[
    {
        "page": 1,
        "title": "AMENORREA",
        "body": "<p><strong style=\"background-color: transparent;\">AMENORREA<\/strong><\/p><p><strong style=\"background-color: transparent;\">DEFINICI\u00d3N<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">Ausencia de menstruaci\u00f3n por causas fisiol\u00f3gicas o patol\u00f3gicas.<\/span><\/li><li><strong style=\"background-color: transparent;\">Amenorrea primaria:<\/strong><span style=\"background-color: transparent;\"> ausencia de menstruaci\u00f3n a los 13 a\u00f1os sin desarrollo puberal o a los 15 a\u00f1os con caracteres sexuales secundarios normales.<\/span><\/li><li><strong style=\"background-color: transparent;\">Amenorrea secundaria:<\/strong><span style=\"background-color: transparent;\"> ausencia de menstruaci\u00f3n por \u22653 ciclos o \u22656 meses en una mujer previamente menstruante.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">FISIOLOG\u00cdA NORMAL DEL EJE HIPOT\u00c1LAMO-HIP\u00d3FISO-OV\u00c1RICO<\/strong><\/p><ul><li><strong style=\"background-color: transparent;\">GnRH<\/strong><span style=\"background-color: transparent;\"> del hipot\u00e1lamo \u2192 estimula secreci\u00f3n de <\/span><strong style=\"background-color: transparent;\">FSH y LH<\/strong><span style=\"background-color: transparent;\"> por hip\u00f3fisis anterior.<\/span><\/li><li><span style=\"background-color: transparent;\">FSH estimula desarrollo folicular y producci\u00f3n de estradiol.<\/span><\/li><li><span style=\"background-color: transparent;\">LH induce ovulaci\u00f3n y formaci\u00f3n del cuerpo l\u00fateo (progesterona).<\/span><\/li><li><span style=\"background-color: transparent;\">Retroalimentaci\u00f3n hormonal regula el ciclo.<\/span><\/li><li><span style=\"background-color: transparent;\">Alteraciones en cualquier nivel del eje pueden causar amenorrea.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">CLASIFICACI\u00d3N ETIOL\u00d3GICA (funcional)<\/strong><\/p><ol><li><strong style=\"background-color: transparent;\">Amenorrea hipotal\u00e1mica.<\/strong><\/li><li><strong style=\"background-color: transparent;\">Amenorrea hipofisaria.<\/strong><\/li><li><strong style=\"background-color: transparent;\">Disfunci\u00f3n ov\u00e1rica.<\/strong><\/li><li><strong style=\"background-color: transparent;\">Trastornos uterinos y del tracto de salida.<\/strong><\/li><\/ol><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">AMENORREA PRIMARIA<\/strong><\/p><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Evaluaci\u00f3n inicial<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">Confirmar presencia o ausencia de caracteres sexuales secundarios.<\/span><\/li><li><span style=\"background-color: transparent;\">Determinar anatom\u00eda del tracto genital: \u00fatero, vagina, ovarios.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">CON \u00fatero presente<\/strong><\/p><ul><li><strong style=\"background-color: transparent;\">Con desarrollo puberal:<\/strong><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Sospechar <\/span><strong style=\"background-color: transparent;\">anomal\u00edas obstructivas<\/strong><span style=\"background-color: transparent;\"> (himen imperforado, tabique vaginal transverso).<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Estudio ecogr\u00e1fico p\u00e9lvico + examen f\u00edsico.<\/span><\/li><li><strong style=\"background-color: transparent;\">Sin desarrollo puberal:<\/strong><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Solicitar FSH:<\/span><\/li><li class=\"ql-indent-2\"><span style=\"background-color: transparent;\">FSH \u2191: falla gonadal primaria (disgenesia gonadal).<\/span><\/li><li class=\"ql-indent-2\"><span style=\"background-color: transparent;\">FSH \u2193 o normal: causas hipotal\u00e1micas o hipofisarias.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">SIN \u00fatero (ausencia uterina en ecograf\u00eda)<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">Sospechar:<\/span><\/li><li class=\"ql-indent-1\"><strong style=\"background-color: transparent;\">S\u00edndrome de insensibilidad a andr\u00f3genos (46,XY):<\/strong><\/li><li class=\"ql-indent-2\"><span style=\"background-color: transparent;\">Fenotipo femenino completo, test\u00edculos intraabdominales, testosterona elevada.<\/span><\/li><li class=\"ql-indent-1\"><strong style=\"background-color: transparent;\">Agenesia m\u00fclleriana (s\u00edndrome de Rokitansky, 46,XX):<\/strong><\/li><li class=\"ql-indent-2\"><span style=\"background-color: transparent;\">Desarrollo puberal normal, genitales externos femeninos.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">AMENORREA SECUNDARIA<\/strong><\/p><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Diagn\u00f3stico diferencial amplio<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">Excluir embarazo siempre en primer lugar.<\/span><\/li><li><span style=\"background-color: transparent;\">Considerar causas hipotal\u00e1micas, hipofisarias, ov\u00e1ricas y uterinas.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Principales causas<\/strong><\/p><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Amenorrea hipotal\u00e1mica funcional<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">Causas: estr\u00e9s, p\u00e9rdida de peso, ejercicio excesivo.<\/span><\/li><li><span style=\"background-color: transparent;\">FSH y LH bajas.<\/span><\/li><li><span style=\"background-color: transparent;\">Se considera un diagn\u00f3stico de exclusi\u00f3n.<\/span><\/li><li><span style=\"background-color: transparent;\">Reversible con correcci\u00f3n del factor causal.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Hiperprolactinemia<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">Inhibe GnRH \u2192 amenorrea.<\/span><\/li><li><span style=\"background-color: transparent;\">Causas:<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Adenoma hipofisario.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">F\u00e1rmacos (antipsic\u00f3ticos, metoclopramida).<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Hipotiroidismo primario (TRH \u2191 prolactina).<\/span><\/li><li><span style=\"background-color: transparent;\">Cl\u00ednica: galactorrea, cefalea, alteraciones visuales.<\/span><\/li><li><span style=\"background-color: transparent;\">Diagn\u00f3stico: prolactina s\u00e9rica elevada.<\/span><\/li><li><span style=\"background-color: transparent;\">Tratamiento: agonistas dopamin\u00e9rgicos (cabergolina, bromocriptina).<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Hipotiroidismo<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">Aumento de TRH \u2192 hiperprolactinemia secundaria.<\/span><\/li><li><span style=\"background-color: transparent;\">TSH elevada, T4 libre disminuida.<\/span><\/li><li><span style=\"background-color: transparent;\">Tratamiento con levotiroxina.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Insuficiencia ov\u00e1rica prematura (IOP)<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">FSH elevada (&gt;40 mUI\/mL).<\/span><\/li><li><span style=\"background-color: transparent;\">&lt;40 a\u00f1os con hipoestrogenismo.<\/span><\/li><li><span style=\"background-color: transparent;\">Causas: autoinmunes, gen\u00e9ticas (s\u00edndrome de Turner), iatrog\u00e9nicas (quimioterapia, radiaci\u00f3n).<\/span><\/li><li><span style=\"background-color: transparent;\">Tratamiento: terapia hormonal sustitutiva.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">S\u00edndrome de ovarios poliqu\u00edsticos (SOP)<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">Anovulaci\u00f3n cr\u00f3nica + hiperandrogenismo.<\/span><\/li><li><span style=\"background-color: transparent;\">FSH normal o baja, LH elevada.<\/span><\/li><li><span style=\"background-color: transparent;\">Hiperandrogenismo cl\u00ednico o bioqu\u00edmico.<\/span><\/li><li><span style=\"background-color: transparent;\">Ecograf\u00eda: morfolog\u00eda poliqu\u00edstica ov\u00e1rica.<\/span><\/li><li><span style=\"background-color: transparent;\">Tratamiento: anticonceptivos combinados, metformina, cambios de estilo de vida.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Trastornos del tracto de salida<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">S\u00edndrome de Asherman (sinequias uterinas):<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Antecedente de legrado, cirug\u00eda uterina.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Diagn\u00f3stico: histerosonograf\u00eda, histeroscop\u00eda.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Tratamiento: resecci\u00f3n histerosc\u00f3pica.<\/span><\/li><li><span style=\"background-color: transparent;\">Obstrucci\u00f3n vaginal o cervical adquirida.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">ABORDAJE DIAGN\u00d3STICO<\/strong><\/p><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Amenorrea primaria<\/strong><\/p><ol><li><span style=\"background-color: transparent;\">Ecograf\u00eda p\u00e9lvica (\u00fatero presente o ausente).<\/span><\/li><li><span style=\"background-color: transparent;\">Determinar caracteres sexuales secundarios.<\/span><\/li><li><span style=\"background-color: transparent;\">Estudios hormonales: FSH, LH, estradiol, prolactina, TSH.<\/span><\/li><li><span style=\"background-color: transparent;\">Cariotipo si se sospecha disgenesia gonadal o insensibilidad androg\u00e9nica.<\/span><\/li><\/ol><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">Amenorrea secundaria<\/strong><\/p><ol><li><strong style=\"background-color: transparent;\">Test de embarazo.<\/strong><\/li><li><span style=\"background-color: transparent;\">Si negativo: FSH, LH, prolactina, TSH, estradiol.<\/span><\/li><li><strong style=\"background-color: transparent;\">Test de progesterona:<\/strong><\/li><\/ol><ul><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Medroxiprogesterona 10 mg \u00d7 5\u201310 d\u00edas.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Hemorragia por deprivaci\u00f3n: anovulaci\u00f3n.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Sin sangrado: hipoestrogenismo o obstrucci\u00f3n.<\/span><\/li><\/ul><ol><li><strong style=\"background-color: transparent;\">Test combinado estr\u00f3geno-progesterona:<\/strong><\/li><\/ol><ul><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Hemorragia \u2192 \u00fatero funcional.<\/span><\/li><li class=\"ql-indent-1\"><span style=\"background-color: transparent;\">Sin hemorragia \u2192 sinequias o agenesia uterina.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">TRATAMIENTO GENERAL<\/strong><\/p><ul><li><strong style=\"background-color: transparent;\">Causal<\/strong><span style=\"background-color: transparent;\">, seg\u00fan etiolog\u00eda.<\/span><\/li><li><span style=\"background-color: transparent;\">Restaurar funci\u00f3n ovulatoria si se desea fertilidad.<\/span><\/li><li><span style=\"background-color: transparent;\">Terapia hormonal para mujeres con hipoestrogenismo cr\u00f3nico \u2192 prevenir osteoporosis y s\u00edntomas vasomotores.<\/span><\/li><li><span style=\"background-color: transparent;\">SOP: anticonceptivos para regular ciclos y reducir hiperandrogenismo.<\/span><\/li><li><span style=\"background-color: transparent;\">Hiperprolactinemia: agonistas dopamin\u00e9rgicos.<\/span><\/li><li><span style=\"background-color: transparent;\">Amenorrea funcional: enfoque nutricional y psicol\u00f3gico.<\/span><\/li><\/ul><p><strong style=\"background-color: transparent; color: rgb(0, 0, 0);\">CONSECUENCIAS A LARGO PLAZO<\/strong><\/p><ul><li><span style=\"background-color: transparent;\">Riesgo de osteoporosis por hipoestrogenismo.<\/span><\/li><li><span style=\"background-color: transparent;\">Infertilidad si no se corrige la causa.<\/span><\/li><li><span style=\"background-color: transparent;\">Riesgo psicol\u00f3gico por disforia sexual o amenorrea persistente.<\/span><\/li><li><span style=\"background-color: transparent;\">Importancia de diagn\u00f3stico y tratamiento precoz.<\/span><\/li><\/ul><p><br><\/p>",
        "footer": "P\u00e1gina 1"
    }
]