Amenorrhea (eBook)

Amenorrhea 3
Preface 5
Contents 7
Contributors 9
Chapter 1: The Hypothalamic-Pituitary-Ovarian Axis 13
Introduction 13
The Neuroendocrine Axis 13
Hypothalamus 13
Anatomy 13
Physiology 15
GnRH Neurons 15
Hypothalamic Neuropeptides and GnRH Neurons 17
Neuropeptide Y 17
Proopiomelanocortin 17
Kisspeptin 18
Hypothalamic Neurotransmitters and GnRH Neurons 18
Pituitary 18
Embryology and Anatomy 18
The Anterior Pituitary 19
The Posterior Pituitary 20
Pituitary Gonadotropins 20
FSH 21
LH 21
Prolactin 21
The Ovary 22
Ovarian Embryology 22
Ovarian Anatomy 22
Follicular Development and Atresia 23
Early Follicular Development 23
Secondary Follicles 24
Antral Follicle 24
Ovarian Physiology 25
Estrogen 25
Progesterone 25
Inhibin 26
Activin 26
Follistatin 26
Summary 26
References 27
Chapter 2: The Mechanism of Menstruation 32
The Endometrium During the Menstrual Cycle 32
Proliferative Phase 33
Secretory Phase 34
Endometrial Growth Regulation 34
Ovarian Steroids 35
Growth Factors 35
Endometrial Stem cells 37
Endometrial Vessels 38
Endometrial Vascular Supply 38
Regulation of Endometrial Vessel Growth 38
Menstruation 40
Loss of Vascular Integrity 40
Matrix Metalloproteins (MMPs) and Tissue Breakdown 41
Endometrial Re-epithelialization 41
Vascular Repair 42
Summary 42
References 42
Chapter 3: Amenorrhea Due to Idiopathic Hypogonadotropic Hypogonadism and Kallmann Syndrome 46
Case Study 46
Development of the Hypothalamic-Pituitary-Gonadal Axis 46
The Diagnosis of Delayed Puberty 47
Hypogonadism 49
Idiopathic Hypogonadotropic Hypogonadism 49
The Genetic Basis of IHH/KS 50
Chromosome Analysis 50
Molecular Analysis 51
Treatment 53
Case Discussion 53
References 54
Chapter 4: Polycystic Ovary Syndrome 56
Introduction 56
Clinical and Endocrine Characteristics of Main PCOS Phenotypes 57
Amenorrhea and PCOS: Prevalence and Clinical Significance 58
Abdominal Obesity as the Main Determinant of the Severity of PCOS Phenotype 58
Adolescent PCOS: Specific Problems and Diagnosis 59
Treatment of PCOS 60
Clinical Case No. 1 60
Questions 61
Answer and Comment 61
Follow-Up 62
Conclusions 62
References 63
Chapter 5: Primary Ovarian Insufficiency 65
A Clinical Vignette 65
Introduction 65
The Clinical Spectrum of POI 67
Etiologies 70
Idiopathic 70
Genetic 70
X Chromosome Abnormalities 70
Autosomal Gene Abnormalities 73
Other Gene Abnormalities 74
Autoimmune Dysfunction 75
Iatrogenic/Environmental 76
Evaluation of Hypergonadotropic Amenorrhea 76
History 76
Physical Examination 77
Laboratory Evaluation 77
Emotional Assessment 79
Delivering the Diagnosis 79
Psychologic Impact 80
Sexual Impact 82
Treatment 82
Genetic Counseling 82
Family Planning 83
Medical Therapy 84
Preventative Therapy 85
Back to the Vignette 85
References 86
Chapter 6: Hyperprolactinemia and Pituitary Causes of Amenorrhea 93
Introduction 93
Case 93
Causes of Hyperprolactinemia 94
Physiologic Causes 94
Pregnancy 94
Nipple Stimulation 95
Macroprolactinemia 96
Medications 96
Psychiatric Medications 96
Antipsychotics 96
Antidepressants 96
Other Medications 97
Pathophysiologic Causes 97
Lactotroph Adenoma 97
Mass Effect/Trauma 97
Primary Hypothyroidism 98
Chronic Renal Failure 98
Clinical Findings in Hyperprolactinemia 98
Reproductive Dysfunction 98
Galactorrhea 99
Bone Loss 99
CNS Disturbances 99
Treatment of Hyperprolactinmeia 99
Other Pituitary Causes of Amenorrhea 101
Non-Lactotroph Adenomas and Sellar Masses 101
Sheehan’s Syndrome 102
Infiltrative and Infectious Causes 103
Lymphocytic Hypophysitis 103
Hereditary Hemochromatosis 103
Other 104
Iatrogenic and Other Causes of Pituitary-Associated Amenorrhea 104
Surgery 104
Radiation 105
Traumatic Brain Injury and Subarachnoid Hemorrhage 105
Genetic Causes 105
Diagnostic Evaluation 106
History 106
Physical Examination 106
Case Correlation 107
References 107
Chapter 7: Amenorrhea Associated With the Female Athlete Triad: Etiology, Diagnosis, and Treatment 111
Introduction 111
A New Model 112
The Prevalence of Athletic Amenorrhea 113
The Etiology of Athletic Amenorrhea 114
Physiological Considerations 114
Psychological Considerations 117
Bone Health Considerations 119
Diagnosis and Treatment 122
Conclusions 128
References 129
Chapter 8: The Role of Body Weight in Menstrual Disturbances and Amenorrhea 136
Low Body Weight and Menstrual Disturbances 136
Case 1 136
Eating Disorders – Definition 137
Epidemiology of Eating Disorders and Weight-Related Amenorrhea 137
Clinical Presentation 138
Pathophysiology 138
Diagnostic Workup 139
Therapeutic Algorithms 140
Obesity and Menstrual Disturbances 141
Case 2 141
Defining Excess Body Mass 141
Epidemiology of Obesity and Menstrual Dysregulation 141
Clinical Presentation 142
Pathophysiology 143
Diagnostic Workup 144
Therapeutic Algorithms 144
References 145
Chapter 9: Natural and Surgical Menopause 149
Defining the menopausal transition 149
Ovarian follicular depletion is the primary driver of the menopausal transition 152
Endocrine changes in the menopausal transition 153
Inhibin and reproductive aging 155
Alterations in the hypothalamic-pituitary-ovarian (HPO) axis with reproductive aging 158
Symptoms of the menopausal transition 159
Hot flashes 161
Urogenital symptoms 166
Bone 167
Surgical Menopause 169
Summary 171
References 172
Chapter 10: Clinical Implications of Prolonged Hypothalamic Amenorrhea 178
Case Scenario 178
Baseline Biochemical Evaluation 179
Followup Biochemical Evaluation 179
Overview 180
Neuroendocrinology of FHA 181
Behavioral Correlates of FHA 183
Potential Health Implications of FHA 185
Treatment Considerations 187
Conclusion 190
References 190
Chapter 11: Long-Term Implications of Oophorectomy at the Time of Hysterectomy for Benign Disease 194
Introduction 194
Arguments for and Against Oophorectomy 194
Long-Term Risks of Hysterectomy 195
Long-Term Risks of Oophorectomy in Premenopausal Women 196
Hot Flashes, Mood, and Quality of Life 196
Urogenital Atrophy 196
Sexual Function 196
Central Nervous Effects: Cognitive Thought, Memory, Depression, Parkinson’s Disease 197
Osteoporosis and Hip Fracture 197
Quality of Life: Lens Opacities, Body Mass 198
Cardiovascular Disease 198
Long-Term Risks of Oophorectomy in Postmenopausal Women 199
Hormone Production in the Postmenopausal Ovary 199
Controversies on Postmenopausal Ovarian Enzyme Activity 200
Osteoporosis and Hip Fracture 200
Quality of Life 201
Examining the Effect of Oophorectomy on Overall Mortality 201
Controversies on Hormone Replacement 202
Conclusions 203
References 204
Chapter 12: Ethnicity and Amenorrhea 209
Ethnic Variations in Menstrual Physiology 209
Menarche 209
Menstruation 210
Ovulation/Anovulation 210
Ovarian Insufficiency 211
Menopausal Transition 212
Variations in Cultural Beliefs and Attitudes Toward Normal and Abnormal Menstrual Cycles 213
Menstrual Symptoms 213
Contraceptive-Induced Amenorrhea 214
Racial Differences in Hysterectomy 214
Menopause 215
Summary 216
References 216
Index 218