SECONDARY AMENORRHOEA

Professor. Dr. Ayla Kh. Ghalib

● Secondary amenorrhoea : Cessation of menstruation
for six consecutive months in a woman who has
previously had regular period and not due to
pregnancy,lactation,and menopause.
● Most of the causes of secondary amenorrhoea can
also cause primary AMENORRHOEA
 ● Causes
● Pregnancy, A shermans syndrome,Sheehans
syndrome, cervical stenosis, polycystic ovary
syndrome,premature ovarian failure,resistant ovary
syndrome, Androgen secreating ovarian tumour,
weight loss,exercise,stress,idiopathic,chronic
illness,hyperprolactaemia, Hypogonadotrophic
hypogonadism (CNS tumours, cranial irradiation and
injury, infections such as sarc., T.B), Endocrine
disorders (Thyroid,cushing).
● POF is defined as cessation of periods before 40
years of age. It is usually unexplained, but may
be due to chemotherapy, radiotherapy,
autoimmune disease or chromosomal disorders
(e.g. Turner's 45XO/46XX). This condition can be
differentiated from resistant ovary syndrome by
ovarian biopsy.
● Asherman's syndrome is the presence of
intrauterine adhesions prevent menstruation, the
most common cause being over-vigorous uterine
curettage, postpartum removal of placenta.
●Mnagement OF 2nd
amenorrhoea
● Examination of weight,signs of hyperandrogenism
and virilism,thyroid, signs of cushing syndrome and
other chronic illness, breast for galactorrhoea
● Abdominal examination :pregnancy,androgen
secreating ovarian tumour,adrenal gland tumour.
 ●Investigations
● BHCG,Ultrasound,FSH,LH,Serum prolactin, serum
testosterone, 24 hour urinary free cortisol, CTscan, MRI
of pituitary fossa, Anti ovarian antibody is difficult to
be mesured so mesure antithyroid antibodies,
Karyotype (TURNERS mosaic 46xx,46xo), TSH,T3 T4.

●
Normal serum prolactin & FSH with
history of uterine instrumentation

● Evaluation for Asherman's syndrome should be

performed. start a progestin challenge (Provera 10
mg tid x 10 d)



Ashermans syn.
● If bleeding does not occur, estrogen and progestin
should be administered (conjugated estrogen x 25 d
with medroxyprogesterone for last 10 d)
● failure to bleed upon cessation of this therapy
strongly suggests endometrial scarring.
● In this situation, a hysterosalpingogram or direct
visualization of the endometrial cavity with a
hysteroscope can confirm the diagnosis of
Ashermans syndrome
● Treatment of Ashermans syndrome
● By hysteroscopic releasing of the adhesions then
insertion of foley catheter or IUCD to prevent
readhesion.
●Polycystic ovary syndrome
● PCOS is a heterogenous collection of signs and
symptoms and is a syndrome of ovarian
dysfunction along with the cardinal features of
hyperandrogenism and polycystic ovary
morphology. Its clinical manifestations include
menstrual irregularities, signs of androgen excess
(e.g. hirsutism) and obesity.
 Elevated serum LH levels and insulin resistance
are also common features. PCOS is associated with
an increased risk of type 2 diabetes and
cardiovascular events. It affects around 5-10 per cent
of women of reproductive age. The prevalence of
polycystic ovaries seen on ultrasound is much
higher at around 25 per cent.
Pathophysiology

Hypersecretion of LH from pituitary stimulates

Stromal cells of the ovary to secrete androgen
leading to hyperandrogenism so follicular growth
is inhibited and there is excess of immature
follicles.


● Hypersecretion of insulin with increase peripheral
resistance
● Insulin is a potent stimulus for androgen secretion
by the ovary, it amplifies the effect of LH on the
ovary
● Insulin suppresses liver production of SHBG so
elevate free androgen level
● Genetic (familial)
● Environmental factor such as nutrition and body
weight
Clinical features

The clinical features of PCOS are as follows:

oligomenorrhoea/amenorrhoea in up to 75 per cent
of patients, predominantly related to chronic
anovulation
hirsutism
subfertility in up to 75 percent of women.


obesity in at least 40 per cent of patients;
recurrent miscarriage in around 50-60 per cent of
women.
acanthosis nigricans (areas of increased velvety
skin pigmentation occur in the axilla and other
flexures)
Diagnosis

Patients must have two out of the three features

below: ( Rotterdam criteria )
amenorrhoea/oligomenorrhoea
clinical or biochemical hyperandrogenism
polycystic ovaries on ultrasound.


The ultrasound criteria for the diagnosis of a
polycystic ovary are eight or more subcapsular
follicular cysts<10 mm in diameter and increased
stroma and increase ovarian volume more than
10 cm3
investigations
● LH:FSH ratio increase
● Increase LH . While FSH normal.
● Increase free Androgen, decrease SHBG
● Increase oestrogen.
● Increase prolactin.
● Increase fasting insulin.
● Impaired G.T.T.
Management
Management of PCOS involves the following:

Lifestyle advice: Dietary modification and

exercise is appropriate in these patients as they are
at an increased risk of developing diabetes and
cardiovascular disease later in life.
Weight reduction improves menstruation and
fertility.
COCP: Low oestrogen content. This should regulate menstruation.
Cyclical oral progesterone: This to can be used to regulate
menstruation.
Medroxy progesteron acetate (provera) for 10 - 12 days every 1 – 3
months and it is given in luteal phase of the cycle.Or introduce
Mirena(IUD secreat progesteron)
Metformin: inhibit production of hepatic glucose
and enhance the sensitivity of peripheral
tissue to insulin so decrease insulin secretion and
ameliorates hyperandrogenisim and abnormalities
in gonadotropin secretion . It regulates
menstruation and improves rate of ovulation and
pregnancy when combined with clomid
Dose: either 850mg 1 tab. bid or 500 mg. tid
Side effect of metformin nausea and diarrhoea
Clomiphene: This can be used to induce ovulation
where subfertility is a factor.
Hirsutism
● Drug treatment needs 6-9 months before improvement
● Eflornithine cream ( Vaniqua )applied topically
● Cyproterone acetate ( Dianette , anti-androgen check
LFT, when symptoms control sheft to oral .
Contraceptive pill,low oestrogen.(DVT)
● Metformin: improves parameters of insulin resistance,
hyperandrogenemia, and acne in PCOS
● GnRH analogues with low-dose HRT: this regimen
should be reserved for women intolerant of other
therapies.
● Spironolactone; antiandrogen and antialdosterone
● Finasteride, 5 alpha-reductase enzyme inhibitor
● Surgical treatments , e.g. laser or electrolysis
Surgical treatment of pcos
● Laparascopic ovarian drilling.
● Previosly used Wedge resection of ovaries (cause
extensive peri-ovarian and tubal adhesions)
Long term complications of pcos

● Hypertension
● Diabetes mellitus
● Cardiovascular disease
● Ca. endometrium
● Ca. breast