Investigação da amenorreia primária e secundária - passo a passo (LIVE REVALIDA INEP)

Summary

This video script delves into the medical investigation of amenorrhea, covering both primary and secondary types. It explains how to approach diagnosis, from evaluating the presence of sexual characteristics to ordering tests such as beta-hCG, TSH, and progesterone. Key conditions such as hypothyroidism, PCOS, and ovarian failure are explored, along with diagnostic steps for amenorrhea in both adolescents and adults. The video also addresses the role of hormonal tests, ultrasound, and genetic evaluations, and outlines treatment options based on the underlying cause. The script serves as a detailed guide for healthcare professionals in managing amenorrhea cases.

Takeaways

• 😀 Amenorrhea can be classified into primary and secondary types. Primary amenorrhea refers to a patient who has never menstruated, while secondary amenorrhea refers to a patient who has previously menstruated but has missed at least three cycles or six months of menstruation.
• 😀 In primary amenorrhea, if a patient has not reached menarche by 14 years old and lacks sexual characteristics like breast development, the investigation should begin. For patients with sexual characteristics developed, the investigation may begin at 16 years old.
• 😀 Secondary amenorrhea is more common and often linked to pregnancy, so a beta-hCG test is the first step in investigation.
• 😀 If the pregnancy test (beta-hCG) is negative, the next steps involve testing for thyroid abnormalities (TSH), prolactin levels, and a progesterone challenge test to evaluate if the patient is ovulating.
• 😀 A positive result from the progesterone test (using medroxyprogesterone acetate) suggests that the patient is ovulating and may have a condition like polycystic ovary syndrome (PCOS).
• 😀 If the progesterone challenge test is negative, further investigation includes administering both estrogen and progesterone to mimic the menstrual cycle and evaluate if the patient has a hormonal or anatomical issue.
• 😀 A positive result from the estrogen-progesterone challenge suggests hypogonadism, where the ovaries are not producing sufficient hormones.
• 😀 If the patient does not menstruate after the estrogen-progesterone challenge, this may indicate a structural issue such as Asherman's syndrome (uterine adhesions) due to past medical procedures.
• 😀 When investigating hypogonadism, it's essential to measure FSH and LH levels. Elevated FSH and LH with low estrogen and progesterone indicate hypergonadotropic hypogonadism, potentially caused by premature ovarian failure.
• 😀 A decreased level of FSH and LH along with low estrogen and progesterone indicates hypogonadotropic hypogonadism, which may be due to hypothalamic or pituitary dysfunction. Further tests like a GnRH test can help pinpoint the origin of the issue.

Q & A

What is amenorrhea and how is it categorized?

Amenorrhea is the absence of menstruation. It is categorized into primary amenorrhea (when a person has never menstruated) and secondary amenorrhea (when a person who previously menstruated stops menstruating for 3 consecutive months or 6 months).

How do we approach the investigation of a patient with secondary amenorrhea?

The first step in investigating secondary amenorrhea is to test for pregnancy using a Beta-hCG test. If pregnancy is ruled out, the next steps involve testing thyroid function (TSH) and prolactin levels. If these tests are normal, a progesterone challenge test is performed to assess ovulation.

What is the progesterone challenge test, and what does it indicate?

The progesterone challenge test involves administering progesterone for 7-10 days. If the patient menstruates after the test, it indicates that the patient is ovulating but may not be producing enough progesterone. If the patient does not menstruate, further investigation is needed.

What conditions should be considered if the progesterone challenge test is negative?

If the progesterone challenge test is negative, the investigation should continue to evaluate for possible anatomical issues, such as uterine anomalies like Asherman’s syndrome (uterine adhesions). It may also suggest issues with the hypothalamic-pituitary-gonadal axis.

How is polycystic ovary syndrome (PCOS) diagnosed?

PCOS can be diagnosed using the Rotterdam criteria, which require at least two of the following: irregular or absent periods (amenorrhea), signs of hyperandrogenism (e.g., hirsutism), and ultrasound findings showing multiple cystic follicles in the ovaries.

What does an increased TSH level indicate in the investigation of secondary amenorrhea?

An increased TSH level suggests hypothyroidism, which can cause secondary amenorrhea. High TSH levels can inhibit GnRH, which in turn affects the menstrual cycle, leading to amenorrhea.

What role does hyperprolactinemia play in secondary amenorrhea?

Hyperprolactinemia, or elevated prolactin levels, can lead to secondary amenorrhea by inhibiting GnRH release. This hormonal imbalance prevents the normal menstrual cycle and ovulation.

How do you differentiate between hypogonadism and other causes of amenorrhea?

Hypogonadism is characterized by low levels of both estrogen and progesterone. A test involving estradiol and progesterone administration can confirm this condition. If the patient does not menstruate after hormone administration, the cause is likely anatomical, such as uterine adhesions or anomalies.

What is the role of karyotype testing in primary amenorrhea investigations?

Karyotype testing is crucial in cases of primary amenorrhea, particularly if there is suspicion of a genetic cause like Turner syndrome. Turner syndrome, a condition where a person has only one X chromosome, is a common cause of hypogonadism and primary amenorrhea.

What are the potential causes of primary amenorrhea with normal sexual characteristics?

In primary amenorrhea with normal sexual characteristics (e.g., development of breasts and body hair), the condition could be due to an anatomical issue such as an imperforate hymen or a uterus that is absent or underdeveloped. Cryptomenorrhea, caused by an imperforate hymen, is one possible explanation.