The document provides a comprehensive overview of amenorrhea, including its definition, types (primary and secondary), common causes, symptoms, diagnosis, treatment options, and the role of pharmacists in patient care. It emphasizes the significance of early diagnosis and treatment while detailing case studies of patients with amenorrhea due to anorexia nervosa and Turner syndrome. Lifestyle changes and the importance of a balanced diet are also highlighted as crucial factors in managing the condition.

1. Topic :
Amenorrhea
Presented by :
Muhammad Abdullah

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The learning objectives:
 Understanding of what amenorrhea is?
 Awareness of the common signs and symptoms.
 Explanation of causes.
 Importance of early diagnosis and treatment.
 Role of the pharmacist.
 Importance of lifestyle changes.
 Explanation of treatment options.
 Case Study.

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Definition:
Amenorrhea is a condition where a woman stops having menstrual
periods.
• Menstrual periods are a normal part of a woman's reproductive cycle and
they occur as a result of hormonal changes in the body.
• However, if a woman stops having menstrual periods for an extended
period of time, she may be diagnosed with amenorrhea.
Types:
There are two types of amenorrhea:
1. Primary Amenorrhea
2. Secondary Amenorrhea

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Primary Amenorrhea:
Primary amenorrhea occurs when a young woman has never had a
menstrual period by the age of 16.
Primary amenorrhea refers to the absence of menarche by age 16 years with
normal pubertal development, by 2 years after completed sexual
maturation, or by age 14 years without the onset of pubertal development
(delayed puberty).
Secondary Amenorrhea:
Secondary amenorrhea occurs when a woman who has previously had
menstrual periods stops having them for a period of at least six months.
Secondary amenorrhea refers to the absence of menstruation for three cycle
lengths in the setting of oligo menorrhea, 6 months after establishing
regular menses, or by 18 months after menarche.

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Sign and Symptoms:
Absence of menstrual periods for an extended period of time is the
most common symptom of amenorrhea.
However, there are other symptoms that may be present as well, such as
• Infertility,
• Hot flashes,
• Headaches,
• Mood swings, and
• Vaginal dryness.
These symptoms can be indicative of a health issue and it is important
for a woman to seek medical attention if she experiences any of them. Early
diagnosis and treatment can help prevent long-term health consequences
and improve overall health.

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Differential Diagnosis:
• Polycystic ovary syndrome (PCOS)
• Thyroid disorders
• Pituitary tumors
• Stress and weight changes
Clinical Findings:
• Pelvic exam to rule out structural abnormalities
• Hormonal tests (such as FSH, LH, and estradiol levels)
• Ultrasound to evaluate the uterus and ovaries
• Pregnancy test

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Causes:
There are several causes of amenorrhea, including;
• Pregnancy,
• Breastfeeding,
• Menopause,
• Hormonal imbalances,
• Structural abnormalities, and
• Weight changes.
Pregnancy is a natural cause of amenorrhea, as menstrual periods stop
during pregnancy.
Similarly, breastfeeding can also cause amenorrhea, as the hormone levels
needed for lactation can prevent ovulation and the menstrual cycle.

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Menopause is another common cause of amenorrhea, as it marks the end of
a woman's reproductive years and the cessation of her menstrual cycle.
Hormonal imbalances, such as those caused by thyroid disorders, can also
lead to amenorrhea.
In some cases, structural abnormalities, such as congenital malformations
of the reproductive system, can cause amenorrhea.
Weight changes, such as significant weight loss or weight gain, can also
affect the menstrual cycle and lead to amenorrhea.
Increased stress lowers progesterone which alters the function reproduction.
Increased exercise after morning increases cortisol levels artificially which
causes suppression of reproduction cycle.

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Diagnosis:
Amenorrhea is diagnosed by a healthcare provider based on the absence of
menstrual periods for an extended period of time.The first step in the
diagnosis process is to take a thorough medical history, including information
about the woman's menstrual cycle and any associated symptoms.
Next, a physical examination is performed to check for any physical
abnormalities that may be contributing to the amenorrhea.This may include a
pelvic exam to check for any structural issues, such as fibroids or polyps.
To further assess the cause of the amenorrhea, the healthcare provider may
order additional tests, such as a pregnancy test, blood tests to check hormone
levels, and imaging tests, such as an ultrasound.
Based on the results of these tests, the healthcare provider can determine the
underlying cause of the amenorrhea and make recommendations for
treatment.

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Management and treatment:
Amenorrhea can be managed and treated in a number of ways, depending
on the underlying cause.
Hormonal therapy: Hormonal therapy may be used to regulate the menstrual
cycle and restore normal hormone levels.This may include birth control pills,
hormonal injections, or hormonal patches.
Surgery: In some cases, surgery may be recommended to correct structural
abnormalities that are causing the amenorrhea, such as fibroids or polyps.
Hormone replacement therapy (HRT): HRT may be recommended for women
experiencing menopause-related amenorrhea. HRT can help relieve symptoms
such as hot flashes and vaginal dryness.

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Lifestyle changes: Making changes to your diet and increasing physical
activity can help regulate your menstrual cycle and manage amenorrhea.
Weight loss, in particular, can help restore hormonal balance and improve
overall health.
Herbal remedies: Some women may choose to use herbal remedies, such as
chasteberry, to manage amenorrhea. However, it's important to discuss this
option with a healthcare provider, as herbal remedies can interact with other
medications and may not be appropriate for everyone.

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Role of the Pharmacist:
The role of the pharmacist is to work with the healthcare team to provide
comprehensive care for patients. Important aspects of this care include;
Medication management: Pharmacists are trained to manage medication
therapy, ensuring that patients receive the correct medications, in the correct
doses, and at the correct times.
Monitoring drug interactions and adverse effects: Pharmacists monitor drug
interactions and adverse effects, and inform patients and their healthcare
providers of any potential risks or side effects.

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Patient education: Pharmacists provide patients with important information
about their medications, including how to properly take them, what to expect,
and what to do in case of adverse effects or emergencies.
Collaboration with the healthcare team: Pharmacists work closely with
physicians, nurses, and other healthcare providers to provide comprehensive
care for patients with amenorrhea.
Support with lifestyle changes: Pharmacists can provide support and advice
on lifestyle changes that may help manage the symptoms of amenorrhea,
such as changes in diet and exercise.

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The role of lifestyle changes in managing health:
Lifestyle changes, such as weight loss and exercise, can play a crucial role in
managing amenorrhea.
For example, women who are overweight or obese may experience irregular
menstrual periods or stop having periods altogether. By losing weight through
a healthy diet and regular exercise, women may be able to regain regular
menstrual cycles.
In addition to weight loss, exercise can also help improve overall health and
reduce symptoms associated with amenorrhea, such as mood swings, hot
flashes, and headaches. Exercise can also improve overall well-being and
reduce stress, which can also have a positive impact on menstrual cycles.

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A balanced diet that includes a variety of nutrient-rich foods can help
support overall health and improve menstrual regularity.
By making positive lifestyle changes, women can improve their overall
health, reduce symptoms associated with amenorrhea, and potentially
regain regular menstrual cycles.

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Case Study:
Case Study-I: Amenorrhea in a 25-year-old Female
Patient Background: A 25-year-old female presents to her gynecologist
complaining of absence of menstrual periods for the past six months. She
reports normal menstrual cycles in the past and has never experienced this
type of problem before.
Medical History: The patient has a history of anorexia nervosa and reports a
significant weight loss over the past year, currently weighing only 35 kg. She
also reports irregular sleeping patterns and intense exercise regimen.The
patient denies any use of hormonal contraceptives or any other medications.
Physical Exam: Upon physical examination, the patient is found to be
underweight with a body mass index (BMI) of 15.5. Her pelvic examination is
within normal limits and her vital signs are stable.

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Diagnostic Work-Up:The patient underwent a series of diagnostic tests
including a complete blood count, thyroid-stimulating hormone (TSH) test,
follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels, and a
prolactin level. All tests came back within normal limits except for a low FSH
level of 3 mIU/mL (normal range being 10-20 mIU/mL).
Diagnosis: Based on the patient's medical history, physical examination, and
diagnostic tests, the patient was diagnosed with secondary amenorrhea due
to hypothalamic amenorrhea secondary to anorexia nervosa.
Treatment:The patient was advised to start a gradual weight gain program
and was referred to a nutritionist for dietary counseling. She was also advised
to reduce her exercise regimen and improve her sleep patterns. Hormonal
therapy with a combination of estrogen and progesterone was initiated to
induce menstrual cycles.The patient was also referred to a psychologist for
support and management of her anorexia nervosa.

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Outcome:The patient showed a gradual improvement in her weight and
menstrual cycles over the next several months. She was able to resume
normal activities and maintain regular menstrual cycles with continued
hormonal therapy.The patient was also able to manage her anorexia nervosa
with psychological support.
Questions:
 What was the main complaint of the patient in this case study?
A. Absence of menstrual periods for the past six months
B. Presence of menstrual periods for the past six months
C. Irregular menstrual cycles for the past six months
D. Heavy menstrual cycles for the past six months

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 What was the patient's BMI at the time of physical examination?
A. 15.5
B. 25
C. 30
D. 35
 What was the most likely cause of the patient's amenorrhea in this case
study?
A. Anorexia nervosa
B. Hypothalamic amenorrhea
C. Polycystic ovary syndrome (PCOS)
D. Endometrial cancer

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 What type of hormonal therapy was initiated to induce menstrual cycles
in the patient?
A. Progesterone only
B. Estrogen only
C.Testosterone
D. A combination of estrogen and progesterone
 What was the outcome of the patient's treatment in this case study?
A.The patient showed no improvement in her menstrual cycles
B.The patient showed a gradual improvement in her menstrual cycles
C.The patient had a complete cessation of menstrual cycles
D.The patient had an increase in menstrual cycle irregularities

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 What is the mechanism of action of the combination of estrogen and
progesterone prescribed to induce menstrual cycles in this patient?
A. Increase in FSH and LH secretion
B. Increase in GnRH secretion
C. Suppression of FSH and LH secretion
D. Suppression of GnRH secretion
 What are the potential side effects of the combination of estrogen and
progesterone therapy in this patient?
A. Headache and nausea
B.Weight gain and breast tenderness
C. Acne and hirsutism
D. Depression and mood changes

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Case Study-II:
Case Study: Primary Amenorrhea in a 17-year-old Female
Patient Background: A 17-year-old female presents to her gynecologist
complaining of the absence of menstrual periods. She reports never having
had a menstrual cycle.
Medical History:The patient reports normal growth and development during
childhood. She denies any significant weight loss or gain, intense exercise
regimen, or use of hormonal contraceptives.
Physical Exam: Upon physical examination, the patient's vital signs are
stable and her pelvic examination reveals a uterus of normal size and no
palpable masses.

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Diagnostic Work-Up:The patient underwent a series of diagnostic tests
including a complete blood count, karyotyping, follicle-stimulating hormone
(FSH) and luteinizing hormone (LH) levels, and an MRI of the pelvis. All tests
came back within normal limits except for elevated FSH levels of 40 mIU/mL
(normal range being 5-25 mIU/mL).
Diagnosis: Based on the patient's medical history, physical examination, and
diagnostic tests, the patient was diagnosed with primary amenorrhea due to
gonadal dysgenesis (Turner syndrome).
Treatment:The patient was referred to a genetic counselor for further
evaluation and management ofTurner syndrome. Hormonal therapy with
estrogen and progesterone was initiated to induce menstrual cycles and
prevent osteoporosis.The patient was also advised to undergo regular
monitoring of her bone density and cardiovascular health.

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Outcome:The patient showed a gradual improvement in her menstrual
cycles with continued hormonal therapy. She was able to maintain regular
menstrual cycles and was monitored regularly for any potential
complications related toTurner syndrome.The patient was also able to
receive proper support and management of her condition with the help of
her healthcare team.
Questions:
 What was the main complaint of the patient in this case study?
A. Absence of menstrual periods
B. Presence of menstrual periods
C. Irregular menstrual cycles
D. Heavy menstrual cycles

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 What was the patient diagnosed with based on her medical history,
physical examination, and diagnostic tests?
A. Primary amenorrhea due to gonadal dysgenesis (Turner syndrome)
B. Secondary amenorrhea due to hypothalamic amenorrhea
C. Polycystic ovary syndrome (PCOS)
D. Endometrial cancer
 What was the patient's FSH level at the time of diagnostic testing?
A. 3 mIU/mL
B. 10 mIU/mL
C. 40 mIU/mL
D. 20 mIU/mL

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 What type of hormonal therapy was initiated to induce menstrual cycles in
the patient?
A. Progesterone only
B. Estrogen only
C.Testosterone
D. A combination of estrogen and progesterone
 What was the patient advised to undergo regularly for monitoring of her
health?
A. Bone density scans
B. Cardiovascular health evaluations
C. MRI of the pelvis
D. Complete blood count

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 What is the rationale for prescribing calcium andVitamin D supplements
in this patient with primary amenorrhea?
A.To improve bone density and prevent osteoporosis
B.To regulate menstrual cycles
C.To prevent cardiovascular disease
D.To improve overall health and wellbeing
 What type of contraceptive method would be most appropriate for this
patient to use while on hormone replacement therapy?
A. Barrier methods
B. Hormonal methods
C. Intrauterine devices (IUDs)
D. Natural family planning method

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ThankYou