Amenorrhea for undergraduate

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Undergraduate course lectures in Obstetrics&Gynecology .Prepared by Dr Manal Behery .Professor of OB&Gyne Faculty of medicine ,Zagazig University

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  • 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)
  • Amenorrhea for undergraduate

    1. 1. Amenorrhea • DR Manal Behery • Professor OB&GYNE • Zagazig University • 2014
    2. 2. Amenorrhea Absence Of Menstruation. ORIGIN from Greek
    3. 3. Classification of amenorrhea AMENORRHEAAMENORRHEA PHYSIOLOGICALPHYSIOLOGICAL PATHOLOGICAL Pre-puberty Pregnancy related Menopause Primary Secondary
    4. 4. Events of Puberty •1-Thelarche : • the breast development • Requires estrogenestrogen •2-Pubarche/adrenarche : pubic hair development Requires androgensandrogens
    5. 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. 6. Stage 3 stage4 Further breast enlargment, hair extend to mons pubis Secondary mound of areola and papilla ,hair extend laterl And increases pigmention
    7. 7. Stage5 Recession of arola to contour of the breast Adult pubertal hair with striaght upper borded
    8. 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:
    9. 9. Hypothalamo-Pituitary-Ov-Ut Axis CNS Hypothalamus Pituitary Ovary Uterus Outflow tract
    10. 10. The Hypothalamic-Pituitary-Ovarian Axis http://www.shen-nong.com/eng/images/exam/missedperiods/img_mp1
    11. 11. CNS-hypothalamus-pituitary ovary-uterus interaction Neural control Chemical control Dopamine (-) Norepinephrine (+) Endorphins (-) Hypothalamus GnRH Ant. pituitary FSH, LH Ovaries Uterus ProgesteroneEstrogen Menses –± ?
    12. 12. Functional menses Compartment ICompartment I outflow tract ( uterine target organ( Compartment ICompartment III Ovary ( Estrogen -Progesterone( Compartment IIICompartment III Anterior Pituitary Compartment IVCompartment IV CNS ( Hypothalamic(
    13. 13. Clinically PrimaryPrimary SecondarySecondary
    14. 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. 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)
    16. 16. primary amenorrhea
    17. 17. Evaluation Categories • 1-Breast Absent – Uterus Present • 2-Breast Present – Uterus Absent • 3-Breast Present – Uterus Present • 4-Breast Absent – Uterus Absent
    18. 18. 46XX
    19. 19. Typical features of Turner SyndromeTurner Syndrome 1st commen cause (45% of causes )1st commen cause (45% of causes )
    20. 20. Turner's S.
    21. 21. •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.
    22. 22. • 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
    23. 23. Mayer-R (okitansky-Kuster-Hauser syndrome(
    24. 24. 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)
    25. 25. • 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
    26. 26. •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
    27. 27. 1-Rule out pregnancy!
    28. 28. 2-Exclude cryptomenohrea
    29. 29. ✴1-Pregnancy ✴2-Cryptomenorrhea: imperforated hymen, vaginal septum, ✴3-Causes 2nd ry Amenorrhea: hypothalamic, pituitary ,other endocrionpathy
    30. 30. Very rare 17,20 -desmolase deficincy agonadieisim 17 alfa-hydroxylase deficincy (46, XY )
    31. 31. Compartment I: Disorders of the Outflow Tract • Eugonadism
    32. 32. MRI: complete low transverse septum with obstruction MRI: complete slightly higher transverse septum with obstruction
    33. 33. Compartment II: Disorders of the Ovary • Hypergonadotropic hypogonadism
    34. 34. Compartment III: Disorders of the Anterior Pituitary • Hypogonadotropic hypogonadism
    35. 35. Microadenoma vs macroadenoma
    36. 36. 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)
    37. 37. 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
    38. 38. Secondary amenorrhea
    39. 39. 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.
    40. 40. Compartment I OCompartment I Outflow tract ( uterine target organ) pregnancy Asherman's Syndrome
    41. 41. Compartment IICompartment II Ovary  PCO Premature Ovarian Failure  Resistance Ovarian Syndrome Radiation & Chemotherapy . )Hypergonadotropic Hypogonadism(
    42. 42. Polycystic ovary syndrome • The most common cause of chronic anovulation
    43. 43. Classic 45-XO Premature ovarian failure Turner’s syndrome Mosaic (46-XX / 45-XO)
    44. 44. Compartment IIICompartment III Anterior Pituitary Hyper – prolactinemia Tumors  Sheehan Syndrome
    45. 45. Compartment IVCompartment IV CNS ( Hypothalamic )  Hypothyrodism  Stress anxiety  Anorexia  Excessive Exercise  Drugs
    46. 46. 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
    47. 47. V. Others 1.Thyroid hypo or hyperthyroidism 2. Adrenal disease Adrenogenital S Cushing S Addison s disease 3. Ch. illness, badly controlled DM.
    48. 48. 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
    49. 49. 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.
    50. 50. 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
    51. 51. Clinical assessment 1-β - hCG 2-TSH 3-Prolactin TOP Bottom
    52. 52. 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:
    53. 53. Step 1
    54. 54. 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
    55. 55. Step 2
    56. 56. • Asharman syndrome(intrauterine synechea)
    57. 57. Step 3
    58. 58. 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
    59. 59. Thanks

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