10. Once Pregnancy and cryptomenorrhoea are excluded: The patient is a bioassay for Endocrine abnormalities Four categories of patients are identified 1. Amenorrhoea with absent or poor secondary sex Characters 2. Amenorrhoea with normal 2ry sex characters 3. Amenorrhoea with signs of androgen excess 4. Amenorrhoea with absent uterus and vagina
11. AMENORRHOEA Absent or poor secondary sex Characteristics FSH Serum level Low / normal High Hypogonadotropic hypogonadim Gonadal dysgenesis
12.
13. FSH Low / normal High Hypothalamic-pituitary Failure Ovarian failure If < 25 yrs or primary amenorrhea karyoptype If < 35 yrs R/O autoimmune disease ?? Ovarian biopsy head CT- scan or MRI - Severe hypothalamic dysfunction - Intracranial pathology
14. Amenorrhoea Utero-vaginal absence Karyotype 46- XX Mullerian Agenesis (MRKH syndrome) Androgen Insenitivity (TSF syndrome) . Gonadal regressioon . Testocular enzyme defenciecy . Leydig cell agenisis 46- XY Normal breasts & sexual hair Normal breasts & absent sexual hair Absent breasts & sexual hair