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BY DR.AKINBI OLUBAYODE.O

AMENORRHOEA

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INTRODUCTION• Proper function of the Hypothalamic-Pituitary ovarian

system is required for normal menstruation.(GnRH-LH/FSH-EST./PROG).

• Regular and predictable menstrual cycles occur if the ovarian hormones estradiol and progesterone are secreted in an orderly fashion in response to stimulation by the hypothalamus and pituitary.

• The occurrence of menstruation also requires healthy and intact outflow tract

• AMENORRHOEA occurs if the above are not met

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DEFINATION• Amenorrhoea, derived from the Greek words men (month) and rein

(to flow), denotes the absence or suppression of menstruation.

• Amenorrhoea is a symptom, not a disease, and it has a variety of causes.

• Traditionally, amenorrhoea is classified as primary or secondary.

• PRIMARY AMENORRHOEA is defined as the absence of menstruation by the age of 14 years in the absence of 20 sexual characteristics, or the absence of menstruation by 16 years.

• The median age of menarche is 10-15 years and weight 51.1kg.

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DEFINATION CTD• SECONDARY AMENORRHOEA is defined as secondary when

no menses have occurred for 6 months in a woman who previously had normal menstrual function, or for 12 months if her cycles were irregular.

• OTHER TERMS:

1. OLIGOMENORRHOEA (INT.>35DAYS

2. HYPOMENORRHOEA (SCANTY VOLUME& SHORT DURATION OF FLOW

3. POLYMENORRHOEA (INT.<21DAYS)

4. HYPERMENORRHOEA (PROLONGD FOR >10DYS)

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PATHOPHYSIOLOGY

• The menstrual cycle is an orderly progression of coordinated hormonal events in the female body that stimulates growth of a follicle to release an egg and prepare a site for implantation if fertilization should occur. Menstruation occurs when an egg released by the ovary remains unfertilized.

• The menstrual cycle can be divided into 3 physiologic phases: follicular, ovulatory, and luteal. Each phase has a distinct hormonal secretory milieu. Consideration of the target organs of these reproductive hormones (hypothalamus, pituitary, ovary, uterus) is helpful for identifying the disease process responsible for a patient’s amenorrhea.

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Fig. 1.0

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ETIOLOGY

1. PHYSIOLOGICAL AMENORRHOEA: Puberty (in young girls), Pregnancy(in women of reproductive age groups), Post menopause (in elderly women)

2. HYPOTHALAMIC DISORDER

• Eating disorder (a minimum of 17% body fat is required for the onset of menarche and 22% body fat for maintenance or resumption of normal menstrual function

• Exercise induced amenorrhea (6% to 18% of women who are recreational runners)

• Medication

• Stress

• Chronic illness

• Kallmanns syndrome

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3. PITUITARY DISORDER

• Hyperprolactinaemia (10–40% of women with hyperprolactinaemia present to their physician with amenorrhea).

• Prolactinoma

• Isolated gonadotrophin deficiency

• Craniopharyngioma (They are epithelial tumors arising from the craniopharyngeal duct in the sellar or parasellar region).

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4. THYROID DISORDER

• Hypothyroidism

• Hyperthyroidism

5. ADRENAL DISORDER

• Congenital adrenal hyperplasia

• Cushing syndrome

6. VAGINAL ANOMALY

• Imperforate hymen

• Transverse vaginal septum

• Vaginal agenesis

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7. UTERINE ANOMALY

• Androgen insensitivity

• Mullerian agenesis (The syndrome, often referred to as Mayer– Rokitansky–Kuster–Hauser syndrome, is the second most common cause of primary amenorrhea).

• Uterine adhesion (Asherman syndrome is the presence of intrauterine synechiae or scarring preventing normal growth of endometrium, typically from a previous infection, endometrium curettage or endometritis).

• Cervical agenesis

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8. OVARIAN DISORDER• Gonadal dysgenesis (Turner's syndrome 45XO) • Ovarian insufficiency or premature ovarian failure

(Onset of menopause before 40 years). • Chemotherapy or radiation injury• Ovarian insensitivity syndrome (Savage's

syndrome) • Polycystic ovarian syndrome

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Polycystic ovarian syndromePCOS is a syndrome of ovarian dysfunction along with the cardinal features of hyperandrogenism and polycystic ovary morphology

Its clinical manifestation include menstrual irregularities,signs of androgen excess and obesity• They are oligo-ovulatory or anovulatory and have oligomenorrhea or

amenorrhea.• In typical cases, the ovaries are enlarged, with white, thickened

capsules beneath which are multiple cystic follicles in various developmental stages.

• High incidence of related Hyperprolactinemia.• Serum LH levels are chronically elevated:LH;FSH INCREASES TO

2:OR 3:1• The constant, tonic LH stimulation of the ovaries results in abnormal

follicular stimulation—hence the polycystic appearance

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CLINICAL EVALUATION OF THE AMENORRHOEIC PATIENT

• HISTORY TAKING

• PHYSICAL EXAMINATION

• INVESTIGATIONS

• TREATMENT

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HISTORY• Pregnancy is the most common cause of amenorrhea.

• Ask about sexual activity

• Use of contraceptive methods

• Difficulty with dates; menstrual calendar X 3 months.

• Absence of breast development or pubertal growth 14 years is abnormal.& requires investigation.

• Breast development, pubertal growth spurt, and adrenarche are delayed or absent in persons with hypothalamic pituitary failure.

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• Normal growth and pubertal development plus primary amenorrhea may suggests:• Imperforate Hymen(cyclical abd.pain+heamatocolpos)• Rokitansky Syndrome(lap.shows rudimentary uterus)• Test.Feminisation syndrome(blind end vaginal, absent

uterus, XY KARYOTYPEHistory of evacuation, post abortal infection, post partum

endometritis, major myomectomy, endometrial procedures may suggest Asherman

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OVARIAN DISORDER

• Symptoms of vaginal dryness, hot flashes, night sweats, or disordered sleep may be a sign of ovarian insufficiency or premature ovarian failure.

• History of chemotherapy or radiation• Hormonal contraceptives use in recent times• Recent surgery .e.g TATH+BSO

• Sometimes no clear cut symptom or sign

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HYPOTHALAMIC DISORDER

• Intracranial tumor; galactorrhea, headaches, or ↓↓peripheral vision

• Impaired sense of smell +primary amenorrhea& failure of normal pubertal development = Kallmann syndrome

• Dieting with excessive restriction of energy intake, especially fat restriction, may lead to loss of menstrual regularity and associated bone loss.

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• Strenuous exercise related to a wide variety of athletic activities can be associated with the development of amenorrhea.

• Abuse of drugs such as cocaine and opioids have central effects that may disrupt the menstrual cycle.

• Anorexia nervosa;intense fear of fatness and a body

image that is heavier than observed.

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EXAMINATION

• GENERAL EXAMINATION.

• SECONDARY SEXUAL CHARACTERISTICS.

• EXAMINATION OF THE EYE-VISUAL FIELD.

• ABDOMINAL EXAMINATION.

• PELVIC EXAMINATION

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INVESTIGATION

• Pregnancy test.

• Ultrasound, CT, MRI.

• Hormonal assay- LH, FSH, prolactin and androgens

• Thyroid function tests.

• Karyotype.

• Autoimmune screen

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TREATMENT

• Depends on the cause of amenorrhoea.

• The most common cause of primary amenorrhoea is constitutional delay.

• MEDICAL.

• SURGICAL

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MEDICAL THERAPY:• Dopamine agonists e.g Bromocriptine for treatment

of Hyper.PRL(build the dose up to 2.5mg tds)• Hormone replacement therapy; In cases of Estrogen

deficiency(estrogen + 10-14 days of medroxyprogesterone)

• Ovulation Induction in those desiring pregnancy: clomiphene, FSH/LH combination, GnRH analogue.

• Treatment of Hyperandrogenism(5α-reductase inhibitors e.g spironolactone, cyproterone acetate, Finasteride)

• cocp+depo provera :rx of hirsuitism

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• SURGICAL THERAPIES:• GONADECTOMY; XY DYSGENESIS

• TUMOR EXCISION FOR LARGE ADENOMAS

• RECONSTRUCTIVE SX:VAGINOPLASTY, PROGRESSIVE VAGINAL. DILATATION

• ADHESIOLYSIS(HYSTEROSCOPY, MANUAL SHARP DISSECTION)+FOLEYS CATHETER OR LIPPES LOOP

• OVARIAN DIATHERMY:4-POINT DIATHERMY AT 40W FOR 4SEC.

• IVF : FOR TURNERS&OTHER GONADAL DYSGENETIC CASES

• ELECTROLYSIS RX.FOR HIRSUITISM

• WEIGHT REDUCTION ORAL CONTRACEPTIVES,OVULATION INDUCTION FOR PCOS

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THANK YOU