presentation regarding amenorrhea and dysmenorrhea

1. Done by : Srikanth Mungara
Tutor : Tamar Badridze

2. + Types and Definitions
 Oligomenorrhea: menstruation occurring with intervals of
more than 35 days
 Polymenorrhea: menstruation occurring regularly with
intervals of less than 21 days
 Metrorrhagia: menstrual bleeding occurring at irregular
intervals or bleeding between menstrual cycles
 Menorrhagia: regular menstrual cycles with excessive flow
(technically more than 80 mL of volume) or menstruation
lasting more than 7 days
 Menometrorrhagia: menstrual bleeding occurring at
irregular intervals with excessive flow or duration

3. +
CASE
A 27-year-old nulligravida female presents to your office for
routine exam. Upon gynecological history, you discover that she
has a 5-year history of oligomenorrhea, with only approximately
two or three menses a year. She denies intercycle spotting or
premenstrual symptoms. Her last menses was 3 months ago. Her
blood pressure is 120/75 mmHg and her BMI is 34. Her physical
exam reveals a moderate amount of facial hair and facial acne.
Her pelvic examination is unremarkable
What condition do you suspect in this patient?

4. Amenorrhea
Definition and types
 Primary amenorrhea is defined as the absence of menses at:
i. age 16 in the presence of normal growth and secondary
sexual characteristics,or
ii. age 14,if no menses have occurred and there is an
absence of secondary sexual characteristics.
 Secondary amenorrhea is the absence of menses for three
months in women with previously normal menstruation and
for nine months in women with previous oligomenorrhea.

5. +
Etiology of primary
Amenorrhea
Hypothalamic and Pituitarycauses
① Functional hypothalamic amenorrhea.
• Abnormal hypothalamic gonadotropin-releasinghormone
(GnRH) secretion  decreased gonadotropin pulsations
i. absent LH surges
ii. absence of normal follicular development
iii. anovulation.
• Multiple factors may contribute to the pathogenesis of
functional hypothalamic amenorrhea, including eating
disorders (such as anorexia nervosa), exercise, and stress

6. +
② Congenital GnRH deficiency or idiopathic
hypogonadotropic hypogonadism
③ Constitutional delay ofpuberty
•
characterized by both delayed adrenarche and gonadarche.
④ Hyperprolactinemia
① Gonadal dysgenesis
Ovarian Causes
② Turner syndrome
③ Polycystic ovary syndrome
④ Premature ovarian failure
• Loss of ovarian function before age of 40
• Idiopathic, but maybe related to a variant gene.

7. +
Congenital disorders of the uterus and vagina
①Müllerian agenesis causes approximately 15 percent
of primary amenorrhea.[4]
②Imperforate
hymen
③Transverse vaginalseptum

8. +
Diagnosis
History
 Detailed history of pubertal development
 Family history of menarche, pubertal development
 History of weight loss, stress,exercise (athletic activity)
 Detailed dietary history
 History of contraception, medications
 History suggestive of CNS disease (eg, headaches, visual
changes)
 History of chronic illnesses (eg, Crohn disease)

9. +
Physical examination
 Height, weight, and growth charts
 Breast development, pubic hair
 Syndromic appearance (eg, short stature,webbed neck)
 Visual fields, thorough neurologic examination, optic fundi
 Evidence of hyperandrogenism (eg, acne,hirsutism,
clitoromegaly)
 Evidence of thyroiddisease
 Evidence of chronicillnesses
 Evidence ofpregnancy

10. +
Evaluation
Primary amenorrhea is evaluated most efficiently by focusing
on the
a) presence or absence of breast development (a marker of
estrogen action and therefore function of the ovary),
b) the presence or absence of the uterus (as determined by
ultrasound, or in more complex cases by magnetic
resonance imaging)
c) and the follicle-stimulating hormone (FSH) level.

11. +Etiology of secondary
Amenorrhea
PREGNANCY is the most common cause of
secondary amenorrhea.
Hypothalamic dysfunction
① Functional hypothalamic amenorrhea
② Inflammatory or infiltrativediseases
(eg.Lymphoma)
③ Brain tumors (i.e.Craniopharyngioma)
④ Cranial irradiation
⑤ Pituitary stalk dissection orcompression

12. +
Pituitary dysfunction
① Hyperprolactinemia
• Prolactinomas account for 20% of secondary amenorrhea
• Account for 90% of secondary amenorrhea due to
pituitary problems
② Pituitary tumors
• Acromegaly
• Corticotroph adenomas (i.e.Cushing’s disease)
• Meningioma (of the sella), germinoma, glioma
③ Empty sella syndrome
④ Pituitary infarct/pituitary apoplexy
• Sheehan’s syndrome

13. +
Ovarian dysfunction
• Menopause: defined as 12 months of amenorrhea in a
woman over age 45 in the absence of other biological or
physiological causes.
• Premature ovarian failure
• Surgical removal
• Polycystic ovarian disease
+Uterine causes
 ① Acquired scarring of the endometrium
due to instrumentation e.g. Asherman’s Syndrome
.due to infection eg. Tuberculosis
① Cervical stenosis, often due to instrumentation

14. +
CASE
A 15-year-old nulligravida female presents with her
mother for evaluation of painful periods. Menarche was
at age 14.Her periods are typically every 4–8 weeks and
are very painful. She has missed 1–2 days of school with
each menses because of the severe pain and has been
suspended from the volleyball team because of missed
practices. She denies intercourse. She has never had a
pelvic examination. Her review of systems is otherwise
negative.

15. + Dysmenorrhea
Definition and types
 Dysmenorrhea is defined as difficult menstrual flow or
painful menstruation. It is one of the most common
gynecologic complaints in young women who present to
clinicians.[5]
 Dysmenorrhea can be divided into 2 broad categories:
primary (spasmodic) and secondary (congestive).

16. +
Primary dysmenorrhea
 Primary dysmenorrhea is defined as menstrual pain that is
not associated with macroscopic pelvic pathology.
 It typically occurs in the first few years after menarche[6]and
affects as many as 50% of postpubertal females.
 In an epidemiologic study of an adolescent population (age
range, 12-17 years), reported that dysmenorrhea had a
prevalence of 59.7%.[7]

17. +
Risk factors
 Early age at menarche (< 12 years)
 Nulliparity
 Heavy or prolonged menstrual flow
 Smoking
 Positive family history
 Obesity

18. + Treatment
 Treatment is directed at providing relief from the cramping
pelvic pain and associated symptoms .
 Nonsteroidal anti-inflammatory drugs (NSAIDs) are the best-
established initial therapy for dysmenorrhea. [9] They
decrease menstrual pain by lowering prostaglandin F2α
(PGF2α) levels in menstrual fluid.
 Oral Contraceptives also relieve symptoms, particularly if
contraception is required.

19. +
Secondary dysmenorrhea
 Less common than primary dysmenorrhea
 It is associated with pelvic pathology
 It tends to occur several years after the menarche
 The woman may complain of a change in the timing and
intensity of her pain
 The pain may last throughout menstruation
 The pain may be associated with discomfort before the onset
of menstruation.

20. + Causes
 Leiomyomata (fibroids)
 PID
 Tubo-ovarian abscess
 Endometriosis
+ Management
 Treatment of secondary dysmenorrhea involves correction of
the underlying organiccause.
 Specific measures (medical or surgical) may be required to treat
pelvic pathologic conditions (eg, endometriosis) and to
ameliorate the associateddysmenorrhea

21. +