Amenore - www.jinekolojivegebelik.com

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Amenore - www.jinekolojivegebelik.com

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  • Amenore - www.jinekolojivegebelik.com

    1. 1. AMENORRHEA Paul Beck, MD, FACOG, FACS
    2. 2. Incidence of Primary Amenorrhea <ul><li>Less than .1% </li></ul><ul><li>Puberty </li></ul><ul><li>Breast: 10.8 +/- 1.10 yrs. </li></ul><ul><li>Pubic Hair: 11.0 +/- 1.21 yrs. </li></ul><ul><li>Menarche 12.9 +/- 1.2 yrs. </li></ul>
    3. 3. Onset of Puberty and Menstruation <ul><li>Ratio of fat to both total body weight and lean body weight </li></ul><ul><li>Moderate obesity (20 – 30 % above ideal body weight) = earlier menarch </li></ul><ul><li>Malnutrition (anorexia nervosa, starvation) = delay </li></ul><ul><li>Prepubertal strenuous exercise (less total body fat) = delay e.g. ballet dancers, swimmers, runners </li></ul>
    4. 4. Diagnostic Evaluation by Compartments <ul><li>I Outflow Tract (uterus – vagina) </li></ul><ul><li>II Ovary </li></ul><ul><li>III Anterior Pituitary </li></ul><ul><li>IV CNS – Hypothalamus (environment and psyche) </li></ul>
    5. 5. Evaluation <ul><li>History/Physical </li></ul><ul><li>Psychiatric, family history-genetic abnormalities, nutritional status, growth/development </li></ul><ul><li>Secondary sexual characteristics </li></ul><ul><li>Presence of breasts – normal reproductive tract (uterus, vagina) </li></ul>
    6. 6. Evaluation Categories <ul><li>Breast Absent – Uterus Present </li></ul><ul><li>Breast Present – Uterus Present </li></ul><ul><li>Breast Present – Uterus Absent </li></ul><ul><li>Breast Absent – Uterus Absent </li></ul>
    7. 7. Initial Tests for Amenorrhea <ul><li>Progesterone challenge </li></ul><ul><li>TSH </li></ul><ul><li>Prolactin </li></ul><ul><li>TSH elevated – hypothyroid </li></ul><ul><li>Prolactin elevated (MRI – 100 ng/ml) </li></ul>
    8. 8. Progesterone Challenge <ul><li>Positive withdrawal bleed </li></ul><ul><li>Normal prolactin </li></ul><ul><li>Normal TSH </li></ul><ul><li>Diagnosis = annovulation </li></ul><ul><li>Treatment: monthly progesterone/O.C. </li></ul>
    9. 9. Progesterone Negative Withdrawal <ul><li>FSH/LH </li></ul><ul><li>FSH/LH normal – estrogen/progesterone cycle </li></ul><ul><li>If negative = end organ defect </li></ul><ul><li>If FSH/LH high = ovarian failure </li></ul><ul><li>Estrogen – positive withdrawal, FSH normal or low, MRI sella = no path </li></ul><ul><li>Diagnosis: hypothalamic amenorrhea </li></ul>
    10. 10. Chromosome Evaluation for Ovarian Failure <ul><li>If the patient is under age 30 – karyotype </li></ul><ul><li>Y chromosome/excision of gonadal area </li></ul><ul><li>Problem – gonadal tumor – malignant </li></ul><ul><li>30% do not develop virilization, therefore even normal appearing female needs karyotype to exclude Y </li></ul><ul><li>After age 30 = premature menopause </li></ul>
    11. 11. Selected Blood Test for Autoimmune Disease <ul><li>Calcium, phosphorus </li></ul><ul><li>Fasting blood sugar </li></ul><ul><li>A.M. cortisol </li></ul><ul><li>Free T 4 – TSH </li></ul><ul><li>Thyroid antibodies </li></ul><ul><li>CBC – ESR – CRP </li></ul><ul><li>Total protein A/G ratio </li></ul><ul><li>Rheumatoid factor </li></ul><ul><li>Antinuclear antibody </li></ul>
    12. 12. Specific Disorders <ul><li>I Outflow - imperforate hymen, ashermans </li></ul><ul><li>mullerian agenesis, androgen insensitivity syndrome </li></ul><ul><li>II Ovary - can be primary or secondary amenorrhea </li></ul><ul><li>40% of primary amenorrhea have gonadal streaks </li></ul><ul><li>Of the 40%, 50% = 45,X </li></ul><ul><li> 25% = mosaics </li></ul><ul><li>25% = 46 XX </li></ul><ul><li>Secondary amenorrhea patients have many karyotypes </li></ul>
    13. 13. Specific Disorders (continued) <ul><li>Turner syndrome </li></ul><ul><li>Gonadal dysgenesis </li></ul><ul><li>Gonadal agenesis </li></ul><ul><li>Savage syndrome </li></ul><ul><li>Premature ovarian failure </li></ul><ul><li>Radiation therapy </li></ul><ul><li>Alkylating agents </li></ul>
    14. 14. Compartment III <ul><li>Anterior pituitary disorders </li></ul><ul><li>Tumors – large bitemperal hemianopsia </li></ul><ul><li>Small tumors – visual defects- rare </li></ul><ul><li>Craniopharyngioma – calcification x-ray may produce blurring of vision </li></ul><ul><li>Acromegaly </li></ul><ul><li>Cushings </li></ul><ul><li>Pituitary prolactin adenomas (micro/macro) </li></ul><ul><li>Sheehan’s syndrome </li></ul>
    15. 15. Compartment IV <ul><li>CNS disorders </li></ul><ul><li>Hypothalamic amenorrhea – problem is a GNRH pulsatile secretion </li></ul><ul><li>Anorexia/Bulemia/weight loss – 25% (onset – 10 – 30 years) </li></ul><ul><li>Exercise </li></ul>
    16. 16. Etiology of Amenorrhea <ul><li>Breast – Absent </li></ul><ul><li>Breast – Present </li></ul>Mullerianagenesis Hypothalamic, pituitary, ovarian pt uterine etiology AIS (T.F.) 3. Pituitary failure 2. Hypothalamic failure 17 a hydroxylase deficiency with 46XX Agonadism Gonadal dysgenisis 17 a hydroxylase deficiency 46xy 1. Gonadal failure turner 45X 17, 20 desmolase deficiency Uterus Present Uterus Absent

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