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Amenorrhea 1434
Amenorrhea 1434
PHYSIOLOGIAL PATHOLOGIAL
AMENORRHEA AMENORRHEA
CONTROL OF MENSTRUAL CYCLE
HYPOTHALAMUS
PITUITARY
ENDOCRINE
OVARIAN
OUTFLOW TRACT
AXIS
CLASSIFICATION OF AMENORRHEA
AMENORRHEA
PHYSIOLOGICAL PATHOLOGICAL
Pre-puberty Primary
Pregnancy related
Menopause Secondary
AMENORRHEA
PATHOLOGICAL AMENORRHEA
Hypothalamic-hypogonadism
HYPOTHALAMUS
Weight related amenorrhea
(anorexia nervosa) Pituitary adenoma
ENDOCRINE Hypothyroidism
Gonadal dysgenesis
Asherman’s syndrome
Etiology of Amenorrhea
Primary
Gonadal failure (43%)
Congenital absence of uterus and vagina (15%)
Constitutional delay (14%)
Secondary
Chronic anovulation (39%)
Hypothyroidism / hyperprolactinemia (20%)
Weight loss/anorexia (16%)
Primary Amenorrhea
Presentation:
Female appearance with normal breast development
and external genitalia.
XY Primary amenorrhea , absent uterus
Gonad - testes
Primary Amenorrhea
- ETIOLOGY -
HYPOTHALAMIC FAILURE (Kallmann’s syndrome)
Phenotype female
Congenital disorder characterized by:
1) Hypogonadotropic hypogonadism
2) Eunuchoidal features
3) Anosmia or hyposmia
Genotype female
4) Primary amenorrhea
ENDOCRINE HYPOTHALAMUS-PITUITARY
Pituitary tumour
Hypothyroidism Sheehan’s
Cushing’s syndrome
Adrenal tumour Hypothalamic
Ovarian tumour dysfunction
(androgen)
Commonest example:
1). Hysterectomy
2). Endometrial ablation
3). Asherman’s syndrome (damage to the
endometrium with adhesion formation)
4). Stenosis of the cervix following cone biopsy
Secondary Amenorrhea
- ETIOLOGY -
PREMATURE OVARIAN FAILURE
HISTORY
EXAMINATION
INVESTIGATIONS
ASSESSMENT
History
A good history can reveal the etiologic
diagnosis in up to 85% of cases of
amenorrhea.
CLINICAL ASSESSMENT
- HISTORY -
ASK ABOUT
Menstrual cycle → age of menarche and previous menstrual
history
Previous pregnancies - severe PPH (Sheehan’s syndrome)
Weight change → A large amount of weight loss (anorexia
nervosa)
Hot flashes , decreased libido → premature menopause
Certain medications
Contraception
Associate symptoms - Cushing's disease , hypothyroidism
BLOOD TESTS
ULTRASOUND
CT scan of pituitary
KAROTYPING
LAPAROSCOPY
INVESTIGATING
PRIMARY AMENORRHEA
SITE OF DISORDER DIAGNOSIS INVESTIGATIONS
HYPOTHALAMUS Hypothalamic-hypogonadism FSH, LH and estradiol - Low
Pubic hair
Progesterone challenge
yes no
congenital uterovaginal
+ -
agenesis complete androgen Estrogenized FSH Level
imperforate hymen insensitivity
complete transverse syndrome
vaginal septum
high low
abnormal hormonal stimulation
Chromosome abnormal ovaries of normal ovaries
Analysis (Hypothalamic-hypogonadism)
INVESTIGATING
SECONDARY AMENORRHEA
WITHDRAWAL NO WITHDRAWAL
BLEEDING BLEEDING
HYPOESTROGENIC COMPROMISED
ANOVULATION OUTFLOW TRACT
Positive E-P
FSH normal + high LH → PCOS challenge test Negative E-P
High prolactin → pituitary tumour challenge test
Normal or Low Very high FSH
FSH Normal FSH
Ovarian
Asherman’s syndrome
Hypothalamic-pituitary Failure
failure (HSG or hysteroscopy)
SECONADARY AMENORRHEA
Ovarian failure
(premature menopause)
chromosomal
autoimmune
anomalies
disease
Hypothalamic-pituitary
failure
Underlying causes
NEED CONTRACEPTION
Confirmed ovarian failure will not required contraception