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Morning Report

April 30, 2012

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HPI 15 year old female presenting with amenorrhea

No recent medical care

Had one menstrual period at age 10 years, which

lasted 3 days, but no menses since Otherwise in good health, without complaints

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ROS: occasional muscle cramps, nipples maybehave fluid if I squish them; no headaches, change invision, rash, or fatigue

PMH: Healthy, no hospitalizations or surgeries.

Hepatitis at age 5.

Medications: none

NKDA

Family History: MGM with arthritis, diabetes. Maternalgreat aunt had menopause at age 34, and has milkexpression with breast stimulation still.

Social History: 10th grade, good student. Lives withmother, father, and 13 year old sister. Denies sexualactivity, alcohol, tobacco, and drug use. No history ofabuse.

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Physical ExamVital signs: T 36.9, BP 121/66Weight 71.1kg (91%ile)

Height 150.5 cm (3%ile)

BMI 31 (97%ile)

General: alert, very pleasant young woman in no distress

HEENT: NCAT. PERRL, EOMI. Visual fields intact. MMM, good dentition. Necksupple without LAD or palpable thyromegaly.

CHEST: Breasts are symmetric and normal to palpation. No nipple discharge.

CV: RRR, no murmurs. Normal peripheral pulses.

LUNGS: CTAB, no increased work of breathing.

ABD: Soft, NTND, no masses. Active bowel sounds.

GU: Tanner 3 pubic hair, Tanner 4 breast development. Normal external femalegenitalia without lesions or discharge.

EXT: Warm and well perfused, no rash. Small light brown birthmark on left ankle.

SKIN: No rash, no acanthosis nigricans. No acne.

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Differential Diagnosis?

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Labs

B-HCG: negativeCBC: WBC 9.8, Hct 42.3, Plt 417

BMP: Na 140, K 4.5, Cl 106, Bicarb 24.7, BUN 15,Cr 0.5, Glucose 87, Ca 9.6

LFT: Protein 7.7, Albumin 4.7, Bili 0.4, AP 81, AST42, ALT 51

Free T4 1.2, TSH 2.03

Prolactin 156 (Nl 3-26)

HbA1C 4.6

Testosterone 23, Direct 1.1

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MRI Brain

14.8 mm nonenhancing mass in the pituitaryfossa extending into the suprasellar region, most

consistent with pituitary hemorrhage. There is alayering hematocrit effect within this massindicating that it does not represent a solid lesion,but is a combination of fluid, presumably serum,

and cellular components. Normal enhancingpituitary tissue is seen surrounding the mass.Infundibular stalk appears normal.

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Amenorrhea

Primary amenorrhea: absence of menarche by 15years

Secondary amenorrhea: absence of menses for morethan three cycles or six months in women who

previously had menses Etiology:

Ovary 40% Hypothalamus 35% Pituitary 19% Uterus 5% Other 1%

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Major causes of primary and secondary amenorrhea

Abnormality Causes

Pregnancy

Anatomic abnormalitiesAbnormality in Mullerian developmentDefect of urogenital sinus development

Acquired scarring of endometrium

Testicular feminization syndrome, 5a reductase deficiencyAgenesis of lower vagina, imperforate hymenAshermans syndrome, Tuberculosis

Hypothalamic dysfunction Gn-RH deficiency: Kallman syndrome, hypogonadotropichypogonadism

Functional hypothalamic amenorrhea: weight loss, eatingdisorder, exercise, stress, severe illnessInflammatory or infiltrative diseaseBrain tumors (eg, craniopharyngioma)Cranial irradiationTBISyndromes: Prader-Willi, Laurence-Moon-Biedl

Pituitary dysfunction Hyperprolactinemia, including lactotroph adenomasOther tumors- meningioma, germinoma, glioma

Genetic hypopituitarismEmpty sella syndromePituitary infarct or apoplexy

Ovarian Dysfunction Polycystic ovary syndromePremature ovarian failure: surgical, autoimmune, genetic, ovariantoxins, idiopathic

Other Hypothyroidism, hyperthyroidism, diabetes mellitus, exogenous

androgen use

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Work-up of amenorrhea1. Rule out pregnancy

2. History

1. Stress, change in diet, exercise, illness

2. Drugs

3. Signs of hyperandrogenism

4. Signs of hypothalamic/pituitary mass

5. Estrogen deficiency

6. Galactorrhea

7. Obstetrical history

3. Physical exam: BMI, skin, breast exam, GU

4. Labs: hCG, Prolactin, FSH, TSH/T4, testosterone