Amenorrhea class powerpoint

1. Amenorrhea
Dr Abenezer G.(R-2)
Moderator: Dr Amenu(Urogynecology and pelvic reconstructive
surgeon)
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2. OUTLINE
• NORMAL MENSTRUAL CYCLE
• CLASSIFICATION SYSTEM
• ANATOMIC DISORDERS
• HYPERGONADOTROPIC HYPOGONADISM
• HYPOGONADOTROPIC HYPOGONADISM
• EUGONADOTROPIC AMENORRHEA
• EVALUATION
• TREATMENT
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3. • Can be defined as primary (no prior menses) or secondary (cessation
of menses).
• Can also be physiologic( prior to puberty, during pregnancy ,lactation,
and following menopause) and pathologic ,3 to 4 percent.
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4. Evaluation indication
(1) No menstruation by age 15 or within 3 years of thelarche.
(2) No menstruation by age 14 and shows signs of hirsutism,
excessive exercise, or eating disorder.
(3) Secondary amenorrhea for 3 months or < 9cycles per
year.
 Stigmata of Turner syndrome, virilization, or a history of
uterine curettage.
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5. NORMAL MENSTRUAL CYCLE
• Ovarian function ,follicular phase (preovulatory), ovulation,
and luteal phase (postovulatory).
• Endometrial ,proliferative phase (preovulatory) and
secretory phase (postovulatory).
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6. • For menses to occur,there should be
 Actively coordinated HPA axis
 Responsive endometrium
 Patent out-flow tract
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7. CLASSIFICATION SYSTEM
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9. ANATOMIC DISORDERS
■ Inherited Disorders
• Can be inherited or acquired
disorders of the outflow tract
(uterus, cervix, vagina, and
introitus).
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10. Lower Outflow Tract Obstruction
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11. Mullerian Defects
• Can be partial or complete.
• In complete miillerian agenesis (MRKH) syndrome, 1 per
5000 ,examination reveals only a vaginal dimple.
• MRKH ranks second only to gonadal dysgenesis as a
cause of primary amenorrhea
 Complete mullerian agenesis Vs complete AIS!!!
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13. ■ Acquired Disorders
Cervical Stenosis ,CS
• Include cervical stenosis and extensive intrauterine adhesions.
• Involves the internal or external os.
• R/f : D & C, cervical conization, LEEP, infection,radiation and
neoplasia.
• SxS: amenorrhea , dysmenorrhea, and infertility.
• Management : reopen the os.
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14. Intrauterine Adhesions
• Also known as uterine synechiae and, when symptomatic,
Asherman syndrome.
• May follow vigorous curettage, abortion & IUD complicated by
infection ,other uterine surgery(metroplasty, myomectomy, C/D),
or tuberculous endometritis ,developing countries.
•Risks will rise with the number of D & C(1x -> 16 %,>3x -> 32 percent).
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15. CLASSIFICATION ,uptodate
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16. Ix and Mgt
• Hysterosalpingography (HSG) : uterine cavity and tube patency.
• Saline-infusion sonography (SIS) : irregular, angulated filling defects
within the cavity.
• Hysteroscopy : Definitive diagnosis!!
• Mgt Goals: To improve fertility rates or to relieve symptoms.
• Rx : hysteroscopic adhesions lysis.
: placement of a Foley catheter in the cavity after lysis.
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17. HYPERGONADOTROPIC HYPOGONADISM
POI
• Is loss of oocytes and surrounding
support cells prior to age 40.
• Dx : two serum FSH levels greater
than a threshold range of 30 to 40
mIU/mL.
• Sample obtained at least 1 month
apart.
• Incidence : 1 in 1000 younger than
30 years and 1 in 100 women
younger than 40.
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18. ■ Heritable Disorders
Gonadal Dysgenesis
• Most frequent cause of POI.
• Ovary is replaced by a fibrous streak- termed a streakgonad.
• 2 types: normal karyorype("pure" gonadal dysgenesis) and
abnormal karyotype
• 46,XY genotype + gonadal dysgenesis => Swyer syndrome.
• 90 percent ,never menstruate, but 10 percent ,experience menses
due to residual follicles.
• 25 percent will develop a malignant tumor If Y chromosome is found.
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19. Specific Genetic Defects
• Fragile X syndrome ,caused by a triple repeat sequence mutation
in the X-linked FMRJ (fragile X mental retardation) gene.
• Fully expanded mutation, >200 CGG repeats, mental retardation
and autism.
• Premutation, 50 to 200 CGG repeats,
Males-> fragile X- associated tremor/ataxia syndrome (FXTAS).
Females -> 13- to 26-percent risk of developing POI.
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20. • CYP 17 gene mutations, X-zed by absent cortisol, androgens,
and estrogens.
• Cause 1ry amenorrhea & sexual infantilism (lack breast
development, absent pubic and axillary hair, and a small uterus)
• Also raise ACTH release -> stimulate mineralocorticoid -> leads to
hypokalemia and hypertension.
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21. • Resistant ovary syndrome ,mutations in genes that encode LH and
FSH receptors.
• Perrault syndrome, characterized by SNHL and ovarian dysfunction.
• Associated with learning disabilities, developmental delay, and
cerebellar ataxia.
• Galactosemia is a rare cause of POI.
• Galactose metabolites have toxic effect on germ cells.
• Associated with neonatal death, ataxic neurologic disease, cognitive
disabilities, and cataracts.
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22. Acquired Abnormalities
• Include infection, environmental exposures, autoimmune disease, or
medical treatments.
 Infection -> mumps oophoritis
 Environmental toxins -> smoking, heavy metals, solvents, pesticides,
and industrial chemicals,
 Autoimmune disease -> Myasthenia gravis, ITP , RA, vitiligo, IBD, and
autoimmune hemolytic anemia.
 Medical treatments -> alkylating chemotherapy and radiation
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23. • Radiation and chemotherapeutic depend on their dose and pt age.
• With radiotherapy, ovaries are preventively repositioned using
surgery (oophoropexy).
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24. HYPOGONADOTROPIC HYPOGONADISM
• Primary abnormality lies in the hypothalamic-pituitary axis.
• Low LH and FSH levels, but in detectable range ( <5 mIU/mL).
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25. ■ Hypothalamic Disorders
Inherited Abnormalities
• Primarily associated with IHH.
• Subset has associated defects in the ability to smell (hyposmia or
anosmia), Kallmann syndrome(KS).
• Kallmann syndrome is associated with cleft palate, renal agenesis,
cerebellar ataxia, epilepsy, NSHL, and synkinesis.
 KS is distinguished from IHH by office based olfactory testing ,strong
odorants like coffee or perfume.
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26. Acquired Abnormalities
• More common than inherited deficiencies.
• Also known as "hypothalamic amenorrhea," with three main
categories: eating disorders, excessive exercise, and stress.
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27. Eating Disorders.
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28. Exercise-induced Amenorrhea.
• Associated with significant loss of fat.
• Puberty may be delayed in girls who begin training before menarche.
• Female athlete triad, menstrual dysfunction, low energy, and low
bone mineral density.
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29. Stress-induced Amenorrhea.
• Can result from negative or positive life events.
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30. Pathophysiology of Functional Hypothalamic
Amenorrhea.
• overlapping mechanisms.
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31. Pseudocyesis/false pregnancy
• Amenorrhea and pregnancy symptoms, but negative pregnancy test.
• Signify the ability of the mind to control physiologic processes.
• R/F: history of severe grief (miscarriage, infant death, or infertility).
• Psychiatric treatment is reserved for depression!!!
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32. Anatomic Destruction.
• Anything destroying hypothalamus can impair GnRH secretion.
• Include tumors(craniopharyngiomas(commonest), germinomas,
endodermal sinus tumors, eosinophilic granuloma, gliomas), trauma,
radiation, infections(tuberculosis, sarcoidosis)
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33. Anterior Pituitary Gland Disorders
• May follow abnormalities in other pituitary cell types, which in turn
alter gonadotrope function.
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34. Inherited Abnormalities
• Septo-optic dysplasia syndrome, pituitary hormone deficiency
combined with central facial and/or neurologic defects.
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35. Acquired Pituitary Dysfunction
• Pituitary adenomas are the most frequent cause, evidenced by
serum prolactin levels > 100 ng/mL.
• "galactorrhea-amenorrhea syndrome"
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36. • May also follow inflammation, surgery, infiltrative disease
(sarcoidosis/hemochromatosis), metastatic lesions, radiation.
• Although rare, peripartum lymphocytic hypophysitis can cause of
pituitary failure.
• Sheehan syndrome refers to panhypopituitarism.
• X-zed by failure to lactate, loss of sexual and axillary hair, and
hypothyroidism or adrenal insufficiency symptoms.
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37. Other Causes of Hypogonadotropic Hypogonadism
• Chronic diseases including ESRD, CLD, malignancies, AIDS, and
malabsorption syndromes.
• Produce amenorrhea via common mechanisms, such as
stress and nutritional deficiencies.
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38. EUGONADOTROPIC AMENORRHEA
• Amenorrhea with normal gonadotropin levels.
• Normal oocyte maturation and ovulation are impaired, and
menstruation fails due to interference with feedback b/n
hypothalamic-pituitary axis and ovary.
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39. Polycystic Ovarian Syndrome
• Common cause of chronic anovulation with estrogen present.
• Evated androgen levels blunt oocyte maturation and result in
anovulation and amenorrhea.
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40. Nonclassic Congenital Adrenal Hyperplasia
• Mimics PCOS in hyperandrogenism and irregular menstrual cycles.
• Also termed adult-onset CAH or late-onset CAH.
• Patients are asymptomatic until adrenarche.
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41. Ovarian Tumor
• Uncommon cause of chronic anovulation with estrogen present.
• Include granulosa cell tumors, theca cell tumors, and other sex cord-
stromal tumors
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42. Hyperprolactinemia and Hypothyroidism
• Include medications(antipsychotic) and herbs.
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43. Patient Approach: History
• Age, parity
• Previous menstrual history
• Mode of onset-Sudden, Gradual
• Family history
• Past medical history or recent illnesses
• Weight fluctuation
• History of any stressful events
• History of drug intake
• Radiation exposure
• History of uterine curettage or uterine surgeries
• History of PPH or shock or infection
• Acne, hirsute
• Inappropriate galactorrhea
• Headache or visual disturbances
• Symptoms of estrogen deficiency

44. Physical examination
V/S
Weight, Height , BMI
Assess thyroid gland
breast
Signs of acromegaly
Signs of Cushing’s disease
Presence of normal reproductive tract
Presence of secondary sexual characteristics
Axillary and pubic hair growth
Neurological examinations and determination of visual field

45. Amenorrheaa
Pelvic examination Absent uterus Sexual hair
Yes No
Müllerian Agenesis AIS
Normal
HCG +Ve
ANC
Negative
Prolactin TSH FSH
See next slide
Increased
Increased
Dopamine Vs
surgery
Thyroid
replacement

46. FSH
Decreased Increased Normal
Stress, exercise & eating
disorders
No Yes
MRI treat
Abnormal Normal
Tumor
IHH,
Kallman
syndrome
Gonadal failure
Karyotype
POF Vs Gonadal
dysgenesis
Testosterone DHEAS 17-OH-P
Increased Increased
CAH
Increased
MRI Adrenal
tumors
Ultrasound
for ovarian
tumor

47. TREATMENT
• Depends on its etiology and patient desire to treat hirsutism or
seek pregnancy.
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