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  1. 1. Amenorrhoea Aboubakr Elnashar Benha university hospital, Egypt
  2. 2. Types Primary: lack of menstruation by age 16 in the presence of 2" sexual characteristics or 14 in their absence. 2ndary: an absence of menstruation for 6 m.
  3. 3. Causes I. Physiological causes •Pregnancy must always be excluded. •Lactation. •Menopause. II. Iatrogenic causes •Progestagenic contraceptives: Depo-Provera", Mirena IUS*, Nexplanon*, POP. •Therapeutic progestagens •Continuous COCP use •GnRH analogues •Rarely danazol.
  4. 4. Sequence of menstruation CNS IV. Hypothalamus  GnRh  III. Ant. Pituitary FSH + LH  II. Ovary  E + P  I. Uterus & outflow tract V. Others
  5. 5. Compartment II: Disorders of the Ovary Compartment I: Disorders of the Outflow Tract Compartment IV: Hypothalamic Disorders Compartment III: Disorders of the Anterior Pituitary Eugonadism Hypogonadotropic hypogonadism Hypogonadotropic hypogonadism Hypergonadotropic hypogonadism Normogonadotropic Hypogonadism(PCOD)
  6. 6. Pathological causes I. Genital tract outflow obstruction: Congenital 1. Imperforate hymen 2. Transverse vaginal septum 3. Cervical stenosis 4. Agenesis of uterus and mulerian duct structures: sporadic or associated with AIS. Acquired 1. Asherman's syndrome (intrauterine adhesions). 2. TB 3. Surgery
  7. 7. MRI: complete slightly higher transverse septum with obstruction MRI: complete low transverse septum with obstruction
  8. 8. Androgen Insensitivity Syndrome Axillary and pubic hair do not develop or spare , reflecting the resistance to testosterone. 46 XY Asherman Syndrome
  9. 9. II. Ovarian: 1. PCOS 2. POF 3. Resistant ovary syndrome 4. ovarian dysgenesis, especially due to Turner's syndrome (45XO). 5. Feminizing-virilizing tumors. granulosa-thecal cell tumors gynandroblastoma.
  10. 10. Turner's S.
  11. 11. III. Anterior pituitary: 1. Micro- or macroadenoma (prolactinoma) or other SOl 2. Surgery 3. Sheehan's syndrome (post-partum pituitary failure). 4. Levi-ilorain S: deficient GH & Gnt dwarfism, retarded sexual development 5. Other causes of hyperprolactinaemia: . Drugs: aldomet, phenothiazine, P, E, cimetidine . CNS: encephalitis
  12. 12. MRI: pituitary macroadenoma (classic "snowman" appearance of the bi- lobed pituitary MRI: pituitary microadenoma (arrows). A. Coronal image.
  13. 13. It is located in the suprasellar region, and presents with :  Endocrine dysfunction (80%), Growth failure and delayed puberty ,Amenorrhea, Hypothyroidism, adrenal failure (eg, orthostatic hypotension, hypoglycemia), diabetes insipidus  Headache (70%)  Visual disturbances (60%). MRI T1 sagittal plan (before i.v. gadolinium ) Extra-axial Craniopharyngioma developing into the intra- and suprasellar space Craniopharyngioma
  14. 14. IV. Hypothalamic Functional Stress Anorexia excessive exercise. pseudocyesis Non-functional SOL. Surgery Radiotherapy Kallman's syndrome (1' GnRH deficiency: primary amenorhea, hypogonadotrophic anosmia.).
  15. 15. V. Others 1. Thyroid Severe hypo or hyperthyroidism 2. Adrenal disease CAH. Cushing S Addison s disease Tumors 3. Ch. illness, badly controlled DM.
  16. 16. Cushing”s S Late onset congenital adrenal hyperplasia
  17. 17. Diagnosis I. History Present 1. Sexual activity, risk of pregnancy, 2. Type of contraceptive used. 3. Galactorrhoea 4. Androgenic symptoms: weight gain, acne, hirsutism 5. Menopausal symptoms: night sweats, hot flushes 6. Issues with eating or excessive exercise. Past 1. Drug use: dopamine antagonists for psychiatric conditions. 2. Genital tract surgery: intrauterine instrumentation
  18. 18. II. Examination General: 1. BMI <17/>30 2. Hirsutism 3. 2° sexual characteristics (Tanner staging). 4. Stigmata of endocrinopathies (including thyroid) or Turner's syndrome. 5. Evidence of virilization (deep voice, male pattern balding, cliteromegaly).
  19. 19. Abdominal: masses due to tumours genital tract obstruction. Pelvic 1. imperforate hymen 2. blind ending vaginal septum 3. absence of cervix and uterus.
  20. 20. Investigations Lab: 1. Pregnancy test. 2. Prolactin should always be tested. 3. TSH 4. FSH/LH: inc in POF, dec in hypothalamic causes not useful in PCOOS 5. Testosterone and (SHBG): most useful for PCOS.
  21. 21. Pelvic ultrasound: •congenital abnormalities •Asherman's syndrome •Haematometra •PCOS morphology •Physiological activity or endometrial atrophy in POF.
  22. 22. Karyotype if uterus absent or suspicion of Tumer's syndrome Specific tests for endocrinopathies where there is clinical suspicion.
  23. 23. Progestin challenge test: (MPA 5mgX5d or P in oil 100 mg /3d X 3) +ve: Anovulation -ve: E + P: -ve: outflow or uterine failure  HSG, hysteroscopy, IVP & laparoscopy. +ve: Ovarian failure or pituitary-hypothalamic dysfunction. FSH: high: Ovarian failure. If 1ry: Karyotyping. If 2ndry: premature menopause Low or Normal: MRI of Pituitary-hypothalamic region. . Abnormal: pituitary disease . Normal: hypothalamic dysfunction.
  24. 24. Management Must be guided by the diagnosis and fertility wishes. Obese or under wt: attain normal BMI. Hyperprolactinaemia: Cabergoline or surgery PCOS: Cyclical withdrawal bleeds (COCP ) POF: HRT Genital tract obstruction: cervical dilation. hysteroscopic resection, incision of hymen. Endocrinopathies and tumours: TT Major congenital abnormalities, AIS: multi­disciplinary teams in specialist centers.
  25. 25. Oligomenorrhoea Aboubakr Elnashar
  26. 26. Define: Cycles are longer than 32 days anovulation or intermittent ovulation. Transient oligomenorrhoea common stress' or emotionally related causes usually self-limiting.
  27. 27. Causes Similar to many of the causes of 2º amenorrhoea: 1. PCOS is the commonest cause 2. Borderline low BMI. 3. Obesity without PCOS. 4. Ovarian resistance: anovulation e.g. incipient POF. is rare, but important, 5. Milder degrees of hyperprolactinaemia 6. Mild thyroid disease.
  28. 28. Management What does the patient want? Regular periods or fertility? 1. Provide reassurance. 2. Treat any underlying causes 3. It is not uncommon for no cause to be found, but serious pathology must be excluded. 4. Attain normal BMI (weight loss or gain as appropriate).
  29. 29. Provide regular cycles: 1. COCP or cyclical progestagens 2. PCOS a minimum of 3 periods/yr {avoid the risk of endometrial hyperplasia due to unopposed oestrogen}. Full fertility screening should be performed if ovulation induction is required