4. Events of Puberty
•1-Thelarche :
• the breast development
• Requires estrogenestrogen
•2-Pubarche/adrenarche :
pubic hair development
Requires androgensandrogens
5. Stage1 stage2
Prepupertal: elevation of
papilla- no pubic hair
Elevation of breast and papilla
on a small mount,increase in
areola – libial hair
Marshall and tunner staging
6. Stage 3 stage4
Further breast enlargment,
hair extend to mons pubis
Secondary mound of areola
and papilla ,hair extend
laterl
And increases pigmention
8. Requires:
GnRHGnRH from the hypothalamus
FSHFSH and LHLH from the pituitary
Estrogen and progesteroneEstrogen and progesterone from
the ovaries
Normal outflow tract
Events Of Puberty
3-Menarche:
14. 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%)
15. 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)
22. •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 de
ficiency.
23. • 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
- Intermediate: Anatomical - ultrasound
Secondary sexual characteristics
absent 14y
25. Utero-vaginal Agenisis
Mayer-Rokitansky-Kuster-Hauser syndrome
• Second most common cause of Primary
amenorrhea.
• Normal breasts and Sexual Hair Normal
looking external female genitalia
• Karyotype 46-XX
• 15-30% renal abnormalities.
• Treatment : Vaginal creation
(Dilatation VS Vaginoplasty)
26. • Normal breasts but no sexual hair
• Normal looking female external genitalia
• Absent uterus and upper vagina
• Karyotype 46, XY
• Male range testosterone level
Androgen insensitivity
Testicular feminization syndrome
27. •Absent/abnormal then karyotype:
-46XX Mullerian agenesis
-46XY Androgen insensitivity
•Present
•+no outflow obstruction
-As for 2o
amenorrhoea
Secondary sexual characteristics
Present by 16 years
Ultrasound uterus
38. Compartment IV: 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)
39. 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
Androgen
Sensitivity
Syndrome
No
Yes
Evaluate
for
secondary
amenorrhea
Imperforat
e hymen or
transverse
vaginal
septum
Perform ultrasonography of uterus
Evaluation of Primary Amenorrhea
FSH > 20 IU/ L
and
LH > 40 IU/ L
41. In women of reproductive age,
pregnancy is the most common
cause of secondary amenorrhea.
Pregnancy
The reality of this must be
ascertained before any
intervention is instituted for non-
obstetric amenorrhea.
48. Anorexia Nervosa
Anorexia 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
49. V. Others
1.Thyroid
hypo or hyperthyroidism
2. Adrenal disease
Adrenogenital S
Cushing S
Addison s disease
3. Ch. illness, badly controlled DM.
50. HistoryHistory
A good history can reveal the etiologic diagnosisA good history can reveal the etiologic diagnosis
in up to 85% of cases of amenorrhea.in up to 85% of cases of amenorrhea.
ASSESSMENTASSESSMENT
51. Present History
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.
52. Past history
1.Drug use: Dopamine antagonists for psychiatric conditions.
Antihypertensive,anticonsulsionvant
Genital tract surgery: intrauterine instrumentation
3--radio or chmotherrapy
4-infection : mumps or TB oophritis
54. 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:
56. 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
60. Treatment
I. Treatment of the cause.
1-if Y chromosome is present gonadectomy is
indicated
2- Create outflow tract or at least a sexually functional
vagina
II. No obvious cause:
. Conception is not required: COCP.
. Conception is required: induction of ovulation
Largest category, absent breast, uterus present. Second is breast and uterus both present. Third, breast present, uterus absent. Fourth and least common is breast absent, uterus absent. ( Maschchak – 62 cases)