Primary amenorrhea is defined as the absence of menses by 16 years of age in the presence of normal secondary sexual characteristics, or by 14 years of age when there is no visible secondary sexual characteristic development.
Secondary amenorrhea - absence of menses for 6 months in a previously menstruating female
1. Genuine & false
2. Primary & secondary
3. Physiological & pathological
4. The hypothalamic amenorrhea,
The pituitary amenorrhea,
The ovarian amenorrhea,
The uterine form of amenorrhea.
The hypothalamic amenorrhea
Amenorrhea during falls pregnancy
Amenorrhea as a symptom of nervous anorexia
Amenorrhea as a symptom of adiposogenital dystrophy
Amenorrhea as a symptom of the Lorence-Moon-Barde-Bidle syndrome
Amenorrhea as a symptom of the Morghani_Stuart syndrome
Amenorrhea as a symptom of the persistent lactation syndrome (the Kiari-Fromel syndrome)
Appears as a result of stress situation or psychic traumas
Excessive production of corticotropin within stress blocs production of releasing hormones by Hypotalamus.
After 2-3 months of treatment without result we prescribe thyroidin.
Amenorrhea during falls pregnancy
Appears in women, who are eager or very afraid to become pregnant.
Swelling of breast
Some enlarging & softening of uterus can appear
But all test for pregnancy are negative.
Rule out pregnancy!
Onset between ages 10 and 30.
Weight loss of 25% or weight 15% below normal for age and height.
— Distorted body image,
— Unusual hoarding or handling of food.
At least one of the following:
— Episodes of overeating (bulimia),
— Vomiting, which may be self-induced.
No known medical illness.
No other psychiatric disorder.
— Low blood pressure,
— Diabetes insipidus.
Cessation of menstrual cycle via endurance activities, inadequate body weight, eating disorder, stress
Reestablish normal hormone levels via diet and exercise counseling, hormone therapy
Amenorrhea as a symptom of adiposogenital dystrophy
It is usually associated with tumours of the hypothalamus , causing increased appetite and depressed secretion of gonadotropin . It seems to affect males mostly.
Is a condition characterized by
Growth retardation and retarded sexual development , atrophy or hypoplasia of the gonads , and altered secondary sex characteristics ,
mental retardation , problems with vision
polyuria , polydipsia .
tumours of the hypothalamus Diagrammatic representation of empty sella syndrome. A, Normal anatomic relationship. B, C, and D, Progression in development of empty sella syndrome. Note thinning of floor and symmetric enlargement of sella turcica.
Amenorrhea as a symptom of the Laurence-Moon-Barde-Bidle syndrome
Laurence-Moon syndrome comprises
Onset in childhood.
Inheritance is autosomal recessive.
retinitis pigmentosa, initially, problem of night vision; then central vision and then peripheral vision loss progressing to blindness.
Spinocerebellar ataxia and progressive spastic paraplegia
The complete syndrome is seldom observed in the same individual, but the features are often scattered among the siblings of one family or generation. Members of these families have an increased number of miscarriages and early deaths.
Amenorrhea as a symptom of the Morghani-Stuart syndrome
The main features of this hereditary syndrome are:
1) hyperostosis frontalis interna,
3) virilism and hirsutism
4) menstrual disorders
Treatment is symptomatic
Hyperprolactinemia has such causes:
-prolactin-secreting pituitary adenomas
-other pituitary or hypothalamic tumors that may distort the portal circulation and thereby prevent effective delivery of hypothalamic dopamine (the putative prolactin inhibitory factor or hormone)
-a variety of drugs that lower dopamine levels or inhibit dopamine action (amphetamines, benzodiazepines, butyrophenones, metoclopramide, methyldopa, opiates, phenothiazines, reserpine, and tricyclic antidepressants)
-breast or chest wall surgery, cervical spine lesions, or herpes zoster (activation of the afferent sensory neural pathway that stimulates prolactin secretion, in a manner similar to suckling)
-other rare, nonpituitary sources (lung and renal tumors) or causes of decreased prolactin clearance (renal failure).
The pituitary amenorrhea
Amenorrhea as a symptom of pituitary nanism
Amenorrhea as a symptom of gigantism and acromegalia
Amenorrhea as a symptom of Itsenco-Kushing’s disease
Amenorrhea as a symptom of Shichane diseas
Amenorrhea in case of pituitary nanism
Disease develops in prenatal period or during the first months of life due to infectious diseases or traumatic damages of anterior part of pituitary. Insufficiency of all its hormones including somatotropin appears as a result.
Treatment mainly is in an endocrinologist competence. One should begin treatment in childhood with grows stimulation. Further replacement hormonal therapy is indicated
Amenorrhea in case of gigantism and acromegalia
Diseases are caused by Somatotropin hyperprodaction, production of gonadothropic hormones is decreased. Amenorrhea has a secondary character.
Treatment. At pituitary tumors rhoentgenotherapy is indicated. For Patients with gigantism estrogen therapy for stopping of excessive growth is prescribed.
Clinical features are :
«buffalo hump» (an excessive deposit of fat over the clavicles and back of the neck),
amenorrhoea or menstrual irregularity.
Most commonly observed in females in childbearing age.
Hirsutism, plethora, abdominal striae, diabetes mellitus, osteoporosis, increased susceptibility to infection, cataracts, renal calculi, senile purpura, proximal myopathy, hypertension may be associated.
The syndrome may be recognized soon after birth; children with it have stunted growth.
It can also be caused by treatment with corticosteroids.
“ Moon face” Plethoric face (NO HIRSUTISM) Supra- clavicular fat pads
Acute infarction and necrosis of the pituitary gland due to postpartum hemorrhage and shock is known as Sheehan's syndrome.
The symptoms of hypopituitarism are usually seen early in the postpartum period, especially failure of lactation and loss of pubic and axillary hair.
Deficiencies in growth hormone and gonadotropins are most common, followed by ACTH, and last, by TSH in frequency. Diabetes insipidus is not usually present. This can be a life-threatening condition, but fortunately, because of good obstetrical care, this syndrome is never encountered by most of us.
The ovarian amenorrhea
The Shereshevsky-Terner’s syndrome
The Stein-Levental syndrome
What is Turner syndrome?
Relatively common disorder caused by the loss of genetic material from one of the sex chromosomes.
Affects only females
X chromosome monosomy
X chromosome mosaicism
X chromosome defects
Short stature (143-145cm tall)
Loss of ovarian function
Hormone imbalances( thyroid, diabetes)
Stress and emotional deprivation
Diseases affecting the kidneys, heart, lungs or intestines
Learning problems( esp. in maths)
Gonadal failure Internal genitalia of patient with gonadal dysgenesis (Turner syndrome), featuring normal but infantile uterus, normal fallopian tubes, and pale, glistening "streak" gonads in both broad ligaments.
Possible during infancy or early childhood
A physical exam is the first indication
The best test is a karyotype, ie a laboratory test presenting the chromosomes
Growth hormone therapy
Estrogen replacement therapy
Cardiac surgery (when needed)
In vitro fertilization (to achieve pregnancy)
Polycystic Ovarian Syndrome Sagittal section of a polycystic ovary illustrating large number of follicular cysts and thickened stroma.
an inversion of the normal LH/FSH ratio
lack of ovulation
increased levels of male hormones ("androgens")
irregular or absent menstruation/ovulation
undesired hair growth and acne
small benign cysts on the ovaries
increased risk of miscarriage
endometrial cancer, heart disease
BBT (basal body temperature)
multiple small ovarian cysts
Endometrium biopsy(Curettage )
before menses reveal to proliferative glands
Determination of LH,FSH,E2,P,T,PRL ， Ins ， (LH:FSH≧3:1)
If pregnancy is desired - cause ovulation
anti-androgens (agents that lower
gonadotropin releasing hormone
If pregnancy is not desired
to reduce the risk of endometrial cancer( birth control pills)
Normal secondary development & external female genitalia
Normal female range testosterone level
Absent uterus and upper vagina & normal ovaries
15-30% renal, skeletal and middle ear anomalies
X-ray film of patient with Asherman syndrome. Patient (33 years, gravida 3, para O, abortus 3) had been amenorrheic for 6 months after D&C for most recent therapeutic abortion (TAB). Filling of endocervical canal and nonvisualization of endometrial cavity are consistent with complete obliteration of cavity by adhesions or with obstruction at internal os level by adhesions in lower endometrial cavity. This appearance may also be seen with advanced endometrial tuberculosis. Asherman syndrome
COMPLICATIONS OF MENSTRUATION
Symptoms include edema, weight gain, restlessness, irritability, and increased tension.
Symptoms must occur in the second half of the menstrual cycle.
There must be a symptom-free period of at least 7 days in the first half of the cycle.
Symptoms must occur in at least 2 consecutive cycles.
Symptoms must be severe enough to require medical advice or treatment.
Pain, and usually swelling, of the breasts caused by edema and engorgement of the vascular and ductal systems is termed mastodynia, or mastalgia.
Management of painful breasts due to fibrocystic changes consists of support of the breasts, avoidance of methylxanthenes (coffee, tea, chocolate, cola drinks), and occasional use of a mild diuretic.
Patients with mastodynia have had improvement with danazol, bromocriptine, oral contraceptives, and vitamins, though with limited success. I
In one study, lisuride maleate, a dopamine agonist, was associated with a significant decrease in pain.
Dysmenorrhea, or painful menstruation, is the most common complaint of gynecologic patients.
There are 3 types of dysmenorrhea: (1) primary (no organic cause),
(2) secondary (pathologic cause),
(3) membranous (cast of endometrial cavity shed as a single entity).
Typically, pain occurs on the first day of the menses, usually about the time the flow begins, but it may not be present until the second day.
Nausea and vomiting, diarrhea, and headache may occur.
Treatment of dysmenorrhea
B. ORAL CONTRACEPTIVES
C. SURGICAL TREATMENT
D. ADJUVANT TREATMENTS
Abnormal uterine bleeding
Abnormal uterine bleeding includes:
abnormal menstrual bleeding
bleeding due to other causes such as pregnancy, systemic disease, or cancer.
Patterns of Abnormal Uterine Bleeding
Metrorrhagia (intermenstrual bleeding)
Contact bleeding (postcoital bleeding)
Evaluation of abnormal uterine bleeding
B. PHYSICAL EXAMINATION
C. CYTOLOGIC EXAMINATION
D. ENDOMETRIAL BIOPSY
E. SALINE HYSTEROSONOGRAM
G. DILATATION AND CURETTAGE
H. OTHER DIAGNOSTIC PROCEDURES
Dysfunctional uterine bleeding
B. YOUNG WOMEN
C. PREMENOPAUSAL WOMEN
D. SURGICAL MEASURES
Postmenopausal bleeding may be defined as bleeding that occurs after 12 months of amenorrhea in a middle-aged woman. When amenorrhea occurs in a younger person for 1 year and premature ovarian failure or menopause has been diagnosed, episodes of bleeding may be classified as postmenopausal, although resumption of ovulatory cycles can occur.