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AmenorrheaAmenorrhea

Osman DoniaOsman DoniaProf. Obstet. Gynaecol.,Prof. Obstet. Gynaecol.,

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Definitions & ClassificationDefinitions & Classification

Amenorrhea: Absence of menses.

Primary amenorrhea: Non occurrence of menarche by age of:

– 14 with no secondary sex characters

– 16 (18) with secondary sex characters.

Secondary amenorrhea: Absence of menses for 3 successive cycles.

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Amenorrhea

PhysiologicPathologic

Puberty

Menopause

Pregnancy

Lactation

TrueFalse

Cervix

Vaginal T. septa

Imperforate hymen

Hypothalamic

Pituitary

Ovarian

Uterine

General

CNS

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False amenorrheaFalse amenorrhea(Cryptomenorrhea)(Cryptomenorrhea)

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CryptomenorrheaCryptomenorrhea

Due to outflow obstruction. The most common cause is imperforate hymen. Blood accumulate behind the hymen hematocolpos

Hematometra Pelvic hemorrhage. Diagnosis:

– P. amenorrhea with good 2ry sex characters.

– PMS.

– Urinary symptoms.

– Abdominal mass ????.

– Local examination is diagnostic.

Treatment: Cruciate incision under anesthesia Slow evacuation + antibiotics.

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True amenorrheaTrue amenorrhea

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CNS CNS CausesCauses

Psychological troubles:– Psychosis # neurosis.

– Pseudocyesis.

– Anorexia nervosa.

Chronic stresses. Weight loss. Exercise:

– Loss of body fat.

– Stress of competition.

– Hyperthermia and dehydration.

– Euphoria of winning causing increased opiates.

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Hypothalamic causesHypothalamic causes

Destruction:– Trauma– Inflammation.– Tumors.– Infiltrations.

Drugs:– Estrogens.– CNS affecting drugs.

Dysfunction & congenital disorders:– Chiari Frommel syndrome.– Del Castillo syndrome.– Kallmann syndrome.– Laurence Moon Biedl syndrome.– Frohlich syndrome.

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Destruction:– Infiltrations.

– Tumors.

– Sheehan syndrome.

Drugs:– Estrogens.

– Prolactin inducing drugs.

Dysfunction and congenital disorders:– Levi Lorain syndrome.

– Empty sella syndrome.

– Prolactinomas.

Pituitary causesPituitary causes

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Congenital:– Turner.– Androgen insensitivity syndrome.

Traumatic:– Surgical removal.– Irradiation.

Inflammatory:– Mumps.– PID.– TB.

Neoplasia:– Benign.– Malignant.

Dysfunctions:– PCO.– Resistant ovary syndrome.

Ovarian causesOvarian causes

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Congenital:– Mullerian agenesis.– Uterine atresia– Severe hypoplasia.

Traumatic:– Surgical removal.– Irradiation.

Inflammatory:– Asherman syndrome.– TB.

Neoplastic:– Obstructing the cervix.

Dysfunctions:– Insensitive endometrium.

Uterine causesUterine causes

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DM:– Glucose metabolism.– Ketosis.– Immunological.

Thyroid:– Hyper.– Hypo.

Adrenal:– Addison.– Cushing.

Debilitating diseases.

General causesGeneral causes

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1- Cryptomenorrhea: All congenital causes.

2- True:– Psychological disturbances before menarche.

– Congenital diseases in the hypothalamus or pituitary.

– Ovarian dysgenesis and removal or destruction before menarche (T.B, irradiation).

– Uterine aplasia or severe hypoplasia, T.B or removal before menarche.

– General cause before menarche.

The most common causes of primary amenorrhea:– Gonadal dysgenesis.

– Mullerian agenesis.– Complete AIS.

Causes of 1ry amenorrheaCauses of 1ry amenorrhea

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Physiological:– Pregnancy, lactation, after menopause.

Cryptomenorrhea: Any acquired cause. True:

– Psychogenic disorders after menarche, Chiari Frommel and Del Castillo syndromes, drugs, OCs, destruction by trauma, infections, tumors after puberty.

– Sheehan syndrome, Simmond's disease, destruction and tumors after puberty.

– Ovarian failure, PCO and ovarian tumors.

– Intrauterine synechia, hysterectomy or T.B endometritis after puberty.

– Any general cause after puberty.

Causes of 2ry amenorrheaCauses of 2ry amenorrhea

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History:History:– Age, occupation, residence, habits and education.

– Primary or secondary amenorrhea.

– History of psychogenic disorders.

– History of neurological disturbances.

– History of endocrinological disorders.

– Past history of operations, pelvic infections, T.B, long drug course or irradiation.

– Family history of similar condition, familial disease.

Diagnosis of amenorrheaDiagnosis of amenorrhea

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Examination:– Psyche, height, weight and span measure. Nutritional status

should be also evaluated.

– Secondary sexual characters.

– Evidence of neurological disorders specially central lesions.

– Evidence of endocrinological disorders with special reference to galactorrhea and hirsutism.

– Evidence of general disease as heart, chest, renal or hepatic disorder.

– Abdominal masses (ovarian, adrenal, renal hepatosplenomegaly or ascites).

– External genital anomaly or hypoplasia.

– Pelvic examination (PV or PR) for uterine and ovarian abnormalities.

Diagnosis of amenorrheaDiagnosis of amenorrhea

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Diagnosis of amenorrheaDiagnosis of amenorrhea

CNSHypothalamus

Pituitary

Ovary

UterusOutflow tract

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Special investigations – Step I:– Search for specific disease if suspected.

– Pregnancy test.

– TSH assay.

– Prolactin assay.

– Progesterone challenge test:

» If (+)ve withdrawal Normal outflow tract and well estrogenized cases The cause is anovulation.

» If (-)ve withdrawal Hypoestrogenic state or uterine cause step II.

Diagnosis of amenorrheaDiagnosis of amenorrhea

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Special investigations – Step II:– Give estrogen + Progesterone:

» If (-)ve withdrawal Uterine cause.

» If (+)ve withdrawal Normal outflow tract and uterus, and there is ovarian failure Step III

Special investigations – Step III:– Measure FSH:

» If high Ovarian cause.

» If low central cause.

Diagnosis of amenorrheaDiagnosis of amenorrhea

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Treatment of the cause

Treatment of amenorrheaTreatment of amenorrhea

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