27.Amenorrhea

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27.Amenorrhea

  1. 1. Amenorrhea Zhanghuiying Department Of Obstetrics & Gynecology Tianjin Medical University General Hospital
  2. 2. Definition ★ <ul><li>Amenorrhea is the absence of menstruation. </li></ul><ul><li>Primary Amenorrhea </li></ul><ul><ul><li>Absence of menses by age 16 with normal secondary sexual characteristics. </li></ul></ul><ul><ul><li>Absence of menses by age 14 without secondary sexual development. </li></ul></ul><ul><li>Secondary Amenorrhea </li></ul><ul><ul><li>Absence of menses for 6 months in a previously menstruating female or 3 normal intervals in a woman with oligomenorrhea. </li></ul></ul>
  3. 3. Events of Puberty <ul><li>Thelarche (breast development) </li></ul><ul><ul><li>Requires estrogen </li></ul></ul><ul><li>Pubarche/adrenarche (pubic hair development) </li></ul><ul><ul><li>Requires androgens </li></ul></ul><ul><li>Menarche ( the first menses) </li></ul><ul><ul><li>Requires: </li></ul></ul><ul><ul><li>GnRH from the hypothalamus </li></ul></ul><ul><ul><li>FSH and LH from the pituitary </li></ul></ul><ul><ul><li>Estrogen and progesterone from the ovaries </li></ul></ul><ul><ul><li>Normal outflow tract </li></ul></ul>
  4. 4. Possible results of amenorrhea <ul><li>Cannot conceive </li></ul><ul><li>Lead to osteoporosis and genital atrophy </li></ul><ul><li>Increased endometrial hyperplasia which can increase the possibility of endometrial carcinoma from unopposed estrogen secretion </li></ul><ul><li>Without secondary sexual characteristics may give rise to major social and psychosexual problems. </li></ul>
  5. 5. Classification of amenorrhea <ul><li>hypothalamic amenorrhea </li></ul><ul><li>pituitary amenorrhea </li></ul><ul><li>ovarian amenorrhea </li></ul><ul><li>uterine amenorrhea </li></ul>
  6. 6. Etiology - hypothalamic amenorrhea <ul><ul><li>Psychological stress </li></ul></ul><ul><ul><li>Anorexia nervosa, weight loss </li></ul></ul><ul><ul><li>Increased exercise levels </li></ul></ul><ul><ul><li>Kallmann syndrome -congenital absence of GnRH </li></ul></ul><ul><ul><li>drug-induced amenorrhea: anti-psychotics, reserpine, Contracepti ve </li></ul></ul><ul><ul><li>Space-occupying lesion of CNS </li></ul></ul>
  7. 7. Weight-related amenorrhoea Anorexia Nervosa <ul><li>A body mass index (BMI) <17 kg/m ²  menstrual irregularity and amenorrhea </li></ul><ul><li>Hypothalamic suppression </li></ul><ul><li>Mean age onset 13-14 yrs (range 10-21 yrs) </li></ul><ul><li>Low estradiol  risk of osteoporosis </li></ul>
  8. 8. Exercise-associated amenorrhoea <ul><li>Common in women who participate in sports (e.g. competitive athletes, ballet dancers) </li></ul><ul><li>Eating disorders have a higher prevalence in female athletes than non-athletes </li></ul><ul><li>Hypothalamic disorder caused by abnormal gonadotrophin-releasing hormone pulsatility, resulting in impaired gonadotrophin levels, particularly LH, and subsequently low estrogen levels </li></ul>
  9. 9. Contraception related amenorrhea <ul><li>Post-pill amenorrhea is not an entity </li></ul><ul><li>Depot medroxyprogesterone acetate </li></ul><ul><li>Up to 80 % of women will have amenorrhea after 1 year of use. It is reversible (estrogen deficiency) </li></ul><ul><li>A minority of women taking the progestogen-only pill may have reversible long term amenorrhoea due to complete suppression of ovulation </li></ul>
  10. 10. Etiology - pituitary amenorrhea <ul><ul><li>tumor </li></ul></ul><ul><ul><li>Empty sella syndrome </li></ul></ul><ul><ul><li>Sheehan syndrome </li></ul></ul>
  11. 11. Sheehan ’s syndrome <ul><li>Pituitary inability to secrete gonadotropins </li></ul><ul><li>Pituitary necrosis following massive obstetric hemorrhage is most common cause in women </li></ul><ul><li>Diagnosis : History and  E2,FSH,LH </li></ul><ul><li>+ other pituitary deficiencies ( TSH Thyroid Stimulating Hormone and ACTH adrenocorticotropic hormone ) </li></ul><ul><li>Treatment : </li></ul><ul><li>Replacement of deficient hormones </li></ul>
  12. 12. Etiology - ovarian amenorrhea <ul><li>◆ Gonadal dysgenesis </li></ul><ul><li>Chromosomally incompetent </li></ul><ul><li>- Classic turner ’s syndrome (45XO) </li></ul><ul><li>- Turner variants (45XO/46XX),(46X- abnormal X) </li></ul><ul><li>- Mixed gonadal dysgenesis (45XO/46XY) </li></ul><ul><li>Chromosomally competent </li></ul><ul><li>- 46XX (Pure gonadal dysgenesis ) </li></ul><ul><li>- 46XY (Swyer’s syndrome) </li></ul><ul><li>◆ resistant ovary syndrome </li></ul><ul><li>◆ Premature ovarian failure </li></ul><ul><li>◆ Polycystic ovary syndrome </li></ul>
  13. 13. Typical features of Turner’s Syndrome Sexual infantilism and short stature High FSH and LH levels. • Bilateral streaked gonads. • Karyotype - 80 % 45, X0 - 20% mosaic forms (46XX/45X0)
  14. 14. Turner’s syndrome ( Classic 45-XO) Mosaic (46-XX / 45-XO)
  15. 15. Ovarian dysgenesis streak gonad
  16. 16. Premature ovarian failure <ul><li>Manopause occurs before 40 years old. </li></ul><ul><li>Serum estradiol < 50 pg/ml and FSH > 40 IU/ml on repeated occasions </li></ul>
  17. 17. Etiology <ul><li>uterine amenorrhea </li></ul><ul><ul><li>Absence of uterus </li></ul></ul><ul><ul><li>Asherman syndrome </li></ul></ul><ul><li>anatomic abnormalities of the reproductive tract </li></ul><ul><ul><li>Imperforate Hymen </li></ul></ul>
  18. 18. Asherman’s syndrome <ul><li>History of pregnancy associated D&C </li></ul><ul><li>Rarely after CS , myomectomy T.B endometritis, </li></ul><ul><li>Diagnosis : HSG or hysterescopy </li></ul><ul><li>Treatment : lysis of adhesions; D&C or hysterescopy + estrogen therapy </li></ul>Hysterosalpingography Uterine synechiae
  19. 19. Imperforate Hymen
  20. 20. Mayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis) <ul><li>15% of primary amenorrhea </li></ul><ul><li>Normal secondary development & external female genitalia </li></ul><ul><li>Normal female range testosterone level </li></ul><ul><li>Absent uterus and upper vagina & normal ovaries </li></ul><ul><li>Karyotype 46-XX </li></ul><ul><li>15 ~ 30% renal, skeletal and middle ear anomalies </li></ul>
  21. 21. Androgen Insensitivity <ul><li>Normal breasts but no sexual hair </li></ul><ul><li>Normal looking female external genitalia </li></ul><ul><li>Absent uterus and upper vagina </li></ul><ul><li>Karyotype 46, XY </li></ul><ul><li>Male range testosterone level </li></ul><ul><li>Treatment : gonadectomy after puberty + HRT </li></ul>
  22. 22. congenital adrenal hyperplasia <ul><li>Autosomal recessive trait </li></ul><ul><li>Most common form is due to 21-hydroxylase deficiency </li></ul><ul><li>Mild forms Closely resemble PCO S </li></ul><ul><li>Severe forms show Signs of severe androgen excess </li></ul><ul><li>High 17-OH-progesterone blood level </li></ul><ul><li>abn ormal looking female external genitalia </li></ul><ul><li>Presence of uterus and upper vagina </li></ul><ul><li>Treatment : cortisol replacement and Corrective surgery </li></ul>
  23. 23. Other causes of Secondary Amenorrhea <ul><li>Pituitary disorders </li></ul><ul><ul><li>Hyperprolactinemia </li></ul></ul><ul><ul><ul><li>Prolactinoma </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><li>Renal failure </li></ul></ul></ul><ul><ul><li>Hypoprolactinemia </li></ul></ul><ul><ul><ul><li>Pituitary resection </li></ul></ul></ul><ul><ul><ul><li>Sheehan’s syndrome </li></ul></ul></ul><ul><li>Thyroid disorders </li></ul><ul><ul><li>Hyper- or hypothyroidism </li></ul></ul>
  24. 24. Diagnosis of Amenorrhea
  25. 25. Diagnosis <ul><li>History </li></ul><ul><li>Physical examination </li></ul><ul><ul><li>Physical examination begins with vital signs, including height and weight, and with sexual maturity ratings </li></ul></ul><ul><li>Laboratory evaluation </li></ul>
  26. 26. Evaluation of Primary Amenorrhea <ul><ul><li>Physical exam to determine presence of uterus </li></ul></ul><ul><ul><li>FSH </li></ul></ul><ul><ul><li>Karyotype </li></ul></ul>
  27. 27. Primary Amenorrhea <ul><li>Is there normal development of secondary sexual characteristics? </li></ul><ul><li>NO </li></ul><ul><li>Think hypogonadism or hypogonadotropism </li></ul>
  28. 28. Amenorrhea with Immature Secondary Characteristics FSH Serum level Low / normal High Hypogonadotropic hypogonadism Gonadal dysgenesis
  29. 29. Hypogonadism (gonadal failure) <ul><li>Gonadal dysgenesis </li></ul><ul><li>Chromosomally abnormal </li></ul><ul><li>- Classic T urner ’s syndrome (45XO) </li></ul><ul><li>- Turner variants (45XO/46XX),(46X-abnormal X) </li></ul><ul><li>- Mixed gonadal dysgenesis (45XO/46XY ) </li></ul><ul><li>Chromosomally normal </li></ul><ul><li>- 46XX (Pure gonadal dysgenesis ) </li></ul><ul><li>- 46XY (Swyer’s syndrome ) </li></ul><ul><li>Irradiation </li></ul><ul><li>Chemotherapy </li></ul><ul><li>galactosemia </li></ul><ul><li>Note: gonadotropins (FSH/LSH) will be high, similar to menopause </li></ul>
  30. 30. Hypogonadotropism <ul><ul><li>Hypothalamic dysfunction </li></ul></ul><ul><ul><ul><li>Kallmann’s syndrome </li></ul></ul></ul><ul><ul><ul><li>Anorexia nervosa </li></ul></ul></ul><ul><ul><ul><li>Space-occupying lesion of CNS </li></ul></ul></ul><ul><ul><li>Pituitary damage (surgery/radiation) </li></ul></ul><ul><ul><li>Constitutional delay </li></ul></ul>
  31. 31. Primary Amenorrhea <ul><li>Is there normal development of secondary sexual characteristics? </li></ul><ul><li>YES </li></ul><ul><li>Think </li></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Mullerian anomaly </li></ul></ul><ul><ul><li>Androgen insensitivity </li></ul></ul>
  32. 32. Mullerian Anomalies <ul><ul><li>Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome) </li></ul></ul><ul><ul><li>Imperforate hymen </li></ul></ul><ul><ul><li>Transverse vaginal septum </li></ul></ul>
  33. 33. Evaluation of Secondary Amenorrhea <ul><li>History </li></ul><ul><ul><li>Nutrition/exercise habits, weight change </li></ul></ul><ul><ul><li>Sexual/contraceptive practice </li></ul></ul><ul><ul><li>History of uterine/cervical surgery </li></ul></ul><ul><li>Physical exam </li></ul><ul><ul><li>Height/weight </li></ul></ul><ul><ul><li>Hirsutism </li></ul></ul><ul><ul><li>Galactorrhea </li></ul></ul><ul><ul><li>Estrogen status of tissues </li></ul></ul><ul><li>Laboratory </li></ul><ul><ul><li>hCG  PRL & TSH  progesterone challenge  FSH  if high  karyotype </li></ul></ul>
  34. 34. Negative Pregnancy.test TSH ,PROLACTIN, Progesterone 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’s FSH low . repeat Repeat+serum estrogen level PreOvFailure hypothalamic-pituitary failure anovulation Procedures of Diagnosis Secondary Amenorrhea
  35. 35. Treatment -- Selfstudy <ul><li>treatment varies depending upon the causes of the amenorrhea. </li></ul>

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