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AMENORRHOEA
Presentedby:-
CHAITANYA SHEORAN
University college of medical science
Delhi, INDIA
Amenorrhea
Absence Of Menstruation.
ORIGIN from Greek
Classification of amenorrhea
AMENORRHEA
PHYSIOLOGICAL PATHOLOGICAL
Pre-puberty
Pregnancy related
Menopause
Primary
Seconda...
The Hypothalamic-Pituitary-Ovarian Axis
http://www.shen-nong.com/eng/images/exam/missedperiods/img_mp1a.gif
Clinically
Primary Secondary
ETIOLOGY OF AMENORRHEA
HYPOTHALAMUS
PITUITARY
ENDOCRINE
OVARIAN
OUTFLOW TRACT
AXIS
Congenital absent of
uterus and vagina
...
Common causes of Amenorrhea
Primary
» Gonadal failure (45%)
» Congenital absence of uterus and vagina (20%)
» Constitution...
Constitutional pubertal delay
• Common cause (15%)
Positive family history
• Under stature and delayed bone
age ( X-ray Wr...
Evaluation Categories
• 1-Breast Absent – Uterus Present
• 2-Breast Present – Uterus Absent
• 3-Breast Present – Uterus Pr...
46 XX
Typical features of Turner Syndrome
1st common cause (45% of causes )
•A craniopharyngioma is a benign tumor that
develops near the pituitary gland .
• most commonly in childhood and adolescen...
• Family history: Consider watchful waiting
• Request: FSH, LH
- Raised: Karyotype: 45 XO Turner syn
46 XX Premature ovari...
Utero-vaginal Agenisis
Mayer-Rokitansky-Kuster-Hauser syndrome
• Second most common cause of Primary
amenorrhea.
• Normal ...
• Normal breasts but no sexual hair
• Normal looking female external genitalia
• Absent uterus and upper vagina
• Karyotyp...
• Absent/abnormal then karyotype:
- 46 XX Mullerian agenesis
- 46 XY Androgen insensitivity
• Present
•+ no outflow obstru...
1-Rule out pregnancy!
2-Exclude cryptomenohrea
✴1-Pregnancy
✴2-Cryptomenorrhea :
imperforated hymen, vaginal septum,
✴3- Secondary Amenorrhea :
hypothalamic, pituitary ,...
Very rare
Gonadal agenesis
Gonadal destruction
Congenital enzyme defects
classification
Classify according to level of serum FSH
• Hypergonadotropic primary amenorrhea
• Eugonadrotropic primary a...
Hypergonadotropic primary
amenorrhoea
Abnormal sex chromosome :-
Turner syndrome
Normal sex chromosome:-
gonadal dysgenesis
Eugonadotropic primary amenorrhoea
• Androgen insensitivity syndrome(testicular
feminisation)
• Rokitansky-kuster-hauser s...
Hypogonadotropic primary
amenorrhoea
Hypothalamic causes
• Hypothalamic hypogonadsim (kallman’s
syndrome)
• Psychogenic ca...
Hypothalamic (Kallmann’s syndrome)
• Hypogonadotropic hypogonadism
• Congenital disorder characterized by:
• 1) Anosmia or...
CNS; HP
Disorder
Gonadal
Failure
History and physical examination completed for a
patient with primary amenorrhea
Secondar...
Secondary amenorrhoea
In women of reproductive age,
pregnancy is the most common
cause of secondary
amenorrhoea.
Pregnancy
Etiology of secondary Amenorrhoea
• Physiological :- pregnancy, lactation
• Pathological:-
• genital tract
• Ovarian
• Pit...
Outflow tract
( uterine target organ)
Asherman's Syndrome
Ovary
 PCOS
Premature Ovarian Failure
 Resistance Ovarian Syndrome
Radiation & Chemotherapy .
(Hypergonadotropic Hypog...
POLYCYSTIC OVARIAN SYNDROME (PCOS)
PCOS accounts for 90% of cases of oligoamenorrhea
Also known as Stein-Leventhal syndrom...
HYPOTHALAMIC CAUSES
Hypothalamic dysfunction is a common cause (30%).
It is more often seen as a result of stress, weight ...
Pituitary failure - It is usually the acquired
type as the result of trauma, treatment of
pituitary tumour or
infarction a...
ENDOCRINE CAUSES
Thyroid disorder and Cushing’s disease
interfere with the normal functioning of
the hypothalamic -pituita...
ANATOMICAL CAUSES
Usually due to previous surgery.
Commonest example:
1). Hysterectomy
2). Endometrial ablation
3). Asherm...
PREMATURE OVARIAN FAILURE
Premature ovarian failure occurs in
about 1% before
the age of 40.
Premature ovarian failure may...
DRUGS CAUSING HYPERPROLACTINAEMIA
Hyperprolactinaemia accounts for 20% of
cases of amenorrhea.
Prolactin inhibits GnRH rel...
Classic 45-XO Mosaic (46-XX / 45-XO)
Turner’s syndrome premature ovarian failure
anorexia nervosaa nervosa
• A psychological disease
characterized by
• Intense fear of gaining weight or being fat,
despit...
THE ASSESSMENT
HISTORY
EXAMINATION
INVESTIGATIONS
The most common cause of secondary amenorrhea
in reproductive age women is pregnancy and this
should always be excluded by...
History
A good history can reveal the etiologic
diagnosis in up to 85% of cases of
amenorrhea.
Hot flashes , decreased libido  premature menopause
Certain medications
Weight change  A large amount of weight loss (an...
Secondary sexual characteristic
Features of Turner’s syndrome
ANDROGEN EXCESS  hirsuitism (PCOS) – virilization (tumour)
...
• Progesterone challenge test
• TSH (thyroid stimulating hormone)
• FSH, LH
• Prolactin level
INVESTIGATING
Once pregnancy...
FSH, LH and Thyroid function test Progesterone
challenge test
WITHDRAWAL
BLEEDING
NO WITHDRAWAL
BLEEDING
HYPOESTROGENIC CO...
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...
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...
Asherman syndrome(intrauterine synechea)
Excessive curretage
Uterine infection
Endometrial TB
Dysfunctional uterine bleedi...
TREATMENT OF AMENORRHEA
The need for treatment depends on
Underlying causes
Need for regular periods
Trying to conceive (f...
TREATMENT OF AMENORRHEA
Underlying causes
PITUITARY TUMOUR  Bromocryptine / Surgery
ANDROGEN producing tumour of ovary  ...
TREATMENT OF AMENORRHEA
TRYING TO CONCEIVE
The prognosis for women with confirmed ovarian failure is poor.
ANOVULATION  r...
TREATMENT OF AMENORRHOEA
WANT REGULAR PERIOD
The use of
1): COMBINED ORAL CONTRACEPTIVE
2): HRT
NEED CONTRACEPTION
Confirm...
Amenorrhoea for undergraduates
Amenorrhoea for undergraduates
Amenorrhoea for undergraduates
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Amenorrhoea for undergraduates

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Amenorrhoea for undergraduates

  1. 1. AMENORRHOEA Presentedby:- CHAITANYA SHEORAN University college of medical science Delhi, INDIA
  2. 2. Amenorrhea Absence Of Menstruation. ORIGIN from Greek
  3. 3. Classification of amenorrhea AMENORRHEA PHYSIOLOGICAL PATHOLOGICAL Pre-puberty Pregnancy related Menopause Primary Secondary
  4. 4. The Hypothalamic-Pituitary-Ovarian Axis http://www.shen-nong.com/eng/images/exam/missedperiods/img_mp1a.gif
  5. 5. Clinically Primary Secondary
  6. 6. ETIOLOGY OF AMENORRHEA HYPOTHALAMUS PITUITARY ENDOCRINE OVARIAN OUTFLOW TRACT AXIS Congenital absent of uterus and vagina Vaginal atresia Imperforate hymen Asherman’s syndrome Pituitary adenoma Sheehan’s syndrome Hypothalamic-hypogonadism Weight related amenorrhea (anorexia nervosa) Hypothyroidism Gonadal dysgenesis Gonadal failure PCOS
  7. 7. 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%)
  8. 8. 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)
  9. 9. Evaluation Categories • 1-Breast Absent – Uterus Present • 2-Breast Present – Uterus Absent • 3-Breast Present – Uterus Present • 4-Breast Absent – Uterus Absent
  10. 10. 46 XX
  11. 11. Typical features of Turner Syndrome 1st common cause (45% of causes )
  12. 12. •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.
  13. 13. • Family history: Consider watchful waiting • Request: FSH, LH - Raised: Karyotype: 45 XO Turner syn 46 XX Premature ovarian failure - Low: Constitutional delay Consider: anorexia exercise illness coeliac disease hypothalamic/pituitary Secondary sexual characters absent 14y
  14. 14. Utero-vaginal Agenisis Mayer-Rokitansky-Kuster-Hauser syndrome • Second most common cause of Primary amenorrhea. • Normal breasts and axillary/pubic hair growth. • Normal looking external genitalia • Karyotype 46-XX • Renal abnormalities in 15-30 % cases. • Treatment : Vaginal creation (Dilatation VS Vaginoplasty)
  15. 15. • Normal breasts but no sexual hair • Normal looking female external genitalia • Absent uterus and upper vagina • Karyotype 46, XY • Male like testosterone level • Treatment : gonadectomy after puberty + HRT Androgen insensitivity Testicular feminization syndrome
  16. 16. • 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 years Ultrasound uterus
  17. 17. 1-Rule out pregnancy!
  18. 18. 2-Exclude cryptomenohrea
  19. 19. ✴1-Pregnancy ✴2-Cryptomenorrhea : imperforated hymen, vaginal septum, ✴3- Secondary Amenorrhea : hypothalamic, pituitary ,other endocrionpathy
  20. 20. Very rare Gonadal agenesis Gonadal destruction Congenital enzyme defects
  21. 21. classification Classify according to level of serum FSH • Hypergonadotropic primary amenorrhea • Eugonadrotropic primary amenorrhea • Hypogonadotropic primary amenorrhea
  22. 22. Hypergonadotropic primary amenorrhoea Abnormal sex chromosome :- Turner syndrome Normal sex chromosome:- gonadal dysgenesis
  23. 23. Eugonadotropic primary amenorrhoea • Androgen insensitivity syndrome(testicular feminisation) • Rokitansky-kuster-hauser syndrome • PCOS • Cryptomenorrhoea
  24. 24. Hypogonadotropic primary amenorrhoea Hypothalamic causes • Hypothalamic hypogonadsim (kallman’s syndrome) • Psychogenic causes, weight loss, stress, anorexia nervosa, malnutrition Pituitary causes • Short stature, obesity, mental retardation • Craniopharyngiomas
  25. 25. 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)
  26. 26. CNS; HP Disorder Gonadal Failure 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 Hypergonadotropic hypogonadism Karyotype analysis 46, XY 46, XX Mullerian Agenesis Androgen Sensitivity Syndrome No Yes Evaluate for secondary amenorrheaImperforate hymen or transverse vaginal septum Perform ultrasonography of uterus Evaluation of Primary Amenorrhea FSH > 20 IU/ L and LH > 40 IU/ L
  27. 27. Secondary amenorrhoea
  28. 28. In women of reproductive age, pregnancy is the most common cause of secondary amenorrhoea. Pregnancy
  29. 29. Etiology of secondary Amenorrhoea • Physiological :- pregnancy, lactation • Pathological:- • genital tract • Ovarian • Pituitary • Hypothalamus • Nutrition • Suprarenal causes • Thyroid
  30. 30. Outflow tract ( uterine target organ) Asherman's Syndrome
  31. 31. Ovary  PCOS Premature Ovarian Failure  Resistance Ovarian Syndrome Radiation & Chemotherapy . (Hypergonadotropic Hypogonadism)
  32. 32. POLYCYSTIC OVARIAN SYNDROME (PCOS) PCOS accounts for 90% of cases of oligoamenorrhea Also known as Stein-Leventhal syndrome The etiology is probably related to insulin resistance, with a failure of normal follicular development and ovulation The classical picture – AMENORRHEA, OBESE, SUBINFERTILITY and HIRSUITISM
  33. 33. HYPOTHALAMIC CAUSES Hypothalamic dysfunction is a common cause (30%). It is more often seen as a result of stress, weight loss and eating disorders It may be due to tumour, infarction, thrombosis or inflammation.
  34. 34. Pituitary failure - It is usually the acquired type as the result of trauma, treatment of pituitary tumour or infarction after massive blood loss ( Sheehan’s syndrome ) Pituitary tumour  hyperprolactinaemia which cause secondary amenorrhea. PITUITARY CAUSES
  35. 35. ENDOCRINE CAUSES Thyroid disorder and Cushing’s disease interfere with the normal functioning of the hypothalamic -pituitary – ovarian axis  present with amenorrhea. High level of thyroxine inhibit FSH release. Androgen – secreting tumours of the ovaries  cause secondary amenorrhea.
  36. 36. ANATOMICAL CAUSES Usually due to previous surgery. Commonest example: 1). Hysterectomy 2). Endometrial ablation 3). Asherman’s syndrome (damage to the endometrium with adhesion formation) 4). Stenosis of the cervix following cone biopsy
  37. 37. PREMATURE OVARIAN FAILURE Premature ovarian failure occurs in about 1% before the age of 40. Premature ovarian failure may be due to: 1). Chemotherapy and radiotherapy. 2). Autoimmune disease following viral infection 3). Following surgery for conditions such as endometriosis
  38. 38. DRUGS CAUSING HYPERPROLACTINAEMIA Hyperprolactinaemia accounts for 20% of cases of amenorrhea. Prolactin inhibits GnRH release from the hypothalamus Drugs that may cause hyperprolactinaemia: 1). Phenothiazines 2). Methyldopa 3). Cimetidine 4). Butyrophenones 5). Antihistamines
  39. 39. Classic 45-XO Mosaic (46-XX / 45-XO) Turner’s syndrome premature ovarian failure
  40. 40. anorexia nervosaa 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
  41. 41. THE ASSESSMENT HISTORY EXAMINATION INVESTIGATIONS
  42. 42. The most common cause of secondary amenorrhea in reproductive age women is pregnancy and this should always be excluded by physical exam and laboratory testing for the pregnancy hormone - HCG.
  43. 43. History A good history can reveal the etiologic diagnosis in up to 85% of cases of amenorrhea.
  44. 44. Hot flashes , decreased libido  premature menopause Certain medications Weight change  A large amount of weight loss (anorexia nervosa) Associate symptoms - Cushing's disease , hypothyroidism Contraception Previous gynaecological surgery CLINICAL ASSESSMENT - HISTORY - ASK ABOUT Menstrual cycle  age of menarche and previous menstrual history Previous pregnancies - severe PPH (Sheehan’s syndrome) Chronic illness
  45. 45. Secondary sexual characteristic Features of Turner’s syndrome ANDROGEN EXCESS  hirsuitism (PCOS) – virilization (tumour) Abdominal (haemato mera) and pelvic masses (ovarian tumour) Breast examination  may revealed galactorrhea, Inspection of genitalia  imperforate hymen, cervical stenosis CLINICAL ASSESSMENT - EXAMINATION - CHECK FOR BODY MASS INDEX (BMI)  weight loss-related amenorrhea BLOOD PRESSURE  elevated in Cushing and PCOS Vaginal examination  blind vagina, vaginal atresia, absent of uterus
  46. 46. • Progesterone challenge test • TSH (thyroid stimulating hormone) • FSH, LH • Prolactin level INVESTIGATING Once pregnancy has been excluded
  47. 47. FSH, LH and Thyroid function test Progesterone challenge test WITHDRAWAL BLEEDING NO WITHDRAWAL BLEEDING HYPOESTROGENIC COMPROMISED OUTFLOW TRACT Negative E-P challenge test Normal FSH Asherman’s syndrome (HSG or hysteroscopy) Normal or Low FSH Ovarian FailureHypothalamic-pituitary failure ANOVULATION Positive E-P challenge test Very high FSH FSH normal + high LH  PCOS High prolactin  pituitary tumour NEGATIVE PREGNANCY TEST INVESTIGATING SECONDAY AMENORRHEA
  48. 48. 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 :
  49. 49. 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
  50. 50. Asherman syndrome(intrauterine synechea) Excessive curretage Uterine infection Endometrial TB Dysfunctional uterine bleeding Uterine packing in PPH
  51. 51. TREATMENT OF AMENORRHEA The need for treatment depends on Underlying causes Need for regular periods Trying to conceive (fertility) Need for contraception)
  52. 52. TREATMENT OF AMENORRHEA Underlying causes PITUITARY TUMOUR  Bromocryptine / Surgery ANDROGEN producing tumour of ovary  Surgery TESTICULAR FEMINIZATION  removed gonad + HRT TURNER’S syndrome  HRT IMPERFORATE HYMEN  surgical incision THYROID disease – appropriate medical treatment EATING DISORDERS  referred to psychiatrist PCOS  HRT/ surgery ASHERMAN’s syndrome  breaking down adhesion + insert IUCD
  53. 53. TREATMENT OF AMENORRHEA TRYING TO CONCEIVE The prognosis for women with confirmed ovarian failure is poor. ANOVULATION  response well with ovulation induction treatment PCOS  ovulation may resume with weight reduction – fertility drugs - use of gonadotrophins or ovarian drilling. HYPERPROLACTINAEMIA  respond to treatment with dopamine agonist. HYPOTHALAMIC DYSFUNCTION  maintenance of normal weight and change of lifestyle ASHERMAN’S syndrome  breaking down adhesion + insert IUCD
  54. 54. TREATMENT OF AMENORRHOEA WANT REGULAR PERIOD The use of 1): COMBINED ORAL CONTRACEPTIVE 2): HRT NEED CONTRACEPTION Confirmed ovarian failure will not required contraception Women requiring contraception  oral contraceptives are method of choice

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