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  1. 1. Dr.Mohammed Abdalla Obst.Gyn.Specialist Egypt, Domiat G. Hospital ASSESSMENT OF A CASE OF AMENORRHEA
  2. 2. AMENORRHEA <ul><li>Amenorrhea is the absence or abnormal cessation of the menses. A patient is diagnosed with primary amenorrhea if she has not reached menarche by age 15.1 </li></ul><ul><li>She meets the criteria for secondary amenorrhea if established menses have ceased for longer than 6 months </li></ul>
  3. 3. Etiology of Amenorrhea <ul><li>Primary    </li></ul><ul><ul><ul><ul><ul><li>  Gonadal failure(43%)   </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Congenital absence of uterus and vagina(15%)   </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Constitutional delay(14%) </li></ul></ul></ul></ul></ul><ul><li>Secondary      </li></ul><ul><ul><ul><ul><ul><li>Chronic anovulation(39%) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>  Hypothyroidism / hyperprolactinemia(20%)   </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Weight loss/anorexia(16%) </li></ul></ul></ul></ul></ul>
  5. 5. Primary amenorrhea vagina no yes <ul><ul><ul><li>congenital uterovaginal agenesis </li></ul></ul></ul><ul><ul><ul><li>imperforate hymen </li></ul></ul></ul><ul><ul><ul><li>complete transverse vaginal septum </li></ul></ul></ul>Pubic hair Estrogenized breasts have developed the (MPA) challenge abnormal ovaries abnormal hormonal stimulation of normal ovaries FSH Level Chromosome Analysis no no yes complete androgen insensitivity syndrome (CAIS) + - high low
  6. 6. Secondary Amenorrhea
  7. 7. <ul><li>Secondary amenorrhea is the absence of menstrual periods for 6 months in a woman who had previously been regular, or for 12 months in a woman who had irregular periods. </li></ul>
  8. 8. incidence <ul><li>1% of women of reproductive age. </li></ul>
  9. 9. <ul><li>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. </li></ul>
  10. 10. History <ul><li>A good history can reveal the etiologic diagnosis in up to 85% of cases of amenorrhea. </li></ul>
  11. 11. Galactorrhea hot flashes, breast atrophy and decreased libido Certain medications A large amount of weight loss or gain Anorexia nervosa Cushing's disease  and hypothyroidism Sheehan's syndrome. Asherman's syndrome Amenorrhea following cervical conization Following discontinuation of oral contraception History
  12. 12. Physical examination <ul><li>Signs of androgen excess </li></ul><ul><li>The breast exam may reveal galactorrhea </li></ul><ul><li>Estrogen deficiency may be suggested on pelvic exam by a smooth vagina that lacks the normal rugae (wrinkles) and a dry endocervix with no mucous </li></ul>
  13. 13. what the doctor will do next?
  14. 14. If the history and physical exam are suggestive of a certain etiology : <ul><li>for the sake of efficiency and cost-effectiveness, the workup can sometimes be more directed. ( in 85% of cases .) </li></ul>
  15. 15. <ul><li>Some patients will not demonstrate any obvious etiology for their amenorrhea on history and physical exam. These patients can be worked up in a logical manner using a stepwise approach. </li></ul>
  16. 16. <ul><li>the first tests to perform after pregnancy is ruled out are : </li></ul><ul><li>a progesterone withdrawal test </li></ul><ul><li>TSH (thyroid stimulating hormone) </li></ul><ul><li>prolactin level. </li></ul>
  17. 17. Preg.test TSH ,PROLACTIN’, Prog.challenge test withdrawal bleeding without withdrawal bleeding hypoestrogenic compromised outflow tract. +ve.est,progest.challenge test -ve.est,progest .challenge test FSH>30-40 Normal FSH HSG OR hysteroscopy asherman 2wk FSH norm . repeat Repeat+serum ,est.level PROF hypothalamic-pituitary failure anovulation -VE
  18. 18. Ovarian failure (premature menopause ) chromosomal anomalies autoimmune disease If the woman is under 30, a karyotype should be performed to rule out any mosaicism involving a Y chromosome. it is prudent to screen for thyroid, parathyroid, and adrenal dysfunction If a Y chromosome is found the gonads should be surgically excised. Laboratory evidence of autoimmune phenomenon is much more prevalent than clinically significant disease
  19. 19. autoimmune related dysfunction <ul><li>The most common association is with thyroid disease, but the parathyroids and adrenals can also be affected. </li></ul><ul><li>Several studies have shown laboratory evidence of immune problems in about 15-40% of women with premature ovarian failure. </li></ul><ul><li>In general, ovarian biopsy is not indicated in patients with premature ovarian failure since no clinically useful information will be obtained. </li></ul>
  20. 20. Hypothalamic-pituitary failure <ul><li>Patients who do not bleed after the progestin challenge but do after estrogen/progestin and have normal or low FSH and LH levels </li></ul>
  21. 21. Hypothalamic-pituitary failure <ul><li>Some medications (e.g. phenothiazines) as well as extremes of weight loss, stress or exercise can cause this type of secondary amenorrhea. </li></ul><ul><li>A pituitary or hypothalamic tumor would be a rare finding in these patients who were all screened with prolactin levels at the beginning of the diagnostic evaluation. </li></ul><ul><li>However, if there is no cause apparent from the history, it would be prudent to obtain a baseline CT (or MRI) evaluation of the sellar region to rule out a space occupying lesion. </li></ul>
  22. 22. Hypothalamic-pituitary failure <ul><li>Patients with normal prolactin levels and normal imaging studies have hypothalamic amenorrhea of uncertain etiology. </li></ul>If the amenorrhea and lack of withdrawal bleeding persists, prolactin levels should be measured annually since a small microadenoma could be present that is escaping laboratory and radiographic detection.
  23. 23. Hypothalamic-pituitary failure <ul><li>In this condition, as well as in the other hypothalamic amenorrhea situations, the patients can be significantly hypo estrogenic (a low estrogen situation similar to menopause). If the state is persistent, hormone replacement therapy should be considered for protection against osteoporosis. One approach is to get an estradiol level and if it is less than 30 pg/ml, counsel the patient that hormonal replacement therapy is indicated </li></ul>