone acetate : Potent progestin & antiandrogen that inhibit LH & decrease androgen levels = used for 10 days

- Diane 35 OCP with CA as a progestin used in hirsutism in females requiring contraception

4- Androgen Receptor blockres:
Inhibit binding of DHT to nadrogen receptor thus directly inhibiting hair growth. Best if combined with OCPs/Progestin

Ex. Finasteride : But teratogenic

- Cimitidene : Competes with androgen at receptor site " 300 mg 5 times per day"

Front 14

Amenorrhea ?
Definition

Classification

Requirements

Back 14

* Definition :

Absensce of menstruation

* Classification :

1- Primary :

Menstruation has never started in female till

14 years without growth & development of 2ry seual characters

16 years Regardless of development of 2ry seual characters

2- Secondary :

Cessation of already present menstruation for

> 3 successive cycles "If regular"

> 6 successive cycles "If irregular"

* Requirements :

1- Pulsatile GnRH by hypothalmus :

depend on EST/PRG feedback signals

2- Pituitary FSH & LH :

In timely seq. & amount under HT GnRH control

3- Ovarian Cyclic EST/PRG :

In appropriate time under FSH & LH control

4- Uterus with normal mullerian development

5- Responsive endometrium :

Built & shed by effect of cyclic ovarian EST/PRG

6- Patent outflow tract :

conduct menstrual flow outwards

Front 15

Causes of Amenorrhea ?

Back 15

1- Physiological absence of menstruation :

- Before Puberty = absent FSH & LH

- After Menopause = No E/PRG = Depletion

- During Pregnancy = No withdrawal

- During Lactation = Elevated Prolactin

2- Outflow tract disorders :

1- Imperforate Hymen

2- Transverse Vaginal Septum

3- Cervical Atresia

3- Uterine developmental anomalies :

1- Mullerian Agenesis "Complete/Partial"

Mayer-Rokitansky- Kauster-Hausser syndrome

2- Complete Androgen Insensetivity

"Testicular feminization syndrome"

3- Asherman's syndroime

"Intrauterine synaechea"

4- Ovarian disorders :

1- Turner Syndrome "Gonadal Dysgenesis"

2- Premature ovarian failure

3- Resistant ovary syndrome

4- PCOs

5- Anterior pituitary disorders :

1- Pituitary adenomas

2- Empty Sella syndrome

3- Pituitary insufficiency

6- Hypothalamic & CNS disorders :

1- Congenital GnRH deficiency

2- Psychatric disorders

3- Rapid weight loss & Excessive exercise

4- Drug Induced

5- Hypothalamic tumors or infilterative lesions

7- Endocrine disorders :

1- Hypothyroidism

2- Cushing's syndrome

7- Endocrine disorders :

Front 16

Common causes for 1ry & 2ry Amenorrehea ?

Back 16

A) 1ry Amenorrhea :

- Cryptomenorrhea "Imperforate Hymen"

- Turner S

- Mullerian Agenesis

- Androgen Insetsetivity

- Congenital GnRH deficiency

- Kallmann's S

B) 2ry Amenorrhea :

- PCOS

- Hyperprolactinemia

- Endocrine disorders "Hypothyroidism"

- Drug induced "Postpill - GnRH agonists"

- Rapid weight loss & Excessive excercise

- Ashermann's S

- POF & POI

Front 17

Outflow Tract Obstruction "Cryptomenorrhea" ?

Back 17

1ry Amenorrhea due to obstruction of menstrual flow at level of :

Hymen - Vagina - Cervix.

Usually at young age with normal 2ry Charac.

- Called Cryptomenorrhea "False Amenorrhea"

Because menstruation occurs but not revealed

A) Imperforate Hymen :

- Definition

Cong. anomaly in which H.orifice is absent

- Due to : Failure of canilization of UGS

- Incidence :

MCC of Cryptomenorrhea

0.1% of newly born females

- Pathogenesis :

Menses start at puberty but accumulate behind imperforate hymen :

1- Hematocolpos : accumulated inside vagina

2- Hematometra : Prolonged = Uterine cavity

3- Hematosalpinx : in tubes from uterus

- C/P :

1rt Amenorrhea at young age with well developed 2ry sexual characters.

- Symptoms :

Lower abdominal Pain sync. with M.Period.

- Signs :

Inspection & Palpation of Lower abdomen :

Suprapubic bulge = large hematocolpos extending upward to suprapubic region

Inspection & Palpation of Vulva & Vagina :

Absent hymenal orifice

If large H.C = bulging hymen at hymenal ring with slight bluish colour

PR Ex. :

Sizable hemtocolpos is easily palpated

- Investigations : Pelvic US = Gold standard

- Treatment : Confirmed Dx = Hymenotomy
Cruciate incision dividing imperforate hymen.

B) Transverse Vaginal Septum :

Congenital prescence of one or more transverse vaginal septae at any level between hymenal ring & Cervix = occlusion of lower / middle / upper part of vagina.

Due to : Failure of fusion of MD & UGS

Incidence : Rare but 2nd MC for Cryptomeno.

C/P : Cryptomenorrhea as Imperforate Hymen

Dx : Pelvic US = H.Colpos + Normal hymen

Tx : Surgical excision of septum

C) Cervical Atresia :

Congenital absence of Cervix "Very Rare"

Due to : Failure of canalization of cervical canal as part of mullerian dysgenesis

C/P : Cryptomenorrhea as Imperforate Hymen

Dx : Pelvic US

Marked H.Metra + absent Cervix +No H.Colpos

Tx :

1- Cervical reconstruction & Canalization

2- Usually poor & Fails = Hysterectomy

Front 18

Complete / Partial Mullerian Agenesis
"Mayer-Rokitansky-Kauster-Hausser S" ?

Back 18

- Description :

Female ( 46XX ) with congenital defect that result in failure of development of Mullerian structures "Uterus - Cervix - Upper Vagina"

- Etiology :

Unwanted IU exposure to AMH with failure of development of mullerian ducts

- Incidence :

1:4000 female birth

20% of 1ry Amenorrhea (2nd MC after Turner)

- C/P :
1ry Amenorrhea with normal 2ry Characters

Due to : Normal ovaries as gonads develop from genital ridges + Normal Estrogen production + Intact H-P-O axis

- P.V : If Not Virgin

Female Ex.genetalia with pubic hair present

Blind ended short vagina with absent cervix & uterus

- Pelvic US :

Absent uterus &Upper vagina

Normal ovaries

- Karyotyping : Blood sample for genetic studies = 46XX chromosomal pattern

- Managment :

- Vaginoplasty "Mclndoe procedure" :

Surgical lengthening of short vagina

- Check for associated Urinary tract / skeletal anomalies.

Front 19

Complete Androgen Insensetivity

"Testicular feminization syndrome" ?

Back 19

- Description :

Male ( 46XY ) with X-linked recessive disorder that render them androgen resistant

- Etiology :

Defect in peripheral androgen receptors.

- Pathogenesis :

- Male gonadal tissue is present in labia / Inguinal canal : Incapable of spermatogenesis

- Y chromosome lead to production of MIF = failure of mullerian system development

"Tubes / Uterus / Cervix / Upper 1/3 of vagina"

- Produce testosterone = normal male lvls but incapable of developing male sexual characters therefore develop phenotypically as females.

- Incidence :
Rare but 3rd MCC of 1ry Amenorrhea after MA

- C/P :

1ry amenorrhea with normal 2ry characters :

At puberty testicles produce increasing amounts of androgens that undergoes peripheral conversion to estrogen causing breas development & feminine contour.

- P.V :

Female ex. genetalia with absent pubic hair

Blind ended vagina with absent cervix & uterus

- Pelvic US :

Absent uterus & Upper vagina

Testicles in labia or inguinal canal

- Karyotyping : Blood sample for genetic studies = 46XY chromosomal pattern

- Managment :

1- Gonadectomy : after puberty as it carries 20% risk of gonadoblastoma

2- Creation of neo-vagina surgically by Mclndoe procedure if the patient desired as such cases are reared as females

3- HT in form of estrogen preparaiton to keep external female appearance & prevent accelerated bone loss

Front 20

Asherman's syndrome ?
"Intrauterine Synechae"

+ Differential Dx for postpartum amenorrhea ?

Back 20

- Definition :

2ry Amenorrhea due to acquired intrauterine adhesions that prevents endometrial proliferation.

- Causes :

1- Endometritis :

Postabortive or Peurperal / IUD induced / TB

2- Iatrogenic : vigorous curettage during D&C especially with surgical evacuation

- C/P :

2ry Amenorrhea following Endometritis or Curretage

- Dx :

HSG & Hysteroscopy

- Tx :
Lysis of adhesions by Operative Hysteroscopy or D&C like procedure + IU Stent followed by

Cyclic combined EST/PRG therapy for at least 3 cycles to restore endometrial regeneration.

- Diff.Dx : Postpartum Amenorrhea :

1- New pregnancy

2- Asherman S

3- Lactation

4- Sheehan S

Front 21

Ovarian Causes of Amenorrhea ?

Back 21

A) Turner "Gonadal Dysgenesis : 45XO
Chromosomal defect "absent X chromosome"
Associated with Streak gonads : ovaries are replaced by fibrous tissue

- Incidence :

MCC of 1ry Amenorrhea = 30% of cases

- C/P :

1ry Amenorrhea with phenotypic characterestics :

Short stature - low hair line - webbing of the neck - increased carrying angle of elbow - cardiac anomales COA

- Pathogenesis :

- No Y : normal development of Mullerian D.
( Tubes - Uterus - Cervix - Vagina )

- Streak gonads : fail to produce enough E2 at puberty despite high FSH & LH = 1ry Amenorr.

- Tx :

HRT : cyclic combined EST/PRG =

Induce regular cycle + Preserve 2ry sex characters + gaurd bone from osteoporosis

NB : Mosaic Turner (45XO/46XX)

Spontaneous Menses + Pregnancy in 2-5%

but POF + Premature menopause.
B) Premature ovarian failure :

Early exhaustion of primordial follicles before age of 40 = premature menopause & Ameno.
- Causes :

1- Idiopathic : autoimmune destruction

2- Karyotype abnormalities : loss of small portion of X chromosome

3- Viral : as mumps

4- Induced : Radiation -Chemotherapy - Surgical removal

- C/P : Premature menopause
2ry Amenorrhea with high FSH & LH

- Treatment :

HRT : Combined E&P to avoid hazards of PMM

C) Resistant ovary syndrome :
- 2ry Amenorrhea with high FSH & LH due to failure of viable ovarian follicles to respond to pituitary gonadotropins due to defective FSH & LH receptors.
- In few cases temporary "may ovulate & concieve " + Estrogen maybe tried

D) PCOS :

Chronic anovulation + hyperandrogenism + histological changes in ovary

- Incidence :

MCC for 2ry amenorrhea due to Anovulation

- C/P : 2ry Amenorrhea or Oligomenorrhea

ass. with hirsutism / infertility / obesity

- Dx :

Pelvic US : Necklace appearance

Hormonal profile : LH/FSH ratio > 2 "reversed"

Elevated : T "total & free" + DHEAS + insulin

- Tx : according to patient complaint
Amenorrhea / infertility / hirsutism / obesity

Front 22

Anterior Pituitary Disorders causing Amenorrhea ?

Back 22

A) Pituitary Adenomas :

Prolactinoma causing Hyperprolactinemia :

Suppression of GnRH & LH surge causing Chronic Oligo then anovulation.
- Hyperprolactinemia :
By itself = 20% of 2ry amenorrhea
- Prolactinomas :

MCC for hyperprolactinemia &

MC pituitary cause for 2ry Amenorrhea

1- Microadenoma < 10 mm :

Commonest = moderate elevation in PRL

2- Macroadenoma > 10 mm :
Rare = High serum PRL + signs of ICT

Dx + Tx : See Hyperprolactinemia

B) Empty Sella syndrome :

Enlarged sella turcica not entirely filled with pituitary tissue due to defect in diaphragma sella allowing CSF to enlarge sella

- C/P : 2ry Amenorrhea or Oligoamenorrhea with hyperprolactinemia

- Dx : MRI & CT scan

C) Pituitary Insufficiency :
Diminished FSH & LH = chronic anovulation with hypogonadotrophic amenorrhea
Causes :
1- Sheehan's syndrome :
Ant.Pituitary necrosis following severe postpartum hge

2- Simmond's disease :
Male or female following any bleeding

- Radiation necrosis / infarction / Non-lactotropihic adenomas

- Infilterative lesions :
Lymphocytic hypophysitis

- Mx :
1- Tx of cause

2- HRT : combined EST/PRG

3- Induction using FSH & hCG "But No CC"

Front 23

Hypothalamic & CNS Disorders Causing Amenorrhea ?
Mechanism

Causes

Back 23

* Mechanism :
Decreased GnRH pulses frequence =

Low FSh & LH, absent LH surge, Low E2 & chronic anovulation = hypogonadotropic amenorrhea
* Causes :

A) Congenital GnRH deficiency :
Rare, 1ry amenorrhea + infantile sexual development =Hypogonadotrophic Hypogonadism

- Kallman syndrome :

Congenital GnRH deficiency + Anosmia : congenital failure of neuronal migration of olfactory placode in the nose
Mx :

1- HRT : Combined EST/PRG : preserve 2ry characters + uterus size + withdrawal bleeding

2- Induction by FSH/LH/hCG : if normal sized uterus + responsive endometrium

B) Psychatric disorders :

- Emotianlly stressful events :

Family problems / work study travel / death or severe illness of a realtive "In some women"

- Pseudocyesis "False Pregnancy" : Rare

Emotional women extremely desirous of pregnancy = voluntry alteration of hypothalamic function = 2ry amenorrhea

+ Galactorrhea + Abdominal distention

- Aneroxia nervosa :

1% of young women "bulemia in 50%"

C) Rapid weight loss & Excessive exercise :

- Rapid weight loss : 20% of body fat by wieht is needed for initiation of menarche & maintenance of menses, Rapid weight loss below 20% of ideal weight = 2ry amenorrhea
- Excessive exercise :

Female athletes as marathon runners / ballet dancers due to increaed circulating endorpohins + marked decreas of body fat

D) Drug induced amenorrhea :

1- Long acting GnRH agonists :

Initial stimulation of GnRH receptors followed by longer suppression of FSH & LH = receptor downregulation = 2ry amenorrhea
Used in : Severe endometriosis / severe AUB / Prior to surgery to decrease size of myomas

2- Progestins :

Continuous use of synthetic progesterone
Prevent shedding & Inhibit GnRH leading to delay in cycle & 2ry amenorrhea

Normal menses is resumed after stopping

3- Combinetd EST/PRG :

- Continous : Prevent shedding & Inhibit GnRH as long as therapy continues

- Post-Pill Amenorrhea : In 1% after long use of OCPs due to chronically depressed gonadotropin levels but self limited = menses resume in 2-6 months

4- Androgenic drugs :

Prolonged use of Danazol for endometriosis
Androgenic = atrophic endometrial changes

5- Anti-Psychotics & TCA :
Anti-Dopaminergic = Hyperprolactinemia

E) Hypothalamic tumors & Infilterative lesions :
Rare present with 2ry amenorrhea with neurological symptoms as severe headavhe / presonality changes / mood changes

- Craniopharigioma : Associated with

Visual field defects + Calcification on x-ray

- Lymphoma / Langerhans cell histyocytosis / Sarcoidosis :

Decreased GnRH = Low FSH/LH = Amenorrhea

Front 24

Other Endocrine dissorders causing Amenorrhea ?

Back 24

Some endocrine disorders cause H-P-O axis disturbance causing transient 2ry amenorrhea which is managed by correcting the cause.
1- Hypothyroidism :

Eleavated TRH = Elevated PRL

2- Cushing :

Hyperandrogenism due to Increased Adrenal activity by high ACTH