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APGO educational topic number 43
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amenorrhea amenorrhea is the absence of
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menstruation and can be classified as
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primary or secondary a young woman with
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primary amenorrhea has never menstruated
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if she has never menstruated by age 13
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and has no secondary sexual development
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than she was classified as having
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primary amenorrhea alternatively by age
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15 if she has never menstruated and has
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secondary sexual development than she is
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also classified as having primary
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amenorrhea secondary amenorrhea is
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diagnosed when a menstruating woman has
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not menstruated for 3 to 6 months or has
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missed 3 periods these terms should not
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be confused with all ago materia which
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is the reduction of the frequency of
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menses with bleeding 3 days greater than
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40 but less than 6 months the objectives
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of this video to explain the
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pathophysiology and identify ideologies
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of amenorrhea and ala komen area
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including possible nutritional causes
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describe associated symptoms examination
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findings diagnostic tests and management
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of amenorrhea discuss the consequences
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of untreated amenorrhea and algal
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malaria the most common cause of
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amenorrhea is pregnancy and this should
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always be ruled out prior to further
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evaluation of amenorrhea the three most
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common causes of amenorrhea not from
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pregnancy are hypothalamic pituitary
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dysfunction ovarian dysfunction and
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anatomic abnormalities let’s start our
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discussion of hypothalamic pituitary
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dysfunction with a quick tutorial about
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the hpo axis the hypothalamus releases
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GnRH in a pulsatile fashion and this
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travels to the anterior pituitary in the
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pituitary stalk this GnRH stimulates the
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anterior pituitary to release FSH and LH
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the FSH and LH stimulate the ovaries to
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begin the cycle of folliculogenesis
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ovulation and estrogen and progesterone
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release anything that alters is delicate
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feedback loop can cause hypothalamic
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pituitary amenorrhea April acting
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secreting pituitary adenomas or
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craniopharyngioma can impinge on the
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pituitary stalk and alter blood flow
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more common functional causes include
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weight loss excessive exercise or
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obesity modifying the causal behavior
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can often restore menses the female
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athlete triad of amenorrhea dis or
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eating and osteopenia or osteoporosis
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demonstrates the need for sufficient
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caloric intake to enable the energy
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expenditure for the hpo access to
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function other potential causes for HP o
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amenorrhea include head injury marijuana
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psychoactive drugs chronic anxiety
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anorexia nervosa and chronic medical
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illness now we will discuss another
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cause of amenorrhea ovarian failure
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ovarian failure occurs when the ovaries
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are exhausted or are resistant to FSH
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and LH the most common causes of ovarian
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failure are chromosomal abnormalities
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such as Turner’s syndrome which lead to
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a variant is genesis or autoimmune
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ovarian failure anatomic abnormalities
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causing amenorrhea can be congenital or
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acquired common congenital causes
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include imperforate hymen or absence of
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the uterus or vagina a Sherman syndrome
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is the most common cause of secondary
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amenorrhea
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this can occur after dilation and
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curettage especially for retain products
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of conception in the setting of
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infection this causes scarring of the
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endometrium the first step of treatment
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is to establish the cause of amenorrhea
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many physicians use the progesterone
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challenge test as the first step a
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patient takes oral progesterone for ten
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days after stopping the progesterone if
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she then has bleeding we refer to this
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as a withdraw bleed for she’s
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essentially withdrawing from the
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progesterone therapy this tells us that
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she has adequate estrogen a competent
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endometrium and a Paton outflow tract if
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bleeding occurs then further workup
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should investigate causes like thyroid
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disease hyperprolactinemia polycystic
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ovarian syndrome and congenital adrenal
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hyperplasia
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if withdrawal bleeding does not occur
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than a combined estrogen and
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progesterone test can be performed to
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differentiate an outflow tract
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abnormality from inadequate estrogen
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levels in this test estrogen is given
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for 21 days then progesterone is given
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for 7 to 10 days and the patient is
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again evaluated for withdrawal bleed if
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no bleeding occurs after this test that
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an ultrasound or MRI should be performed
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to look for anatomic abnormalities if
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bleeding occurs after the test FSH
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levels should be checked a high serum
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FSH is indicative of primary ovarian
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insufficiency
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a karyotype should then be performed to
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assess for complete or partial deletion
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of the X chromosome as in Turner
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syndrome treatment of amenorrhea depends
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on the etiology anatomic abnormalities
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such as imperforate hymen can be
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surgically corrected which will allow
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for menstruation and fertility a Sherman
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syndrome can be treated with license of
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adhesions and post-operative estrogen
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therapy women with ovarian failure
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should receive hormone therapy to avoid
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the negative side effects of estrogen
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deficiency especially for bone and heart
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health hypothalamic pituitary
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dysfunction can be improved by
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correcting the functional cause of the
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disruption the consequences of untreated
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amenorrhea depend also on the underlying
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etiology for women with the athletes
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trier there are many issues that may
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need to be addressed including
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disordered eating patterns body image
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issues and bone health this may involve
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a multidisciplinary team with cognitive
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behavioral therapy the consequences for
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these women can involve long term
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cardiovascular and osteoporosis risk
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from years of low estrogen exposure this
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concludes the aapko educational video on
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amenorrhea we have discussed many of the
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causes evaluation and treatment options
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for this condition in women