How to approach a case ofamenorrheaDr Manal BeheryAssistant professorZAGAZIG University 2013Dr Manal BeheryAssistant profe...
“Doctor, I’m not getting my period”(blank, like no period……)
Amenorrhea:“absence of menses” Normal cycle is 28 days This occurs in 15% of cycles Normal Highest rate of anovulatory ...
Menstrual cycleSource Undetermined
PRIMARY AMENORRHEA Patient has never menstruated– No period by age 14 with no secondarysexual characteristics– No period ...
SECONDARY AMENORRHEA– absence of menses in women who previouslyhad menses.– Absence must be for> 3 cycles according to ce...
ALWAYS RULE OUTPREGNANCY!!!!!!!No matter WHAT!!!Then evaluate the four parts of thesystem
Don’t forget PREGNANCY!Is the Most common cause of secondaryamenorrhea Consider each level of the control of themenstrual...
The Hypothalamic-Pituitary-OvarianAxishttp://www.shen-nong.com/eng/images/exam/missedperiods/img_mp1a.gif
REASONS FOR AMENORRHEA Pregnancy Menopause Thyroid/Prolactin Disorders Anovulation Outflow obstruction CNS/hypothala...
STEP ONE –will diagnose pregnancy, thyroid disorder,hypoprolactinemia and anovulation LABS– Beta hcg– TSH– Prolactin MED...
STEP TWO –will diagnose outflow tractobstruction Give estrogen “priming”, followed by progestin– Estrogen x 21 days– Add ...
STEP 3- will determine if lack ofestrogen is due to ovarian failurevs. altered CNS/pituitary axisFSH(LH)
I. UTERUS – VAGINA –OUTFLOW TRACT Asherman’s – secondary amenorrhea Imperforate hymen – primary amenorrhea Vaginal sept...
Asharman syndrome(intrauterinesynechea)
Imperforate Hymen
Transverse Vaginal Septum
Mayer-Rokitansky-Kuster-HauserSyndrome (utero-vaginal agenesis) 15% of primaryamenorrhea Normal secondarydevelopment & e...
Testicular feminization syndrome Phenotype:female Genotype46xx Internal gentilia:no mullerinducts Male androgen level ...
11 OVARY Chromosomes Normal-– Menopause– Radiation/Chemo– Autoimmune Disorder– Infection Chromosomes Abnormal-– Primary ...
Turner syndrome” ovariandysgensis”
Streak gonads
III. ANTERIOR PITUITARY Prolactin Secreting Tumors Sheehan’s Syndrome
IV. CNS / HYPOTHALAMUS Weight loss, anorexia, stress, intense exercise Hypothyroidism – TRH/drugs which affectdopamine ...
Case 1: 17 yo female with primaryamenorrhea Normal pubertal development Normal health No family history of delayed pube...
Case 1: Physical Exam Thin young woman (10% below IBW) Normal genitalia No galactorrhea Tanner stage 4Laboratory value...
Case 1: Further historyPatient’s parents concerned about her eatinghabits (very low fat intake and restrictingcalories)
Diagnosis: Hypothalamic Amenorrhea Etiology is most likely inadequate caloric andfat intake. Patient should be referred ...
Case 2: 24 yo woman with secondaryamenorrhea Menarche at age 12 Periods have always been irregular Now c/o amenorrhea x...
Case 2: Physical Exam Obese female Acne Normal genitalia Mild hirsutism
Case 2: Laboratory findings Urine B-HCG negative TSH, FSH and Prolactin wnl Testosterone 180 ng/dL Pelvic U/S findings...
Laparoscopic &U/S findings inPCOS
Case 3: 29 yo woman with 18-month h/oamenorrhea Normal development No family history of amenorrhea Does not exercise ex...
Case 3: Physical Exam WDWN young woman Normal exam No galactorrhea
Case 3: Laboratory findings Urine B-HCG negative Prolactin wnl TSH, FSH, LH all wnl
Case 3: Further work-up Fails Provera challenge Fails 1-month trial of estrogen + progesterone Pelvic U/S shows no uter...
Case 4 A 24-year-old G2 P2 woman delivered vaginally8 months previously. Her delivery was complicated by postpartumhemor...
 She denies taking medications or havingheadaches or visual abnormalities. Her pregnancy test is negative. She was not ...
 A 19-year-old G1 p1 woman underwent a uterinecurettage after amiscarriage. She has had nomenses since then and is not pr...
 A 24-year-old G1 P1 woman is seen in the officewith secondary amen-orrhea after her delivery.She is given a diagnosis of...
 A 32-year-old G2 P1 woman presents to thegynecologist’s office with secondary amenorrhea of8 months’ duration. She had n...
 A 25-year-old woman presents with a 6-monthhistory of amenorrhea.Her pregnancy test isnegative. She is evaluated for oth...
Case 5A 30-year-old parous woman notes a waterybreast discharge of 6 months’ duration. Her menses have been somewhat irre...
On examination ,She appears alert and in good health. Blood pressure (BP) is 120/80 mm Hg, andheart rate (HR) is 80 (bpm...
 What is the most likely diagnosis? Galactorrhea due to hypothyroidism. ➤ What is your next step? Check serum prolacti...
 A 25-year-old woman presents with galactorrheaand irregular menses of 10 months duration. Her pregnancy test is negativ...
 A 38-year-old woman is seen by her physicianbecause of headaches,amenorrhea, and galactorrhea. Her pregnancy test was n...
 A 47-year-old woman is being evaluated for apossible pituitary tumor. She complains of headaches and some visualdifficu...
 A 33-year-old woman with a microadenoma of thepituitary gland becomes pregnant.,When she reaches 28 weeks’ gestationshe ...
Case 6 A 33-year-old woman complains of 7 months ofamenorrhea following a spontaneous abortion. She had a dilation and c...
 A 33-year-old woman complains of 7 months ofamenorrhea following a spontaneous abortion.She had a dilation and curettage...
 Her general physical examina-tion isunremarkable. The thyroid is normal to palpation, and breastsare without discharge....
 What is the most likely diagnosis? Intrauterine adhesions (IUA):Ashermansyndrome ➤ What is the next test to confirm t...
 A 34-year-old woman states that she has had nomenses since she had a uterine curettage andcone biopsy of the cervix 1 ye...
 Which of the following is the most likelyetiology of second-ary amenorrhea? A. Hypothalamic etiology B. Pituitary etio...
 A 29-year-old woman G2 P0 underwent anevaluation for amenorrhea of 10 months duration. Her menses had been regular prev...
 Which of the following statements is mostaccurate?A. Her condition usually occurs after uterinecurettage for a pregnancy...
 A 32-year-old G1 P1 woman presents with an 8-month history of amenorrhea. A pregnancy testis negative. TSH and prolactin...
 A 41-year-old woman is suspected of havingintrauterine adhesions because she has hadirregular menses since a spontaneous...
CASE 7 . A 17-year-old nulliparous adolescent femalecomplains that she has not yet started menses She denies weight loss...
On examination She is 5 ft 6 in tall and weighs 140 lb. Her bloodpressure is 110/60 mm Hg. Her thyroid gland is normal o...
 What is the most likely diagnosis? Müllerian (or vaginal) agenesis. ➤ What is the next step in diagnosis? Serum testo...
 An 18-year-old nulliparous adolescent femalecomplains of not having started her menses. Her breast development is Tanne...
 A 20-year-old G0 P0 woman is told by herdoctor that there is a strong probability that hergonads will turn malignant. S...
 A 19-year-old girl has primary amenorrhea,Tanner stage IV breast development, and apelvic kidney. Which of the followin...
 Which of the following is the best explanationfor breast development in a patient withandrogen insensitivity? A. Gonada...
 A 15-year-old adolescent female is brought intothe pediatrician due to absence of breastdevelopment and short stature. ...
Thank you
How to approch a case of amenorrhea
How to approch a case of amenorrhea
How to approch a case of amenorrhea
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Undergraduate course lectures in Obstetrics&Gynecology -PREPARED BY DR MANAL BEHERY -FECULTY OF MEDICINE ,ZAGAZIG UNIVERSITY

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How to approch a case of amenorrhea

  1. 1. How to approach a case ofamenorrheaDr Manal BeheryAssistant professorZAGAZIG University 2013Dr Manal BeheryAssistant professorZAGAZIG University 2013
  2. 2. “Doctor, I’m not getting my period”(blank, like no period……)
  3. 3. Amenorrhea:“absence of menses” Normal cycle is 28 days This occurs in 15% of cycles Normal Highest rate of anovulatory cycles <20 or >40yo age Average duration 4-6 days (3-8 normal) Average blood loss per cycle = 30 ml.– > 80 ml. Leads to risk for anemiaMenarche age 129years16years
  4. 4. Menstrual cycleSource Undetermined
  5. 5. PRIMARY AMENORRHEA Patient has never menstruated– No period by age 14 with no secondarysexual characteristics– No period by age 16 regardless ofsecondary sexual characteristics
  6. 6. SECONDARY AMENORRHEA– absence of menses in women who previouslyhad menses.– Absence must be for> 3 cycles according to certain sources> 6 months according to most sources
  7. 7. ALWAYS RULE OUTPREGNANCY!!!!!!!No matter WHAT!!!Then evaluate the four parts of thesystem
  8. 8. Don’t forget PREGNANCY!Is the Most common cause of secondaryamenorrhea Consider each level of the control of themenstrual cycle:– Hypothalamus– Pituitary– Ovary– Uterus– Cervix– VaginaInvolved structurally in the outflow ofmenstrual bloodInvolved in endocrine regulation ofthe menstrual cycleResponds to endocrine cues fromthe HPG axis
  9. 9. The Hypothalamic-Pituitary-OvarianAxishttp://www.shen-nong.com/eng/images/exam/missedperiods/img_mp1a.gif
  10. 10. REASONS FOR AMENORRHEA Pregnancy Menopause Thyroid/Prolactin Disorders Anovulation Outflow obstruction CNS/hypothalamic dysfunction Drugs/Stress/Nutrition Chromosomal/Abnormal Sexual Differentiation
  11. 11. STEP ONE –will diagnose pregnancy, thyroid disorder,hypoprolactinemia and anovulation LABS– Beta hcg– TSH– Prolactin MEDS– Progestin challenge {If galactorrhea, obtain MRI ofpituitary/sella turcica}
  12. 12. STEP TWO –will diagnose outflow tractobstruction Give estrogen “priming”, followed by progestin– Estrogen x 21 days– Add progesterone for the last 5 days
  13. 13. STEP 3- will determine if lack ofestrogen is due to ovarian failurevs. altered CNS/pituitary axisFSH(LH)
  14. 14. I. UTERUS – VAGINA –OUTFLOW TRACT Asherman’s – secondary amenorrhea Imperforate hymen – primary amenorrhea Vaginal septum – primary amenorrhea Agenesis – primary amenorrhea Testicular feminization – primary amenorrhea
  15. 15. Asharman syndrome(intrauterinesynechea)
  16. 16. Imperforate Hymen
  17. 17. Transverse Vaginal Septum
  18. 18. Mayer-Rokitansky-Kuster-HauserSyndrome (utero-vaginal agenesis) 15% of primaryamenorrhea Normal secondarydevelopment & externalfemale genitalia Normal female rangetestosterone level Absent uterus and uppervagina & normal ovaries Karyotype 46-XX 15-30% renal, skeletal andmiddle ear anomalies
  19. 19. Testicular feminization syndrome Phenotype:female Genotype46xx Internal gentilia:no mullerinducts Male androgen level 7.8nglml
  20. 20. 11 OVARY Chromosomes Normal-– Menopause– Radiation/Chemo– Autoimmune Disorder– Infection Chromosomes Abnormal-– Primary Amenorrhea– Premature Menopause
  21. 21. Turner syndrome” ovariandysgensis”
  22. 22. Streak gonads
  23. 23. III. ANTERIOR PITUITARY Prolactin Secreting Tumors Sheehan’s Syndrome
  24. 24. IV. CNS / HYPOTHALAMUS Weight loss, anorexia, stress, intense exercise Hypothyroidism – TRH/drugs which affectdopamine Anovulation Hypothalamic Suppression
  25. 25. Case 1: 17 yo female with primaryamenorrhea Normal pubertal development Normal health No family history of delayed puberty Not involved in athletics Does well in school Not taking any meds
  26. 26. Case 1: Physical Exam Thin young woman (10% below IBW) Normal genitalia No galactorrhea Tanner stage 4Laboratory values Urine and serum B-HCG negative Prolactin, FSH, TSH all normal
  27. 27. Case 1: Further historyPatient’s parents concerned about her eatinghabits (very low fat intake and restrictingcalories)
  28. 28. Diagnosis: Hypothalamic Amenorrhea Etiology is most likely inadequate caloric andfat intake. Patient should be referred for evaluation for aneating disorder. Chances of normal menstruation are very goodif patient takes in adequate calories.
  29. 29. Case 2: 24 yo woman with secondaryamenorrhea Menarche at age 12 Periods have always been irregular Now c/o amenorrhea x 10 months Overweight Wants to get pregnant
  30. 30. Case 2: Physical Exam Obese female Acne Normal genitalia Mild hirsutism
  31. 31. Case 2: Laboratory findings Urine B-HCG negative TSH, FSH and Prolactin wnl Testosterone 180 ng/dL Pelvic U/S findings show polycystic ovaries
  32. 32. Laparoscopic &U/S findings inPCOS
  33. 33. Case 3: 29 yo woman with 18-month h/oamenorrhea Normal development No family history of amenorrhea Does not exercise excessively or restrict diet Denies galactorrhea Has h/o SAB with subsequent D & C
  34. 34. Case 3: Physical Exam WDWN young woman Normal exam No galactorrhea
  35. 35. Case 3: Laboratory findings Urine B-HCG negative Prolactin wnl TSH, FSH, LH all wnl
  36. 36. Case 3: Further work-up Fails Provera challenge Fails 1-month trial of estrogen + progesterone Pelvic U/S shows no uterine stripe Hysteroscope confirms diagnosis of…Asherman’s Syndrome
  37. 37. Case 4 A 24-year-old G2 P2 woman delivered vaginally8 months previously. Her delivery was complicated by postpartumhemorrhage requiring curettage of the uterus anda blood transfusion of two units of erythro-cytes. She complains of amenorrhea since her delivery.
  38. 38.  She denies taking medications or havingheadaches or visual abnormalities. Her pregnancy test is negative. She was not able to breast-feed her baby ➤ What is the most likely diagnosis? Sheehan syndrome (anterior pituitarynecrosis). ➤ What are other complications that are likelywith this condition? Hypothyroidism or adrenocorticalinsufficiency
  39. 39.  A 19-year-old G1 p1 woman underwent a uterinecurettage after amiscarriage. She has had nomenses since then and is not pregnant.The physician is suspecting intrauterine adhesions. Which of the following is a feature ofintrauterine synechiae (Asherman syndrome)? A. Usually occurs after uterine curettage B. Associated with low gonadotropin levels C. Associated with a monophasic basal bodytemperature chart D. Associated with low cortisol level
  40. 40.  A 24-year-old G1 P1 woman is seen in the officewith secondary amen-orrhea after her delivery.She is given a diagnosis of pituitary necrosis(Sheehan syndrome). Which of the following is consistent with herpresumed diagnosis? A. Usually associated with hypertensive crisis ator soon after a delivery B. Is caused by an ischemic necrosis of theposterior pituitary gland C. Is associated with decreased prolactin levels D. Is often associated with elevated TSH levels
  41. 41.  A 32-year-old G2 P1 woman presents to thegynecologist’s office with secondary amenorrhea of8 months’ duration. She had normal and regularmenses before this time. And diagnosed as intrauterine adhesions Which ofthe following is the best description of themechanism of intrauterine synechiae A. Trophoblastic hyperplasia B. Pituitary engorgement C. Myometrial scarring D. Endometrial hypertrophy E. Disruption of large segments of the endometrium
  42. 42.  A 25-year-old woman presents with a 6-monthhistory of amenorrhea.Her pregnancy test isnegative. She is evaluated for other causes ofsecondary amenorrhea, and diagnosised as (PCOS) . Which of the following is consistent with thisdisorder? A. Estrogen deficiency and vaginal atrophy B. Osteoporosis C. Endometrial hyperplasia D. Hypoglycemia E. A history of regular menses each month prior to 6months
  43. 43. Case 5A 30-year-old parous woman notes a waterybreast discharge of 6 months’ duration. Her menses have been somewhat irregular. She denies a family history of breast cancer. The patient had been treated previously withradioactive iodine for Graves disease. Currently, she is not taking any medications.
  44. 44. On examination ,She appears alert and in good health. Blood pressure (BP) is 120/80 mm Hg, andheart rate (HR) is 80 (bpm). Breasts are symmetric and without masses.No skin retraction is noted. A white discharge can be expressed from bothbreasts. No adenopathy is appreciated. The pregnancy test is negative.
  45. 45.  What is the most likely diagnosis? Galactorrhea due to hypothyroidism. ➤ What is your next step? Check serum prolactin and TSH levels ➤ What is the likely mechanism for this disorder? Hypothyroidism is associated with an elevatedthyroid-releasing hormone (TRH) level, whichacts as a prolactin-releasing hormone.
  46. 46.  A 25-year-old woman presents with galactorrheaand irregular menses of 10 months duration. Her pregnancy test is negative. Laboratory tests reveal normal TSH and serum-free T4 and hyperprolactinemia. Which of the following is most likely to be acause of her condition? A. Posterior pituitary adenoma B. Abdominal wall trauma C. Psychotropic medication D. Hyperthyroidism
  47. 47.  A 38-year-old woman is seen by her physicianbecause of headaches,amenorrhea, and galactorrhea. Her pregnancy test was negative. prolactin level wasmarkedly elevated and TSH was normal. A diagnosis of pituitary adenoma and an MRI of thebrain was orderd . Which of the following clinical presentations is con-sistent with a prolactin-secreting pituitary adenoma? A. Diabetes insipidus B. Occipital cerebral defect C. Central field visual defect D. Amenorrhea due to inhibition of gonadotropin-releasing hormone pulsations
  48. 48.  A 47-year-old woman is being evaluated for apossible pituitary tumor. She complains of headaches and some visualdifficulties. The MRI shows a mass in the posterior pituitarygland Which of the following is a hormone contained inthe posterior pituitary gland? A. Follicle-stimulating hormone (FSH) B. Prolactin C. Thyroid-stimulating hormone (TSH) D. Oxytocin
  49. 49.  A 33-year-old woman with a microadenoma of thepituitary gland becomes pregnant.,When she reaches 28 weeks’ gestationshe complains of headaches and visualdisturbances. Which of the following is the best therapy? A. Craniotomy and pituitary resection B. Tamoxifen therapy C. Oral bromocriptine therapy D. Expectant management E. Lumbar puncture
  50. 50. Case 6 A 33-year-old woman complains of 7 months ofamenorrhea following a spontaneous abortion. She had a dilation and curettage (D and C) atthat time. Her past medical and surgical histories areunremarkable. menarche at age 11 years and her menseshave been every 28 to 31 days until recently
  51. 51.  A 33-year-old woman complains of 7 months ofamenorrhea following a spontaneous abortion.She had a dilation and curettage (D and C) atthat time. Her past medical and surgical histories areunremarkable. menarche at age 11 years and her menseshave been every 28 to 31 days until recently
  52. 52.  Her general physical examina-tion isunremarkable. The thyroid is normal to palpation, and breastsare without discharge. The abdomen is nontender. The pelvic examination shows a normal uterus,closed and normal-appearing cervix, and noadnexal masses. A pregnancy test is negative
  53. 53.  What is the most likely diagnosis? Intrauterine adhesions (IUA):Ashermansyndrome ➤ What is the next test to confirm the diagnosis?Hysterosalpingogram,.Hystroscopy
  54. 54.  A 34-year-old woman states that she has had nomenses since she had a uterine curettage andcone biopsy of the cervix 1 year previously. Since those surgeries,she complains of severe,crampy lower abdomi-nal pain “similar to laborpain” for 5 days of each month. Her basal body temperature chart is biphasic,rising 1°F for 2 weeks of every month.
  55. 55.  Which of the following is the most likelyetiology of second-ary amenorrhea? A. Hypothalamic etiology B. Pituitary etiology C. Uterine etiology D. Cervical condition
  56. 56.  A 29-year-old woman G2 P0 underwent anevaluation for amenorrhea of 10 months duration. Her menses had been regular previously. A pregnancy test, TSH, prolactin level, FSH, andLH levels were normal. The patient had sequential estrogen andprogestin therapy without vaginal bleeding. Her presumptive diagnosis was intrauterineadhesions, which was con-firmed with imaging.
  57. 57.  Which of the following statements is mostaccurate?A. Her condition usually occurs after uterinecurettage for a pregnancy-related process.B. She would best be diagnosed by laparoscopy.C. The patient likely has cramping pain everymonth.D. Her treatment includes endometrial ablation
  58. 58.  A 32-year-old G1 P1 woman presents with an 8-month history of amenorrhea. A pregnancy testis negative. TSH and prolactin levelsare normal.The FSH level is elevated at 40 IU/L. Which of the following is the most likelycomplication for this patient? A. She is at significant risk for endometrialcancer. B. She is at increased risk for ovarian cancer. C. She is at increased risk for osteoporosis. D. She is at increased risk for multiplegestations.
  59. 59.  A 41-year-old woman is suspected of havingintrauterine adhesions because she has hadirregular menses since a spontaneous abortion18 months previously. Which of the following would support thisdiagnosis? A. Presence of hot flushes B. FSH level too low to be measurable C. Normal estradiol levels for a reproductive-aged woman D. Monophasic basal body temperature chart
  60. 60. CASE 7 . A 17-year-old nulliparous adolescent femalecomplains that she has not yet started menses She denies weight loss or excessive exercise. Each of her sisters achieved menarche by 13years of age. The patient’s mother recalls a doctor mentioningthat her daughter had a missing right kidney on anabdominal x-ray film.
  61. 61. On examination She is 5 ft 6 in tall and weighs 140 lb. Her bloodpressure is 110/60 mm Hg. Her thyroid gland is normal on palpation. Shehas Tanner stage IV breast development andfemale external genitalia. She has Tanner stage IV axillary and pubic hair.There are no skin lesions.
  62. 62.  What is the most likely diagnosis? Müllerian (or vaginal) agenesis. ➤ What is the next step in diagnosis? Serum testosterone, or karyotype
  63. 63.  An 18-year-old nulliparous adolescent femalecomplains of not having started her menses. Her breast development is Tanner stage V. Shehas a blind vaginal pouch and no cervix. Which ofthe following describes the most likely diagnosis? A. Müllerian agenesis B. Kallman syndrome C. Gonadal dysgenesis D. Polycystic ovarian syndrome
  64. 64.  A 20-year-old G0 P0 woman is told by herdoctor that there is a strong probability that hergonads will turn malignant. She has not had a menses yet. She has Tannerstage I breast development. Which of the following describes the most likelydiagnosis? A. Müllerian agenesis B. Androgen insensitivity C. Gonadal dysgenesis D. Polycystic ovarian syndrome
  65. 65.  A 19-year-old girl has primary amenorrhea,Tanner stage IV breast development, and apelvic kidney. Which of the following describes the most likelydiagnosis? A. Müllerian agenesis B. Androgen insensitivity C. Gonadal dysgenesis D. Polycystic ovarian syndrome
  66. 66.  Which of the following is the best explanationfor breast development in a patient withandrogen insensitivity? A. Gonadal production of estrogens B. Adrenal production of estrogen C. Breast tissue sensitivity to progesterone D. Peripheral conversion of androgens E. Autonomous production of breast-specificestrogen
  67. 67.  A 15-year-old adolescent female is brought intothe pediatrician due to absence of breastdevelopment and short stature. A karyotype is performed which reveals 46 XY. Which of the following is the most likelydiagnosis? A. Androgen insensitivity C. Gonadal dysgenesis B. Kallmann syndrome C. Testicular atrophy syndrome
  68. 68. Thank you

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