Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Amenorrhea
Marshal
Marshal WA,
WA, Tanner
Tanner JM,
JM, Variations
Variations in
in the
the pattern
pattern of
of pubertal
pubertal
changes
changes in
in girls.
girls. Arch
Arch Dis
Dis Child
Child 1969;44-291
1969;44-291
norrhea, FEU-NRMF Department of Obstetrics and Gynecology, 2012 5
Breast Growth:
B1 Prepubertal: elevation of papilla
only
B2 Breast budding
B3 Enlargement of breasts with
glandular tissue, without
separation of breast contours
B4 Secondary mound formed by
areola
Marshal WA, Tanner JM, Variations in the pattern of pubertal
B5 Single
changes in girls. Archcontour of breast and
Dis Child 1969;44-291
areola
norrhea, FEU-NRMF Department of Obstetrics and Gynecology, 2012 6
Pubic Hair Growth:
PH1 Prepubertal: no pubic hair
PH2 Labial hair present
PH3 Labial hair spreads over mons
pubis
PH4 Slight lateral spread
PH5 Further lateral spread to form
inverse triangle and reach
Marshal WA, Tanner JM, Variations in the pattern of pubertal changes in
medial thighs
girls. Arch Dis Child 1969;44-291
during childhood
Compartment III GnRH
Anterio
Estrogen is Low
r
pituita
ry
Ovary
Menses
After menarche.
Stress
(-)
CRH GnRH
ACTH, Cortisol
(-)
Anterio
secreted estradiol. r
pituita
ry
FSH LH
Compartment II
Ovary
Compartment I
X
Estrogen
Uterus
Progesterone
Menses
(ovarian) failure
Compartment III GnRH
Estradiol
Anterio
r
Progesterone pituita
Compartment II FSH
ry
LH
LH and FSH
Ovary
HYPERGONADOTRO
PIC
HYPOGONADISM
Compartment I
X
Estrogen
Uterus
Progesterone
Menses
duct development or
wolffian duct Compartment III GnRH
Anterio
regression, the internal r
pituita
ry
and external genitalia Compartment II FSH LH
X
normal female.
Compartment I Estrogen Progesterone
Uterus
Menses
Anterio
Breast development r
pituita
ry
does not occur Compartment II FSH LH
X
circulating E2 levels.
Compartment I Estrogen Progesterone
Uterus
Menses
However, they will have premature ovarian failure; usually before age
25. Rarely, ovulation and pregnancy can occur.
Speroff L, et al.
Clinical Gynecologic Cholester Acetate
Endocrinolgy and
Infertility, ed 6, Lip- ol P450scc
pincott, 1999
X
5 pathway 4 pathway
Pregnenolo
DHEA Progesterone 3-OHSD
P450c17 pathway ne pathway
17OHlase 5,4 isomerase
X
17- Progesterone
Hydroxypregnenolone
P450c17, 20 lyase P450c17
17OHlase
Dehydroepidandrosterone 17-
3-OHSD P450c17 Hydroxyprogesterone
5,4
isomerase 17, 20 lyase
17-OHSD
Androstenedio Testosteron
ne e
P450arom P450arom
Estrone
17HSD
P450c17
P450c17
X
P450scc
DHEA
Pregnenolo 17-OH
ne pregnenolone
3-OHSD 5,4 isomerase
C17,20 lyase
Progesteron 17 OH lase 17- Androstenedio
e OHprogesterone ne
21-OH lase 17-HSD
11 deoxycortisone
(DOC)
11-OH lase
11
deoxycortisol
X
Testosteron
e
Corticosteron
e
18-OH lase, 19-
OHdehydrogenase
X
Cortisol
because of Hypothalamus
hypothalamic failure
Compartment III GnRH
Estradiol
Anterio
r
Progesterone pituita
Compartment II FSH
ry
LH
LH and FSH
Ovary
HYPOGONADOTROP
IC HYPOGONADISM
Compartment I
X
Estrogen
Uterus
Progesterone
Menses
Anterio
r
pituita
ry
FSH LH
Compartment II
Ovary
Compartment I
X
Estrogen
Uterus
Progesterone
Menses
failure
Compartment III GnRH
Estradiol
Anterio
r
Progesterone pituita
Compartment II FSH
ry
LH
LH and FSH
Ovary
HYPOGONADOTROP
IC HYPOGONADISM
Compartment I
X
Estrogen
Uterus
Progesterone
Menses
NOT respond to a
GnRH Compartment III GnRH
Anterio
bolus/stimulation. r
pituita
ry
FSH LH
Compartment II
Ovary
Compartment I
X
Estrogen
Uterus
Progesterone
Menses
YES NO
38
norrhea, Excise gonads
FEU-NRMF Department ofLeave
Obstetrics and Gynecology, 2012 38
PRIMARY AMENORRHEA: Breast (-)
Uterus (+)
HIGH Serum FSH
Hypergonadotropic hypogonadism
BP Measurements
NORMAL HYPERTENSION
Gonadal dysgenesis
17 -hydroxylase
deficiency 46,XX
Karyotyping
Hypernatremia
Hypokalemia
45,X; 46,X/abnormal X; Mosaicism
Serum progesterone > 3 ng/ml
Pure gonadal dysgenesis; 17 OH Progesterone (0.2 ng/ml)
45,X/46,XY DOC (>17 ng/100ml)
45,X/45Xi (Yq); 45,X Testicular
determinant position
39
norrhea, FEU-NRMF Department of Obstetrics and Gynecology, 2012 39
39
PRIMARY AMENORRHEA: Breast (-)
Uterus (+)
Serum FSH NV: 5-20IU/L
biologically active
estrogen. Compartment III GnRH
Anterio
?
r
pituita
ry
female.
Uterus
Menses
AMH
MIS
Mullerian DuctRegresses
TESTESMALE Internal
Wolfiaan Duct Develop genitalia
s
Eternal Genitalia
TESTOSTER
Develops in the
absence of sex
steroids
ONE
X
Feminine
Short or absent
Penis vagina
Pubic & axillary
hair scanty
Normal breast
development
norrhea, FEU-NRMF Department of Obstetrics and Gynecology, 2012 43
Androgen Resistance (Testicular Feminization)
Why (+) breasts? Breast development is normal or
enhanced
Estrogen levels here are in the
male range but are sufficient for
breast proliferative activity.
Testosterone inhibits breast
proliferation. The absence of
androgen action allows even
low levels of estrogen to cause
unabated breast stimulation.
Karyotype 46 XY 46 XX
Axillary and pubic hair absent to sparse, Scanty Normal female body hair, ovulatory.
Anterio
a male phenotype. r
pituita
ry
FSH LH
Compartment II
GONADS
Uterus
Menses
Karyotype (46,XY)
category.
Compartment III GnRH
Uterus
Menses
Zawadzki
Zawadzki JK,
11
JK, Dunaif
Dunaif A.
A. In:
In: Dunaif
Dunaif A,
A, et
et al,
al, eds.
eds. Polycystic
Polycystic Ovary
Ovary Syndrome.
Syndrome.
Boston:
Boston: Blackwell
Blackwell Scientific
Scientific Publications,
Publications, 1992,
1992, pp.
pp. 377-384.
377-384. The
22
The Rotterdam
Rotterdam
ESHRE/ASRM-Sponsored PCOS consensus workshop group. Fertil
ESHRE/ASRM-Sponsored PCOS consensus workshop group. Fertil Steril. Steril.
2004;81:19-25.
2004;81:19-25. 33The
The Rotterdam
Rotterdam ESHRE/ASRM-Sponsored
ESHRE/ASRM-Sponsored PCOS PCOS consensus
consensus
workshop
workshop group.
group. Hum
Hum Reprod.
Reprod. 2004;19:41-47.
2004;19:41-47. Ehrmann
44
Ehrmann DA.
DA. N
N Engl
Engl JJ Med.
Med.
2005;352:1223-36.
2005;352:1223-36.
norrhea, FEU-NRMF Department of Obstetrics and Gynecology, 2012 61
Functional hypothalamic amenorrhea
No underlying pituitary, hypothalamic or ovarian
causes
No cyclic alterations in LH pulsatility no pulses or
only one pattern seen throughout menstrual cycle
(persistent luteal pattern)
Possibly due to CNS neurotransmitter abnormality,
increase opioid acitivity
2 Gonadal irradiation
3 Chemotherapy
no PCO by ultrasound
(+) history of drug ingestion, stress, weight loss,
exercise
Diagnosis: Hypothalamic pituitary dysfunction
Self limiting, not life threatening
Elevated TSH
+ withdrawal bleed after - withdrawal bleed after
PCT PCT
E2 30-40pg/mL E2 low
HYPO
THYROIDISM Prl > 100ng/ml
ANOVULATION
PCOS FSH assay
HYPER-
Ptolactinemia
LOW HIGH
HYPOTHALAMIC
AMENORRHEA
OVARIAN
FAILURE
CT SCAN or MRI