A 52-year-old menopausal female sees you because of vaginal bleeding for 3 days in the preceding month. Since developing hot flushes 12 months ago, she has taken conjugated equine estrogens, 0.9 mg/day. You perform an endometrial biopsy and the pathologist reports a histologic diagnosis of adenomatous hyperplasia with atypia.
At this point, which one of the following would be most appropriate?
Correct Answer E:
Treatment depends on the histology of the lesion and on the patient’s age and her desire to preserve fertility. Simple hyperplasia can be treated with induction of ovulation in premenopausal patients or with long term progestin administration. Renewed evaluation of the endometrium after about 4 months is recommended to rule out an endometrial cancer that may have been missed the first time. The alternative to endocrine therapy is hysterectomy.
Hysterectomy is the treatment choice for complex or atypical hyperplasia (adenomatous hyperplasia with or without atypia). Bilateral salpingo-oophorectomy is generally performed in patients with atypical hyperplasia.
A 27-year-old patient complains of 6 months of amenorrhea. A pregnancy test is negative.
Which of the following is the most likely associated with secondary amenorrhea in this patient?
Correct Answer C:
After excluding pregnancy, the most common causes of secondary amenorrhea are:
1- Disorders associated with a low or normal FSH, which account for 66% of cases of secondary amenorrhea, include the following:
2- Disorders in which the FSH is high (12%) include the following:
3- Disorders associated with a high prolactin level comprise 13% of cases. Anatomic disorders (ie, Asherman syndrome) account for 7%.
4- Hyperandrogenic states as a cause of secondary amenorrhea (2%) include the following:
After pregnancy testing, all women who present with 3 months of secondary amenorrhea should have a diagnostic evaluation initiated at that visit. A complete blood cell count, urinalysis, and serum chemistries should be evaluated to help rule out systemic disease. Serum prolactin, FSH, estradiol, and thyrotropin levels should also be measured routinely in the initial evaluation of amenorrhea once pregnancy has been excluded.
A 20-year-old female long-distance runner presents with a 3-month history of amenorrhea. A pregnancy test is negative, and other blood work is normal. She has no other medical problems and takes no medications.
With respect to her amenorrhea, you advise her:
Correct Answer A:
Amenorrhea is an indicator of inadequate calorie intake, which may be related to either reduced food consumption or increased energy use. This is not a normal response to training, and may be the first indication of a potential developing problem. Young athletes may develop a combination of conditions, including eating disorders, amenorrhea, and osteoporosis (the female athlete triad). Amenorrhea usually responds to increased calorie intake or a decrease in exercise intensity. It is not necessary for patients such as this one to stop running entirely, however.
An 18-year-old woman who has a height of 158 cm, and normal breast development, presents with complaint of primary amenorrhea. Physical exam does demonstrate a small uterus.
All of the following should be done to investigate, except:
Correct Answer D:
Amenorrhea is absence of menstruation. The cause is usually endocrine dysfunction resulting in anovulation, often with mild estrogen deficiency and hyperandrogenism. Diagnosis is clinical and by pregnancy testing, measurement of hormone levels, and a progesterone challenge. Treatment aims to correct any underlying disorder and minimize excess androgenic effects.
Routine testing includes a pregnancy test, a progesterone challenge, and measurement of hormone levels (eg TSH, Prolactin, FSH, LH). If a genetic defect is suspected (eg, in primary amenorrhea), karyotype is determined.
A 30-year-old black female is being evaluated because of absent menses for the last 6 months. Menarche was at age 12; her menstrual periods were frequently irregular and were accompanied only occasionally by dysmenorrhea. She had her first child 4 years ago, but has not been able to become pregnant since. Her physical examination and pelvic examination are unremarkable. A serum pregnancy test is negative, prolactin levels are normal, and LH and FSH levels are both elevated (three times normal) on two occasions.
These findings are consistent with:
Correct Answer B:
The history and physical findings in this patient are consistent with all of the conditions listed. However, the elevated FSH and LH indicate an ovarian problem, and this case is consistent with ovarian failure (choice B) or premature menopause.
→ Hypothalamic amenorrhea (choice A) is a diagnosis of exclusion, and can be induced by weight loss, excessive physical exercise (jogging, ballet), or systematic illness, and is associated with tonically low levels of LH and FSH.
→ Most pituitary tumors (choice C and choice D) associated with amenorrhea produce hyperprolactinemia.
→ Polycystic ovarian syndrome (choice E) usually results in normal to slightly elevated LH levels and tonically low FSH levels.
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