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Contents
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Amenorhea Amenorhea Dysmenorhea

&  Introduction  Introduction

 Amenorrhea  Epidemiology
Dysmenorhea  Classification  Primary
 Magnitude of the dysmenorhea
problem  Secondary
 Causes dysmenorhea
Dr Eyasu Mesfin
 Approach to work up
2021
 Treatment

Introduction Classification
3 4

 Amenorrhea = absence / abnormal cessation of menses  PRIMARY AMENORRHEA:

Greek: a = negative, men = month, rhoia = flow
A transient, intermittent, or permanent condition
A common symptom of an underlying abnormality
 Puberty = …. development to reproductive capacity.
Growth  thelarche  pubarche menarche,
Age at puberty is variable & declining at the rate of 1–3
months per decade for >175 years.
Definition:
 The absence of menses by age 13 years in the
absence of normal growth or secondary sexual
development; or
 The absence of menses by age 15 years in the
setting of normal growth and secondary sexual
development
Seen in approximately 2.5% of the population,

Regulation of Reproduction: General Pathways

Classification; contd…

{
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 SECONDARY AMENORRHEA: IV
Definition:
 The absence of menses for more than 3 cycles, or
6 consecutive months, in a previously menstruating
woman.
III {
Variable incidence:
 From 3% in the general population to 100% in

{
conditions of extreme physical/emotional stress. Out
 Up to 50% in competitive runners. II flow
tract
I

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COMPARTMENT – I
Causes of Amenorrhea (Disorders of outflow tract)
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ALWAYS RULE OUT PREGNANCY!!!!!!! IA. CONGENITAL:

Müllerian anomalies
 Physiologic / non-pathologic  Imperforate hymen
Pre-menarche (10 physiologic amenorhea)  Transverse vaginal septum
Pregnancy
 Cervical atresia
Lactational
 Vaginal agenesis
Hormonal contraceptives
Postmenopausal  Unresponsive endometrium
 Endometrial hypoplasia / aplasia
 Compartment –I (outflow tract) - 20% 10 & 5% 20
Mullerian agenesis (absent uterus & vagina)
 Compartment –II (ovary) - 50% 10 & 40% 20
 Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome
 Compartment – III (pituitary) - 5% 10 & 20% 20 Androgen insensitivity syndrome
 Compartment – IV (hypothalamic) - 20% 10 & 35% 20

COMPARTMENT – I;
Androgen Insensitivity contd…
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 XY Karyotype IB. ACQUIRED:

 Testosterone and AMH -  Asherman's syndrome
present in normal male level 2
0
ary to prior uterine currettage (esp. postpartum)
 Blind vaginal pouch and scant  Secondary to infections:
or absent axillary & pubic hair • Pelvic inflammatory disease,
 Abundant breast development • Tuberculosis,
at puberty • Schistosomiasis
 Immature nipples with pale  Cervical stenosis
areolae  Cone biopsy

 long arms with big hands and  Loop electroexcision procedure

feet

Compartment –II Compartment –II

(ovarian disorders) (ovarian disorders); contd…
11 12

 Gonadal agenesis /dysgenesis –

 Steroidogenic enzyme defects (primary amen.)
Cause of primary amenorrhea in~ 30%–50%
Turner's syndrome (45,XO) & variants – most common
17α-hydroxylase, 17-desmolase, 17-
ketoreductase
Classic Turner True gonadal Mixed
Turner’s Variant Dysgenesis Dysgenesis  True hermaphroditism
Phenotype Female Female Female Ambiguous
 Gn-resistant ovary syndrome (Savage's syndrome)
Gonad Streak Streak Streak - Streak
-Testes  Polycystic ovarian syndrome (Stein Levantal
Hight Short - Short Tall Short syndrome)
- Normal
Somatic stigmata Classical ± Nil ±
karyotype XO XX/XO or 46-XX(Pure) 46XO/46XY
abnormal X 46-XY (Swyer)

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Compartment –II; Compartment -III

contd… (Pituitary disorder)
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 Premature ovarian failure: ~1% to 5% of women  Pituitary tumours:

develop POF before the age of 40 yrs
Idiopathic premature ovarian failure
 ? From inadequate germ cell migration during
embryogenesis or accelerated atresia
Autoimmune oophoritis
Postinfection (eg, mumps)
Postoophorectomy (also wedge resections)
Postirradiation
Postchemotherapy
Ovarian tumours (Feminizing / musculinizing)
Prolactinomas
Other hormone-secreting pituitary tumors (corticotropin,
thyrotropin, GH)  Cushing's disease, Acromegaly
Nonfunctional tumors (craniopharyngioma)
 Space-occupying lesions (Empty sella syndrome, Arterial aneurysm)
 Necrosis/Infarction (Sheehan’s syndrome, Panhypopituitarism)
 Inflammatory/infiltrative (Sarcoidosis, hemochromatosis,
Lymphocytic hypophysitis)
 Isolated gonadotropin deficiency
 Diabetic vasculitis
 Surgical or radiologic ablations

Compartment -IV Compartment -IV

(Hypothalamic dysfunction) (Hypothalamic dysfunction); contd…
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 Kallmann's syndrome – congenital GnRH deficiency  Functional:

ass. with anosmia Severe Stress,
 Tumors of hypothalamus (craniopharyngioma, Severe weight loss (BMI < 19)
meningioma, hamartoma, chordoma)
Malnutrition,
 Traumatic brain injury
Psychological eating disorders
 Infections- Tb, sarcoidosis (anorexia nervosa, bulimia),
 Cranial irradiation Excessive exercise,
 Constitutional delay of puberty:
Pseudocyesis
 Positive family history,
 Diagnosis by exclusion

EVALUATION OF AMENORRHEA
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• HISTORY
• PHYSICAL EXAMINATION
• INVESTIGATION

Exclude Pregnancy
Exclude Cryptomenorrhea

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Cryptomenorrhea Imperforate hymen

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 Outflow obstruction to menstrual flow (10 or 20)

 Symptoms:-
Intermittent abdominal pain
Possible difficulty with micturition
Possible lower abdominal swelling
Bulging bluish membrane at the introitus or absent
vagina (only dimple)

Evaluation; Contd…
Evaluation; Contd…
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 STEP -1: Evaluate for thyroid disorder, PRL & anovulation.
Determine serum FSH, TSH and Prolactin level
 If hyperprolactinemia  X-ray of sella tursica ( lateral &
coned down views), MRI.
 If normal  do progesterone challenge test (PCT)
PCT: Assess level of E & intactness of out flow tract.
 MPA 10 mg,po/day for 5 days.
 Within 2-7 days look for withdrawal bleeding.
 +ve - Functional out flow tract & reactive endometrium.
 No withdrawal bleeding  Step 2
 STEP -2: Evaluate the outflow tract
Estrogen-Progesterone Challenge Test
 Conjugated estrogen 1.25 mg or estradiol 2 mg po daily
for 21 days  then progesterone for 5 days.
 Conclusion- Withdrawal flow
 +ve: Comp’t 1 systems have normal functional
abilities if properly stimulated by estrogen  Step 3.
 -ve: Defect in comp’t 1

Evaluation; Contd… Evaluation; Contd…

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 STEP -3:  STEP -4:

Is lack of estrogen due to ovarian failure or Is the hypogonadotrophin due to pituitary or
CNS/pituitary axis dysfunction? hypothalamic failure.
Involves serum gonadotropin level assay i.e.:-
With GnRH administration:
 Eugonadotrophic  FSH=5-20 IU/L, LH= 5-20 IU/L
 Hypothalamic Or pit failure  Pituitary gonadotrophin:-

 Hypogonadotrophic  FSH <5 IU/L, LH <5 IU/L  Increased: Hypothalamic failure

 Hypothalamic Or pit failure  Not increased: Pituitary failure
 Hypergonadotrophic  FSH >20 IU/L, LH >40 IU/L
 Ovarian follicular dysfun.
 Karyotype- if age less than 30

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Treatment Of Amenorrhea;
contd…
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 Genital Tract Abnormalities

Surgical correction
Neovagina for women with vaginal/müllerian
agenesis,
Operative hysteroscopy preferred for synechiae /
Aherman’s syndrome

Treatment Of Amenorrhea;
contd… Treatment Of Amenorrhea; contd…
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 Ovarian Disorders  Pituitary Disorders

Gonadal dysgenesis & sexual infantilism:  Growth Majority are prolactin-secreting adenomas or
& sex hormones (E & P) replacement therapy nonfunctioning tumors.
 topromote growth to maximum potential,
normal bone density development, and  Hypothalamic Disorders
 to initiate and maintain secondary sexual xics Long-term pulsaile GnRH therapy with indwelling
catheter and a portable pump
 symptomatic relief,
Women with 45XY or 45X / 46XY gonadal
dysgenesis  prophylactic oophrectomy.

DYSMENORRHEA
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 Definition: Difficult menstrual flow or painful

menstruation.

DYSMENORRHEA Usually cramping & centered in the lower abdomen.

Reserved for women whose pain prevents normal
activity and requires medication.
 Affects ~50% of menstruating women, but ~5-10%
have severe dysmenorrhea affecting daily activities.
 Is the most common cyclic pain phenomenon

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Classification
Primary Dysmenorhea
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 Spasmodic
 Two types :  Not associated with macroscopic pelvic pathology
(i.e. absence of pelvic disease)
Primary (no organic cause),
 Associated with ovulatory cycles
Secondary (pathologic cause), and  Usually appears within 1 to 2 years of menarche,
when ovulatory cycles are established.
 Affects younger women but may persist into the
40s.

Primary Dysmenorhea: Primary Dysmenorhea:

Etiology Symptoms
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 Increased endometrial prostaglandin production
(amount not sensitivity).
PGs are found in higher conc. in secretary (3- fold
increase) than in proliferative endometrium.
Prostaglandins  Increased uterine tone with high
amplitude contractions  reduced blood flow 
ischemic pain.
Prostaglandin F is the main agent responsible.
 Pain usually begins few hours before or just after
onset of menstrual period & may last 48 to 72 hrs.
 The pain is similar to labor, with:-
Suprapubic cramping,
May be accompanied by lumbosacral backache,
Radiating down the anterior thigh,
Nausea, vomiting, diarrhea, and rarely syncopal episodes.
 Pain relieved by abdominal massage, counter-pressure,
or movement of body.

Primary Dysmenorhea: Primary Dysmenorhea:

Diagnosis Treatment
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 Goal: To provide adequate relief of pain.

 Usually relieved spontaneously after delivery.
 Self-care:
 Rule out underlying pelvic pathology. Heat
Exercise
Behavioral interventions: Reassurance.
 Drug therapy:
Prostaglandin synthase inhibitors:
 Effective in ~80%
 NSAIDs: Ibuprofen, Diclofenac, Mefenamic acid, etc
Hormonal contraceptives:  Inhibit ovulation  …
Gn-RH Agonists and Androgens:

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Primary Dysmenorhea:
Treatment; contd… Secondary Dysmenorrhea
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 Surgery:  Secondary, congestive or acquired.

For cases refractory to conservative management.
Hysterectomy is effective; but…
Transcutaneous electrical nerve stimulation (TENS),
paracervical block etc. may be useful.
Laparoscopic uterine nerve ablation LUNA or
Pre-sacral neurectomy.
 ?? Complementary & Alternative Medicine:
Diet changes, herbal medicine, and physical treatments
Acupuncture,
 Cyclic menstrual pain that occurs in association with
anatomic and/or macroscopic pelvic pathology.
 The mechanisms are diverse and not fully elucidated,
Most involve either:-
 Excess prostaglandin production or
 Hypertonic uterine contractions secondary to cervical
obstruction, intrauterine mass or foreign body.
 Causes: Gynecologic and non-gynecologgic

Secondary Dysmenorrhea: Secondary Dysmenorhea:

Causes Symptoms
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Gynecologic causes:-
Uterine leiomyoma
Endometriosis
Adenomyosis
PID
Ovarian cysts & tumors
Cervical stenosis/occlusion
Uterine polyps
Intrauterine adhesions
Congenital malformations (eg,
bicornate/subseptate Ux)
IUCD
Transverse vaginal septum
Pelvic congestion syndrome
Non-Gynecologic causes
Inflammatory bowel
disease
Irritable bowel syndrome
Utero-pelvic junction
obstruction
Psychogenic disorders
 The pain often begins 1-2 wks before menstrual flow
and persists until few days after cessation of flow.
 Usually develops years after menarche
 Most common in women aged 30-45 years.
 Can occur with anovulatory cycles.
 Typically
Dull or crampy
Begins before menses (up to 2 weeks), persists during
menses and sometimes for several days afterward.
Less responsive to NSAIDs and COCs.

Secondary Dysmenorhea:
Management Summary
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 Diagnosis  Amenorhea
Hx & P/E Physiologic or pathologic
Evaluation:- Always rule-out pregnancy
 CBC, ESR
 Cultures for STD Primary or secondary
 U/S Ovarian – commonest source of pathologic
 HSG
 Laparoscopy
 Hysteroscopy  Dysmenorhea
 D&C
Primary or secondary
 Treatment Primary typically starts just before or just after onset of
Analgesics. menses
Treatment of underlying cause accordingly.
Secondary typically starts before menses

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