Amenorrhea for undergraduate
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Amenorrhea
• DR Manal Behery
• Professor OB&GYNE
• Zagazig University
• 2014
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Amenorrhea
Absence Of Menstruation.
ORIGIN from Greek
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Classification of amenorrhea
AMENORRHEAAMENORRHEA
PHYSIOLOGICALPHYSIOLOGICAL PATHOLOGICAL
Pre-pubertyPregnancy relatedMenopause
Primary
Secondary
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Events of Puberty
•1-Thelarche :
• the breast development
• Requires estrogenestrogen
•2-Pubarche/adrenarche :
pubic hair development
Requires androgensandrogens
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Stage1 stage2
Prepupertal: elevation of papilla- no pubic hair
Elevation of breast and papilla on a small mount,increase in areola – libial hair
Marshall and tunner staging
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Stage 3 stage4
Further breast enlargment,
hair extend to mons pubis
Secondary mound of areola and papilla ,hair extend laterl
And increases pigmention
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Stage5
Recession of arola to contour of the breast
Adult pubertal hair with striaght upper borded
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Requires:
GnRHGnRH from the hypothalamus
FSHFSH and LHLH from the pituitary
Estrogen and progesteroneEstrogen and progesterone from the ovaries
Normal outflow tract
Events Of Puberty
3-Menarche :
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Hypothalamo-Pituitary-Ov-Ut Axis
CNSHypothalamus
Pituitary
Ovary
UterusOutflow tract
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The Hypothalamic-Pituitary-Ovarian Axis
http://www.shen-nong.com/eng/images/exam/missedperiods/img_mp1a.gif
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CNS-hypothalamus-pituitaryovary-uterus interaction
Neural control Chemical control
Dopamine)-(
Norepinephrine)+(
Endorphins)-(
Hypothalamus
GnRH
Ant. pituitary
FSH, LH
Ovaries
Uterus
ProgesteroneEstrogen
Menses
–± ?
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Functional menses
Compartment ICompartment Ioutflow tract ( uterine target
organ)
Compartment ICompartment IIIOvary ( Estrogen -Progesterone)
Compartment IIICompartment IIIAnterior Pituitary
Compartment IVCompartment IVCNS ( Hypothalamic )
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Clinically
PrimaryPrimary SecondarySecondary
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Common causes of Amenorrhea
Primary • Gonadal failure )45%( • Congenital absence of uterus and vagina )20%(
• Constitutional delay )15%(
Secondary
Chronic anovulation )40%(
• Hypothyroidism / hyperprolactinemia )20%( • Weight loss/anorexia )16%(
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Constitutional pubertal delay
• Common cause (15%) Positive family history
• Under stature and delayed bone age ( X-ray Wrist joint)
•• Diagnosis by exclusion and follow up
• Prognosis is good(late developer)
• No drug therapy is required – Reassurance (? HRT)
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primary amenorrhea
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Evaluation Categories
• 1-Breast Absent – Uterus Present
• 2-Breast Present – Uterus Absent
• 3-Breast Present – Uterus Present
• 4-Breast Absent – Uterus Absent
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46 XX
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Typical features of Turner Syndrome Turner Syndrome 1st commen cause (45% of causes )1st commen cause (45% of causes )
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Turner's S.
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•A craniopharyngioma is a benign tumor that develops near the pituitary gland.
• most commonly in childhood and adolescence and
•in later adult life.compresses the pituitary stalk or gland, the tumor can cause partial or complete pituitary hormone deficiency.
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• Family history: Consider watchful waiting
• Request: FSH, LH- Raised: Karyotype: 45 XO Turner syn
46 XX Premature ovarian failure
- Low: Constitutional delayConsider: anorexia
exerciseillnesscoeliac diseasehypothalamic/pituitary
- Intermediate: Anatomical - ultrasound
Secondary sexual characteristicsabsent 14y
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Mayer-R )okitansky-Kuster-Hauser syndrome(
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Utero-vaginal Agenisis Mayer-Rokitansky-Kuster-Hauser syndrome
• Second most common cause of Primary amenorrhea.
• Normal breasts and Sexual Hair Normal looking external female genitalia
• Karyotype 46-XX
• 15-30% renal abnormalities.
• Treatment : Vaginal creation (Dilatation VS Vaginoplasty)
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• Normal breasts but no sexual hair
• Normal looking female external genitalia
• Absent uterus and upper vagina
• Karyotype 46, XY
• Male range testosterone level
• Treatment : gonadectomy after puberty + HRT
Androgen insensitivityTesticular feminization syndrome
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• Absent/abnormal then karyotype: -46 XX Mullerian agenesis
-46 XY Androgen insensitivity
• Present • +no outflow obstruction
-As for 2o amenorrhoea
Secondary sexual characteristics Present by 16 yearsUltrasound uterus
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1-Rule out pregnancy!
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2-Exclude cryptomenohrea
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✴1-Pregnancy
✴2-Cryptomenorrhea :imperforated hymen, vaginal septum,
✴3-Causes 2nd ry Amenorrhea :hypothalamic, pituitary ,other endocrionpathy
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Very rare
17,20 -desmolase deficincy
agonadieisim
17 alfa-hydroxylase deficincy (46, XY )
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Compartment I: Disorders of the Outflow Tract
• Eugonadism
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MRI: complete low transverse septum with obstruction
MRI: complete slightly higher transverse septum with obstruction
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Compartment II: Disorders of the Ovary
• Hypergonadotropic hypogonadism
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Compartment III: Disorders of the Anterior Pituitary
• Hypogonadotropic hypogonadism
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Microadenoma vs macroadenoma
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Compartment IV: Hypothalamic (Kallmann’s syndrome) • Hypogonadotropic
hypogonadism
• Congenital disorder characterized by:
• 1) Anosmia or hyposmia
• 2) Primary amenorrhea
• Caused by defect in synthesis and/or release of gonadorelin (LH releasing hormone)
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History and physical examination completed for a patient with primary amenorrhea
Secondary sexual characteristics present
No Yes
Measure FSH and LH levels
Uterus absent or abnormal
Uterus present or normal
Karyotype analysis Outflow obstruction
FSH and LH < 5 IU/ L
Hypogonadotropic hypogonadism
Hypergonadotropichypogonadism
Karyotype analysis 46 ,XY
46 ,XX
Androgen Sensitivity Syndrome
NoYes
Evaluate for
secondary amenorrhea
Imperforate hymen or transverse
vaginal septum
Perform ultrasonography of uterus
Evaluation of Primary Amenorrhea
FSH > 20 IU/ L and
LH > 40 IU/ L
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Secondary amenorrhea
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In women of reproductive age, pregnancy is the most common cause of secondary amenorrhea .
Pregnancy
The reality of this must be ascertained before any intervention is instituted for non-obstetric amenorrhea.
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Compartment I OCompartment I Outflow tract ( uterine target organ)
pregnancy
Asherman's Syndrome
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Compartment II Compartment II Ovary
PCO
Premature Ovarian Failure
Resistance Ovarian Syndrome
Radiation & Chemotherapy .
(Hypergonadotropic Hypogonadism )
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Polycystic ovary syndrome• The most common cause of chronic
anovulation
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Classic 45-XO Premature ovarian failure
Turner’s syndrome Mosaic )46-XX / 45-XO(
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Compartment III Compartment III Anterior Pituitary
Hyper – prolactinemia
Tumors
Sheehan Syndrome
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Compartment IV Compartment IV CNS ( Hypothalamic )
Hypothyrodism
Stress anxiety
Anorexia
Excessive Exercise
Drugs
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Anorexia NervosaAnorexia nervosa
• A psychological disease characterized by
• Intense fear of gaining weight or being fat, despite being underweight
• Disturbance in one’s experience of body weight, size, and shape
• the refusal to maintain normal body weight, and amenorrhea
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V. Others1.Thyroid hypo or hyperthyroidism
2. Adrenal disease Adrenogenital SCushing SAddison s disease
3. Ch. illness, badly controlled DM.
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HistoryHistoryA good history can reveal the etiologic diagnosis A good history can reveal the etiologic diagnosis
in up to 85% of cases of amenorrhea.in up to 85% of cases of amenorrhea.
ASSESSMENTASSESSMENT
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Present History
1.Sexual activity, risk of pregnancy ,
2.Type of contraceptive used .
3.Galactorrhoea
4.Androgenic symptoms: weight gain, acne, hirsutism
5.Menopausal symptoms: night sweats, hot flushes
6.Issues with eating or excessive exercise .
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Past history
1.Drug use: Dopamine antagonists for psychiatric conditions. Antihypertensive,anticonsulsionvant
Genital tract surgery: intrauterine instrumentation
3 --radio or chmotherrapy
4 -infection : mumps or TB oophritis
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Clinical assessment
1 -β - hCG
2 -TSH
3 -Prolactin
TOP
Bottom
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1. Provera 10 mg PO once daily 7-10 days or
2. Norethindrone 5 mg PO once daily for 7-10 days or
3. Progesterone 200 mg IM for one dose .
Progesterone Challenge Test :
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Step 1
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1. Premarin 1.25 mg orally daily for 21 days
2. Oral Contraceptive for 2 Cycles
3. Estradiol 2 mg orally daily for 21 days and Follow with 7-10 days of Progesterone
Estrogen progesterone challenge test
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Step 2
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• Asharman syndrome)intrauterine synechea)
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Step 3
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TreatmentI. Treatment of the cause.1-if Y chromosome is present gonadectomy is
indicated2- Create outflow tract or at least a sexually functional
vagina
II. No obvious cause:
. Conception is not required: COCP.
. Conception is required: induction of ovulation
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Thanks