SHIGREF MUSHTAQ

FINAL YEAR

AMENORRHEA

“ABSENCE OF MENSTURATION” .

TYPES OF AMENORRHEA  PHYSIOLOGICAL  PATHOLOGICAL  PRIMARY  SECONDARY .

PHYSIOLOGICAL  BEFORE MENARCHE  ADOLOSCENCE  PREGNANCY  LACTATION  MENOPAUSE .

PATHOLOGICAL  PRIMARY “ Girls failing to have their menarche by age of 16” .

CAUSES OF PRIMARY AMENORRHEA  ABSENT SECONDARY SEX CHARACTER  NORMAL SECONDARY SEX CHARACTER  HETEROSEXUAL DEVELOPMENT  CONSTITUTIONAL DELAY .

Ovarian Failure . Hypothalamic pituitary dysfunction       HYDROCEPHALUS CRANIOPHARYNGIOMA PANHYPOPITUITARISM TURNER’S SYNDROME MOSAIC TURNER MIXED GONADAL DYSGENESIS 2.ABSENT SECONDARY SEX CHARACTER • SHORT STATURE 1.

Ovarian Failure    TRUE GONADAL AGENESIS PREMATURE MENOPAUSE GALACTOSAEMIA .• NORMAL STATURE 1. Hypothalamic pituitary dysfunction    ISOLATED GnRH DEFICIENCY OLFACTOGENITAL SYNDROME HYPERPROLACTNEMIA 2.

Resistant ovary syndrome 4. Polycystic Ovarian disease 5. Prolactinoma . Androgen Insensitivity 3.NORMAL SECONDARY SEX CHARACTERS 1. Anatomical Abnormalities 2.

Ovarian / adrenal tumours 4. 5 alpha reductase deficiency 3. True hermaphrodite . Congenital adrenal hyperplasia 2. Absent anti Mullerian factor 5.HETEROSEXUAL DEVELOPMENT 1.

CONSTITUTIONAL DELAY .

SECONDARY AMENORRHEA “THE MENSTURATION STOPS FOR ATLEAST SIX MONTHS AFTER THE WOMAN HAS MENSTURATED REGURARLY OR AT LEAST ONCE”  10 times more common than primary Amenorrhea  Commonest cause is pregnancy .

Andrgenizing conditions 7. Gynaecological conditions 5. Social Factors 3. Other causes . Pregnancy related conditions 4. Drugs 6.CAUSES OF SECONDARY AMENORRHEA 1. Medical/Surgical conditions 8. Physiological 2.

5% 20% HYPOTHALAMUS ANTERIOR PITUITARY OVARY UTERUS 55% OTHER CAUSES 20% .0.5% 4.

MANAGEMENT ABSENT SECONDARY SEX CHARACTERS MEASURE HEIGHT NORMAL MEASURE LH & FSH LOW 1 ISOLATED GnRH DEFICIENCY 2 OLFACTOGENITAL SYNDROME 3 HYPERPROLACTINOMA SHORT HIGH 1 PREMATURE OVARIAN FAILURE 2 GONADAL AGENESIS 3 GLACTOSAEMIA ABSENT ASSOCIATED FEATURES | LOW LH/FSH CT SCAN | INTRACRANIAL LEISION ASSOCIATED FEATURES PRESENT (webbed neck carrying angle etc) | KARYOTYPING | 45xo 45x0/46xx 45xo/46xy .

FSH PROLACTIN NORMAL | CONS TITUTIONAL DELAY NORMAL ANATOMY | LH/FSH Prolactin Prolactin | Prolactinoma LH&FSH RATIO | RESISTANT OVARIAN SYNDROME LH&FSH LEVEL | RESISTANT OVARIAN SYNDROME 46 XY ANDROGEN INENSITIVIT Y .NORMAL SECONDARY SEX CHARACTERS PELVIC ULTRASONOGRAM UTERUS PRESENT OUTFLOW OBSTRUCTION UTERUS ABSENT | Karyotyping 46xx Absent uterus & vagina | ROCKYTENSKY SYNDROME LH.

HETROSEXUAL DEVELOPMENT CTADRENAL DHEAS TESTOSTERONE 17 alpha hydroxy progesterone PELVIC USG TESTOSTERONE GONADAL BIOPSY CONGENTAL ADRENAL HYPER PLASIA ANDROGEN PRODUCING OVARIAN TUMOUR ADRENAL TUMOUR TRUE HERMAPHRODITE .

FSH prolactin TSH Abnormal thyroid function tests PELVIC USG MENOPAUSE -DRUG RELATED -PITUITARY ADENOMA SHEEHANS’s SYNDROME THYROID DYSFUNCTION -polycystic ovarian disease -ovarian tumour .SECONDARY AMENORRHOEA HISTORY AND EXAMINATION BASE LINE INVESTIGATION { LH FSH PROLACTIN THYROID FUNCTION TESTS PELVIC USG LH& FSH LH/ FSH ratio POLYCYSTIC OVARIES Prolactin Level LH.

“TREATMENT” .

Once they are developed Note: when conception is desired ovulation can induced by human menopausal gonadotrophin injections.ABSENT SECONDARY SEX CHARACTERS  SHORT STATURE CAUSE TREATMENT DOSE Hypothalamic Growth Hormone pituitary dysfunction For secondary sex development 0.01mg ethinyl estradiole bd for 3 weeks. every month for several month Combine oral contraceptives as hormonal replacement therapy. .2 micro gram/kg/day 0.

CAUSE OVARIAN FAILURE (turner’s syndrome and mixed gonadal dysgenesis) TREATMENT SEXUALLY MATURE by LOW DOSE ESTROGENS OCPs as HRT NOTE: In mixed Gonadal genesis Gonads are removed because malignancy arising from them is 30% .

NORMAL STRATURE CAUSE ISOLATED GnRH deficiency TREATMENT Same as hypogonadrophic hypogonadism association with short strature except for the need of growth hormone DOSE HYPER PLOCATENEMIA Bromocriptine Ruled out on CT scan sometimes require surgical treatment 2.5mg bd PITUITARY ADENOMA TRUE GONADAL AGENESIS Treated as turner syndrome & induced with XY genotype would require gonadectomy .

NORMAL SECONDARY SEX CHARACTERS CAUSES ANATOMICAL ABNORMALITIES ANDROGEN INSENSTIVITY TREATMENT SURGICAL RECONSTRUCTION VAGINOPLASTY + GONADECTOMY FOLLOWED BY OCP’s OCP’s FOLLOWED BY OVULATION INDUCTION BY CLOMIPHENE CITRATE WEDGE RESECTION OR LAPROSCOPIC OVARIAN DRILLING FOLLOWED BY OVULATION INDUCTION BY CLOMIPHENE CITRATE RESISTANT OVARIAN SYNDROME PCO’s .

HETEROSEXUAL DEVELOPMENT CAUSES CONGENITAL ADRENAL HYPERPLASIA OVARIAN/ADRENAL TUMOUR TREATMENT Steroid therapy and fertility is restored with clomephene citrate Surgical Resection .

FOLLOWED BY IUCD INSERTION MODEREN TECHNIQUE CAUTERY UNDERDIRECT VISION THROUGH HYSTEROSCOPE OCP’s .SECONDARY AMMENORRHAE T/M CAUSES TREATMENT ADRENAL/OVARIAN TUMOUR SURGICAL RESECTION CONG ADRENAL HYPERPLASIA PELVIC TB PIT ADENOMA ASHERMAN’S SYNDROME STEROIDS + OVULATION INDUCTION ANTI TB MEDICATION BROMOCRIPTINE AND SURGERY BREAK IU ADHESIONS WITH UTERINE SOUND.

ULH/75 I. 1.25mg once a day for 1 week.5 mg bd . GONADOTROPHINS (LH/FSH) 2. HYPERPROLACTINEMIAC AMENORRHEA BROMOCRIPTINE 1.UFSH one injection on any day.OVULATION INDUCTION 1.NON HYPERPROLACTINEMIAC AMENORRHEA DRUGS DOSE CLOMIPHENE CITRATE 50 mg daily on any day and continued for 5 days and dose is increased by 50mg every month till menstruation is achieved INJECTIONS 75 I.25 bd for next week followed by 2.

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