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SECONDARY   AMENORRHEA,[object Object],By  ,[object Object],Dr. Maryam B. Mahmmud,[object Object],College of medicine – university of sulaimania,[object Object]
Amenorrhea is divided into either:,[object Object],Primary: faiuler to establish menstruation by age 16.,[object Object], Secondary: cessation of menstruation for 6 consecutive months in a woman who has previously had regular period.  ,[object Object]
Woman with secondary amenorrhea must have an intact hypothalamic-pituitary-ovarian-uterine axis. ,[object Object]
CAUSES:,[object Object],1. Physiological: pregnancy-lactation-menopause.,[object Object],2. Pathological: this is subdivided into:,[object Object],Hypothalamic causes e.g. weight loss,exercise,irradiation,TB,,[object Object],head injury, chronic illness, psychological, sarcoidosis.,[object Object],Pituitary; e.g.hyperprolactinaemia, Sheehan syndrome, tumors (crainopharangioma, glioma).,[object Object]
Ovarian; e.g. PCOS, premature ovarian failure (genetic, autoimmune, infective, radio/chemotherapy).,[object Object],Uterine; e.g. Ashermans syndrome, cervical stenosis.,[object Object],Systemic causes; e.g. chronic illness,wt.loss,thyroid disorder,[object Object],Drugs; e.g. post pill amenorrhea , GnRH analogue.,[object Object]
Premature ovarian failure,[object Object],     Is defined as cessation of periods accompanied by raised gonadotrophin level prior to age of 49 years. The true incidence is not known but is about 5-10%. Onset before puberty is mainly due to either chromosomal anomaly or childhood radio/chemotherapy. The main concern with this problem is impaired fertility and risk of osteoporosis, so HRT is indicated.,[object Object]
Ashermans syndrome,[object Object],     Results from acquired scarring and adhesion of endometrial lining secondary to postpartum hemorrhage or endometrial infection, followed by instrumentation (i.e. D & C).,[object Object]
Diagnosis:,[object Object],    Is suggested by absence of normal uterine stripe on pelvic ultrasound, absence of withdrawal bleeding after administration of estrogen, then progestin for several weeks or by HSG OR Hysteroscopy evaluation of the endometrium.,[object Object]
Asherman’s  syndrome,[object Object]
Post pill amenorrhea,[object Object],	Is defined as absence of menstruation for 6 months following cessation of the combined oral contraceptive pill. It probably results from A transient inhibition of gonadotrophin-releasing hormone. ,[object Object]
Assessment:,[object Object],In any woman in reproductive age group and secondary amenorrhea pregnancy should be ruled out at first; this can be achieved by serum  B-hCG testing which is most sensitive.,[object Object]
[object Object],[object Object]
Treatment:,[object Object],It somewhat depend on the cause; e.g. dietary counseling in wt. related amenorrhea reduction of exercise, HRT in those with ovarian failure. Asherman syndrome can be treated with adhisolysis using hysteroscopy.  Long-term estrogen administration to stimulate regrowth of endometrial tissue.,[object Object]
Complication:,[object Object], Infertility: usually they do not ovulate.,[object Object],Endometrial hyperplasia: women with amenorrhea but no associated estrogen deficiency are at increased risk of endometrial hyperplasia and endometrial carcinoma,[object Object],Osteoporosis: women with amenorrhea associated with estrogen deficiency are at significant risk of developing osteoporosis.,[object Object]
HYPERPROLACTINAEMIA,[object Object],	Is the commonest cause of amenorrhea, the causes including:,[object Object],Mild elevation: (prolactin level less than 1000 mu/l e.g. stress, recent physical or breast examination.,[object Object],Moderate elevation: (prolactin level up to 2500mu/l e.g. hypothyroidism, PCOS , drugs like dopamine antagonist phenothiazines , metoclopramide.,[object Object]
Sever elevation:  with up to 8000mu/l may be due to pituitary tumors which could be non-functioning, producing only disruption of inhibitory factor; or functioning prolactin secreting adenoma (micro adenoma less than 1cm size or macro adenoma more than 1 cm size which may cause pressure symptom like disturbed visual field and asymmetrically enlarged pituitary fossa with double contour of its floor and erosion of clinoid process. Other investigations may be required in sever elevation like CT scan or MRI.,[object Object]
Treatment:,[object Object],	If it’s due to drugs; discontinue it.,[object Object],	Medical treatment inform of dopamine agonist like Bromocriptine (parlodel) starting with 1.5mg and increasing gradually every 5 days. the drawback   of parlodel is associated side effects like nausea, vomiting, headache and postural hypotension. Newer drug are available like Cabargolin (dostinex) which can be given twice weekly with lower side effects.,[object Object]
These drugs cause fall in prolactin level within few days of starting the treatment, and reduction in size of tumor within 6 weeks.,[object Object],Surgical treatment in the form of trans sphenoidaladenectomy indicated for cases of drug resistance, failure to shrink macro adenoma .,[object Object]
Patients with micro adenoma who want to conceive have of only less than 2% of tumor expansion on the other hand if macro adenoma not treated has 25% risk of tumor expansion during pregnancy. Bromocreptin can be discontinued during pregnancy but if symptoms reoccur like visual field defect CT or MRI are indicated and treatment should be recommenced.,[object Object]
Thanks,[object Object]
Gynecology 5th year, 1st lecture (Dr. Maryam)

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Gynecology 5th year, 1st lecture (Dr. Maryam)

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