This document discusses amenorrhea, which is the absence of menstruation. It describes physiological amenorrhea that occurs before puberty, during pregnancy and breastfeeding, and after menopause. It also describes pathological amenorrhea, including primary amenorrhea which is the absence of menstruation without previously established cycles, and secondary amenorrhea which is the absence of menstruation for 3-6 months in women with previous regular cycles. It provides classifications and potential causes of primary and secondary amenorrhea, as well as evaluations and treatments.
2. PHYSIOLOGICAL AMENORRHOEA:
Prior onset of puberty
During pregnancy
Lactation
After menopause
PATHOLOGICAL AMENORRHOEA
3. Primary amenorrhea
absence of normal menstruation in a patient
without previously established cycles
No menses by age 14 + absence of 2º sexual
characteristics.
= No menses by age 16 + presence of 2º sexual
characteristics.
4. Secondary amenorrhea
No menses for 3 months if previous menses were
regular.
= No menses for 6 months if previous menses
were irregular
5. NORMAL MENSES REQUIRES
Outflow tract
Endometrium
Hormones estrogen and progesterone from
the ovary
LH/FSH (anterior pitiutary)
GNRH (Hypothalmus)
Inhibitory and stimulatory functions
6. CLASSIFICATION OF PRIMARY AMENORRHOEA
1. Hypergonadotropic primary
amenorrhoea
a. Abnormal sex chromosomes: turner’s
syndrome(45ox),mosaics,abnormal x.
b. Normal sex chromosome:
46xx pure gonadal dysgenesis
46xy gonadal dysgenesis- Swyer’s syndrome,
testicular feminizing syndrome.
Gonadrotropin-resistant ovary syndrome – savage
syndrome
7. 2.EUGONADOTROPHIC PRIM AMENORRHOEA
A. Absence of mullerian development:
Androgen insensitivity syndrome(testicular feminization)
Mullerian agenesis- rokitansky-kuster-hauser
syndrome(absence of uterus/ vagina)
B. Normal mullerian development:
Female or true intersex
Polycystic ovary syndrome
C. Cryptomenorrhoea-imperforate hymen,
vaginal septum
8. 3.HYPOGONADOTROPIC PRIM AMENORRHOEA
A. Hypothalamic causes:
Delayed menarche and puberty
Hypothalamic hypogonadism(kallman’s syndrome)
Psychogenic causes, weight loss, stress, anorexia nervosa,
malnutrition
B. Pituitary causes :
Pituitary underdevelopment
Neoplasms- prolactinomas, craniopharyngiomas, adenomas,
empty sella turcica
Hypopituitary states- simmonds diesase, chiari- frommel
syndrome, forbes albright syndrome,pineal gland tumor
C. severe systemic disease like tuberculosis
D. other endocrinal disorders-thyroid or adrenal gland
10. CRYPTOMENORRHOEA(CONG)
Primary Amenorrhoea
common cause : intact hymen or vaginal
septum(Failure of complete canalization of lower end
of mullerian duct in the region of the sinovaginal bulb.
Rarely due to congenital atresia of cervix
A history :
cyclic abdominal colicky pain without the discharge of
ordinary mensestrual bleeding
retention of urine,
presence of a palpable abd. lump( up to 2.5 lits
blood)
visualization of a tense bluish bulging membrane on
separation of the labia
11. HEMATOCULPUS: BLOOD IN VAGINA (bluish
buldge of membrane due to retained blood
HEMATOMETRA: blood in uterine cavity
HEMATOSALPINX: blood in tube
Gentle pressure on the abdominal tumor will
transmit a thrill to the vaginal membrane and
cause it to bulge more distinctly
12. Ultrasound scan of the pelvis: confirms the
diagnosis.
Management: Simple cruciate incision of the
hymen permits free drainage of the collected
menstrual blood
leads to normal reproductive function.
13. Rarely crptomenorrhoea cause by failure of
canalization of entire vagina
Usually associated with renal anomalies
Septate vagina or atresia vagina requires
excision and vaginoplasty
Artificial vagina is made by creating a space
between the urethra and bladder infront and
the rectum behind until the cervix is reached
14. The vaginal septum :recognized from the
imperforate hymen by pinkish concave
covering (in contrast to bluish convex bulge
in the latter).
The vaginal septum, i.e. atresia, requires a
more extensive dissection and vaginoplasty.
The atresia in the upper vagina and cervix
often restenoses after surgery and eventually
requires hysterectomy.
15. ACQUIRED CRYPTOMENORRHOEA
All operation on cervix: amputation , cone
biopsy and trachelorrhaphy– stenosis
Cervical cautry and diathermy: occlusion
Radium treatment for malignant condition
Too vigorous currettage: cervical obstruction
All: hematometra
Precaution: all operation are preceded by a
through cervical dilatation
16. AETIOLOGY OF SECONDARY AMENORRHOEA
1. GENITAL TRACT:
Acquired obstruction(gynatresia): cervical
stenosis or atresia following electrocautrization,
chemical burns, cervical amputation in
fothergill’s repair,genital tuberculosis
Asherman’s syndrome: excessive curratage,
infection, endometrial tuberculosis
Vesicovaginal fistula
22. INITIAL WORKUP OF AMENORRHEA
. History and physical examination (clinical
evaluation of estrogen status)
2. R/O pregnancy
3. Measure plasma FSH, prolactin, TSH
4. Progestin administration
23. Tanner staging.(secondary sexual
characteristic)
Breast present ?
Uterus present ?
PV exam.
Rule out possibility of pregnancy.
24.
25. CLINICAL PRESENTATION
History
milestones, development, diet, exercise, wt change
drug use (antipsychotics, hormones, narcs, anti-HTN’s
systemic disease (hypothyroidism, adrenal insuff., GH
excess)
past surgery, glactorrhea, hirsutism
gyn/ob hx (hemorrhage, D&C, infection)
genetic history
26. CLINICAL PRESENTATION
Physical
ht, wt, vitals
signs of thyroid dz (protuberant eyes, enlarged gland,
puffy face, heat/cold intolerance)
secondary sex changes
thelarche (breast devel): avg. age 10.8 yrs; indication
of estrogen exposure
adrenarche (pubic/axillary hair development): avg.
age 11 and indicates ovarian and adrenal androgen
production and end organ response
decreased breast size or vaginal dryness indication
decreasing estrogen exposure (or increasing androgens)
presence of a cervix (confirms presence of a uterus)
27. CLINICAL APPROACH TO 2º AMENORRHEA
β-hCG level should be obtained:
rule out pregnancy (commonest cause of 2º
amenorrhea).
Progesterone challenge to assess
estrogen status.
Medroxy-progesterone acetate 10 mg OD
X 1 week look for withdrawal bleeding:
28. CONT
(+)ve test if any bleeding occurs within 2-7
days always due to anovulation.
Do S-Prolactin & TSH rule out correctable
cause.
e.g. pituitary prolactinomas / hypothyroidism.
Mx:
Treat underlying cause.
Periodic cyclic progestins prevent endometrial
hyperplasia from unopposed estrogen.
Ovulation induction with Clomiphene citrate
if pregnancy is desired.
29. CONT
(-)ve test if no bleeding occurs:
hypo-estrogenism / outflow tract obstruction.
Combined Estrogen-Progesterone Challenge
Test (EPCT) clarifies etiology of amenorrhea.
EPCT should be administered to see whether
withdrawal bleeding occurs:
Conjugated estrogen 1.25 mg PO for 21 days
followed by medroxy-progesterone acetate 10
mg PO X 1 week.
Or OCP
30. Estrogen should be provided to prevent
sequelae of estrogen deficiency, along
with cyclic progestins to prevent
endometrial hyperplasia, regardless of
the specific cause.
(-)ve test if no bleeding occurs:
always due to outflow tract obstruction.
Mx: Obtain hystero-salpingo-gram (HSG).
identify site of obstruction (e.g. cervical stenosis).
rule out endometrial adhesions (Asherman’s synd).
32. PCO
A state of persistent anovulation
Elevated circulating levels of testosterone,
androstenedione, DHEAS, DHA, 17
hydroxyprogesterone and estrone
The ovary secretes normal levels of estradiol
33. ULTRASOUND FINDINGS OF PCO
Multiple follicles around the periphery of the
ovary (this is a finding not the cause-25% of
normal women can have this fining)
Ultrasound is not necessary to make the
diagnosis
35. TREATMENT OF PCO IN PATIENTS NOT WANTING
TO CONCEIVE
Weight loss (decreases insulin and androgen
levels)
Glucaphage start with 500mg BID
Oral contraceptives unless contraindicated
Spironolactone 100-200mg per day for
hirsuitism
Progesterone if not a candidate for BCP’s
36. TREATMENT OF PATIENTS THAT WANT TO
CONCEIVE
Ovulation induction with clomid 50mg X5
days start cycle day 3-5
Glucophage 500mg BID
May need to induce a withdrawal bleed prior
to ovulation induction
37. SHEEHAN'S SYNDROME
Simmond's disease: related to pregnancy (obstetrics hemorrhage or
shock
Sheehan's syndrome: following severe postpartum haemorrhage causes
pituitary necrosis by arterial thrombosis of its vessels and causes
panhypopituitarism.
The woman fails to lactate following delivery, remains lethargic,
poikilothermic and shows signs of hypothyroidism and cortisol
deficiency.
Amenrrhoea; axillary and pubic hair is lost ; skin pigmintation is also
deficient
Blood sugar is low
Bimanual examination: hypoplastic uterus
She requires appropriate hormonal support.
A young woman may require ovulation induction drugs to achieve
conception.
38. RESISTANT OVARIAN SYNDROME
Resistant ovarian syndrome: autoimmune disease,
ovaries fail to respond to gonadotropin hormones and
induce amenorrhoea.
The ovaries show plasma cells and lymphocyte
infiltration.
Biopsy, however, is not necessary for the diagnosis.
FSH level is high.
may be prudent to study antithyroid, rheumatoid
factors and antinuclear antibodies to establish
autoimmune disease.
Pregnancy with donor egg in in vitro fertilization (IVF)
is possible.