Source / episode info

• **Episode:**278
• **Title:**Divine Intervention Episode 278 – The NBME and Amenorrhea (For Step 1-3).
• **Published:**2020-12-13
• Source:Episode page

One-liner

This episode provides a comprehensive review of amenorrhea, detailing the classification into primary versus secondary causes and exploring the underlying endocrinological mechanisms—including genetic defects (Turner, AIS) and functional deficiencies (hypogonadotropic hypogonadism due to prolactinoma, low BMI, or pituitary failure).

High-yield summary

• Initial Workup: Always rule out pregnancy first in any woman of reproductive age presenting with amenorrhea.
• Primary Amenorrhea Age Criteria: If secondary sexual characteristics are present, wait until age 16; if absent, investigate aggressively starting at age 14.
• Hypergonadotropic Hypogonadism (High FSH/LH): Indicates primary ovarian failure (e.g., Turner Syndrome, Premature Ovarian Failure post-chemo). The pituitary is working correctly but the ovaries are failing.
• Hypogonadotropic Hypogonadism (Low FSH/LH): Indicates a problem with GnRH release or pituitary function (e.g., Hyperprolactinemia, low BMI, Sheehan syndrome, anti-psychotics).
• Androgen Insensitivity Syndrome (AIS): A 46,XY male presenting with female phenotype; the defect is in the androgen receptor, leading to underdeveloped pubic/axillary hair and a blind pouch vagina.
• MRKH Syndrome: Congenital absence of uterus and upper vagina, but normal ovaries and hormonal function, resulting in normal FSH/LH levels.

Learning objectives

• Classify amenorrhea into primary (never menstruated) and secondary (cessation of menses).
• Identify the hormonal patterns associated with hypergonadotropic vs. hypogonadotropic states.
• Differentiate between genetic causes (Turner, AIS) and acquired/functional causes (POF, low BMI, prolactinoma).
• Understand the pathophysiology behind common endocrine disruptions leading to amenorrhea (e.g., GnRH suppression by high ghrelin or hyperprolactinemia).
• Recognize that initial workup for any woman of reproductive age with amenorrhea must include a pregnancy test.