‫‪E‬‬‫‪A‬‬

‫‪R‬‬ ‫‪H‬‬
‫‪R‬‬
‫‪E‬‬ ‫‪NO‬‬
‫‪A‬‬ ‫‪M‬‬
‫ويني‬
‫الث‬ ‫طشر‬
‫م‬ ‫صبا‬
‫أ‪.‬م‪.‬د‪.‬‬

‫‪١‬‬ ‫‪ ٦‬كانون األول‪amenorrhea-1 - ٢٠٢٢ ،‬‬

Amenorrhea
Is defined as absence of menstruation , as we know there are many
factors influencing the age of menarche .

🔔All of the physical changes of puberty occur as a result of

endocrine maturation-——>ovarian stimulation and the production
of oestradiol from the follicles which begin to develop around the
age of 8.5 years .
‫اول ﺷﻲ ﯾﺘﻜﻮن اﻟﻌﻼﻣﺎت اﻟﺜﺎﻧﻮﯾﺔ وﺑﻌﺪﯾﻦ اﻟﺤﯿﺾ‬
🔔This rise in oestrogen leads to secondary sexual development of
the breast and the establishment of menstruation
🔔 while the secretion of androgen " primarily
dihydroepiandrosterone sulphate DHEAS " begins to rise at the age
of 6 years and continues to rise until the age of 12 years . These
seem to be the prime of pubic and axiallary hair growth .

٢ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦

Types of Amenorrhea:
primary Amenorrhea : defined as
🌵either failure of development of secondary sexual
characteristics by the age of 14 years
🌵 in the presence of secondary sexual characteristics , but
absence of menstruation until the age of 16 years
🔔 failure to do so would warrant investigations and this may not lead
to diagnosis of abnormality , the proof of normality is also extremely
important .
* Aetiology of primary Amenorrhea :
📚Its depend on classification of primary Amenorrhea secondary
sexual characteristics normal :
1. Imperforated hymen
2. Transverse vaginal septum
3. Abscent vagina with or without functioning uterus " 46XX mayer-
rokitansky syndrome " .
4. XY female-androgen insensitivity .
5. Resistant ovarian syndrome
6. Constitutional delay
٣ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦
 ‫اذا اﻟﻣرﯾﺿﺔ ﻋدھﺎ طﺑﯾﻌﻲ اﻟﺻﻔﺎت اﻟﺛﺎﻧوﯾﺔﻣﻌﻧﺎھﺎ ﻋدھﺎ‬
‫اﻧدروﺟﯾن واﻻﺳﺗروﺟﯾن ﯾﻌﻧﻲ اﻟﻣﺑﯾض ﻣوﺟود وﻛﺎﻋد‬
‫ﯾﺷﺗﻐل وﯾﻔرز ھرﻣوﻧﺎت‬
‫ﻓد ﺑﮭﺎي اﻟﺣﺎﻟﺔ اﺷك ﺑﺎﻟرﺣم ﻣوﺟود ﻟو ﻻ ﻣن ﺧﻼل اﻟﺳوﻧﺎر‬
‫وﺣﺳب اﻟﻣﺧطط ﯾﻠﻲ ﺟوه ﯾوﺿﺢ ﺷﻧو ﻧﺳوي‬
‫اھم ھرﻣوﻧﺎت اﺣﻠﻠﮭﺎ اذا ﻣوﺟود اﻟرﺣم ھو اﻟﮭرﻣوﻧﺎت اﻟﻛوﻧﺎد‬
‫اﻟﺑروﻻﻛﺗﯾن واﻟﺗﺳﺗﺳﺗﯾرون ﻣﻊ ﻣرات اﻟﺛﺎﯾروﯾد‬

‫‪٤‬‬ ‫‪ ٦‬كانون األول‪amenorrhea-1 - ٢٠٢٢ ،‬‬

Androgen
insestivity

٥ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦

٦ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦
📚Secondary sexual characteristics absent :
Normal stature :
1-Hypo gonadotrophic hypogonadism
- congenital e.g -kall.mann's syndrome : the patient also presented
with anosmia due to defect at olfactory nucleous.
-Acquired --- weight loss , anorexia .
2-Hypergonadrophic hypogonadism :
=gonadal sgenesis XX XY agenesis
= dysgenesis
=turner mosaic
= ovarian failure
= Galactosemia .

٧ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦

b. Short stature :
=Hydrocephalus
=Trauma
=Tumours
=X0 Turner syndrome and other X Hetero sexual development :
congenital adrenal hyperplasia
= 5 – reductase deficiency
= androgen secreting tumour
=True hermaphrodite and obsent mullerian inhibitor .deletions .

٨ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦

٩ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦
١٠ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦
B. secondary amenorrhoea :
Cessation of menstruation for 6 consecutive months in a women who
has previously had regular periods , is the usual criteria for
investigation

🔔 However , some authorities consider 3 or 4 months is the grey area

between amenorrhoea and oligomenorrhoea .

🔔Women with secondary amenorrhoea must have a patent lower

genital tract , an endometrium that is responsive to ovarian hormone
stimulation and ovaries that have responded to pituitary
gonadotropins .

‫ﻣﻦ ﺗﺠﯿﻨﻲ ھﯿﺞ ﻣﺮﯾﻀﺔ ﻻزم ﺷﻐﻼت اﺳﻮﯾﻠﮭﺎ وھﯿﮫ‬

‫اﺧﺬ ھﺴﺘﺮي ﻛﺎﻣﻞ ﻋﻦ اﻟﺪورة واﻟﺤﻤﻞ واﻻﻧﺠﺎب اذا ﻣﺰوﺟﺔ وﻣﺸﺎﻛﻠﮭﺎ اﻟﻤﺘﻌﻠﻘﮫ ﺑﺎﻟﺠﻨﺘﻞ ﻟﻮ ﺑﺎﺟﮭﺰة‬
‫ﺛﺎﻧﯿﺔ‬
‫اﺷﻮف ﺣﺎﻣﻞ ﻟﻮ ﻻ‬
‫اﺷﻮف اﻟﻤﺒﯿﺾ وﺿﻌﯿﺘﮫ واﻟﺮﺣﻢ ھﻢ‬
congenital‫ ﻣﺎﻋﺪا ال‬primary‫وادور اﻓﻜﺮ ﺧﺎف اﻟﻤﺸﻜﻠﺔ ھﺮﻣﻮﻧﺎت وﻧﻔﺲ ﻣﺴﺒﺒﺎت ال‬
١١ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦
* Classification of secondary amenorrhoea according to the site
of disorder :
- Uterine causes :
=A Sherman's syndrome
= cervical stenosis .
- Ovarian causes :
= polycystic ovarian syndrome PCOS
=premature ovarian failure (( genetic , auto immune , infective ,
radio , chemo therapy )) .
- Hypothalamic causes :
=weight loss
=exercise
= chronic illness
=Idiopathic
=psychological distress .

١٢ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦

Pituitary causes :
= Hyperprolactinaemia
=Hypopitutirism sheehan's syndrome
=Tumours
=head injury
= cranial radiation
= T.B
=sarcoidosis.
- Systemic causes :
=endocrine disorder e.g thyroid
=cushing syndrome
=chronic illness
=sickle cell disease ….ect.

١٣ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦

Asherman's syndrome :is a condition in which intra-uterine
adhesions prevent normal growth of the endometrium .
🔔This may be the result of a too vigorous endometrial curettage
affecting the basalis layer of the endometrium or adhesions may
follow an episode of endometritis .

🔔Typically amenorrhoea is not absolute , and it may be possible to

induce a withdrawal bleeding using a combined oestrogen /
progesterone preparation .

🔔This condition can be diagnosed by hysterosalpingogram or

hysteroscope inspection of the uterine cavity .

١٤ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦

Treatment :
1-Surgery and adhesiolysis
2- 3 months course of cyclical progesterone / oestrogen
should be given
3- some clinicians insert foley catheter into the uterine
cavity for 7-10 days post-operatively or intra-uterine
contraceptive device for 2-3 months to prevent recurrence
of adhesions .

🔔Those patients when get pregnant have risk of placenta

accreta .

١٥ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦

‫‪* Hyper-prolactinaemia : is the commonest pituitary cause of‬‬
‫‪amenorrhoea .‬‬
‫‪There are many causes of mildly elevation serum prolactin level is‬‬
‫‪greater than 1000mu/L then the test should be repeated and if still‬‬
‫‪elevated it is necessary to image the pituitary fossa by C.T or MRI‬‬
‫‪scan .‬‬
‫ﯾﻠﻲ ﯾﺜﺒﻄﮫ اﻟﺪوﺑﺎﻣﯿﻦ‬
‫وﯾﻠﻲ ﯾﺤﻔﺰه ھﻮ اﻟﺜﺎﯾﺮوﯾﺪ ﻟﺬﻟﻚ ﯾﻠﻲ ﻣﺮﺗﻔﻊ ﻋﺪھﻢ ﻣﺮات اﺣﻠﻠﮭﻢ ﺛﺎﯾﺮوﯾﺪ‬
‫وﯾﻠﻲ ﯾﺰوده ﯾﻠﻲ ﯾﺎﺧﺬون ‪anti emetic‬‬
‫او ھﺬوﻟﺔ ﯾﻠﻲ ﯾﺎﺧﺬون ادوﯾﺔ ﻣﺎل ‪eratable bowel syndrome‬‬
‫او ﯾﺎﺧﺬون ﻣﻮاﻧﻊ ﺣﻤﻞ‬
‫ﯾﻠﻲ ﻋﺪھﻢ ﺗﻜﯿﺲ ھﻨﺎ ﺷﻠﻮن اﻓﺮق ﺑﯿﻦ اﻧﮫ اﻟﺴﺒﺐ اﻟﺒﺮوﻻﻛﺘﯿﻦ ﻟﻮ اﻧﮫ ھﻮ اﻟﻤﺒﯿﺾ ﺻﺎﯾﺮ ﺑﯿﮫ‬
‫ﺗﻜﯿﺲ ﺑﮭﺎي اﻟﺤﺎﻟﺔ ﻻزم اﻓﺮق ﻣﻦ ﺧﻼل اﺣﻠﻞ ﺑﺮوﻻﻛﺘﯿﻦ ﻛﻮن ﻣﻮاﻛﺜﺮ ﻣﻦ ‪ ١٠٠٠‬واذا ﺳﺒﺐ‬
‫اﻟﺒﺮوﻻﻛﺘﯿﻦ ﯾﻜﻮن اﻻﺳﺘﺮوﺟﯿﻦ ﻗﻠﯿﻞ‬

‫‪١٦‬‬ ‫‪ ٦‬كانون األول‪amenorrhea-1 - ٢٠٢٢ ،‬‬

🔔Hyperprolactinaemia may result
1-from prolactin secreting pituitary adenoma
(1cm )‫اﻛﻮ ﻧﻮﻋﯿﻦ ﻣﺎﯾﻜﺮو واﻛﺮو‬
‫اﻣﺎ اﻛﺜﺮ او اﻗﻞ‬
‫ ﻓﺪ‬hemiamenopia ‫اﻟﻤﺰﻋﺞ ﺑﺎﻟﻤﺎﻛﺮو اﻧﮫ ﻣﻦ ﺗﻜﺒﺮ ﺗﻀﻐﻂ ﻋﻠﻰ اﻟﻌﺼﺐ ﻣﺎل اﻟﻌﯿﻦ وﺗﺴﺒﺐ‬
‫ﻧﺴﺄﻟﮭﺎ ﻋﺪھﺎ ﺻﺨﻮﻧﺔ راﺳﺞ ﯾﺄذﯾﺞ‬
2- non-functioning disconnection tumour in the region of
hypothalamus which distrups inhibitory effect of dopamine on
prolactin secretion .
🔔 The women usually develop symptoms of oestrogen deficiency , in
contrast to hyperprolachinaemia due to PCOS , usually the patient has
.adequate oestrogen
‫ﻋﻈﺎﻣﮭﺎ ﺗﺄذﯾﮭﺎ‬
🔔Galactorrhoea may be found in up to a third of hyper
prolacinaemia , although its appearance is neither correlated with
prolactin level or with the presence of tumour .

🔔5% of patients present with visual field defects .

١٧ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦
* Diagnosis :
1. prolactin is an excellent tumour marker (( expect in
pregnancy )) and so the higher the serum level the larger the
size of the tumour :

e.g
=in microadenoma " size < 1 cm " --- level 1500-4000 mIu/L
=in macroadenoma " size > 1cm " --- ≥ 8000 mIu /L
non-functioning tumour ---- = 3000 mIu/L .
2. X-ray to the skull: signs are enlarged pituitary fossa ,
double contour to its floor and erosion of the clinoid process
3- others CT , MRI .

‫اذا اﻟﻤﺮﯾﺾ‬
‫ﻋﺪھﺎ ﻣﺎﯾﻜﺮو ادﯾﻨﻮﻣﺎ اﻋﻄﯿﮭﺎ ﻣﺎﻧﻊ ﺣﻤﻞ واﺷﻮﻓﮭﺎ ﯾﻜﺒﺮ ﻟﻮ ﻻ ﻗﺒﻞ ﻻ اﺧﻠﻲ اﻟﻤﺮة‬
‫ﺗﺼﯿﺮ ﺣﺎﻣﻞ‬

١٨ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦

* Treatment :
medical :
bromocriptine starting dose 1.25 mg and gradually increase " because
its sever side effect " until 7.5 mg/day in two or three divided doses . ‫اطﯿﮫ‬
‫ﺑﺤﺎﻻت اﻟﺤﻤﻞ‬
or cabergoline , less side effect use twice weekly in 0.25-1 mg dose ,
most patients show fall in prolactin level within few days and reduction
of tumour volume in 6 weeks .
‫ھﺬا ﻣﺎ اطﯿﮫ وﯾﻤﻜﻦ اطﯿﮫ ﺑﺤﺎﻻت ﻣﻌﯿﻨﮫ‬
surgery in the form of trans-sphenoidal adenectomy to those patient
who:
1. Drug resistance
2. Failure to shrink of macroadenoma
3. Intolerable side effects of the drug " most common indication "
4. Non-functioning tumour .
* In pregnancy there is 2% risk of expansion of microadenoma while
macroadenoma has 25% risk so it is important to prevent pregnancy at
least 3 month for treatment and shrinking of tumour to prevent supra
sellar expansion which my lead to loss of vision .
١٩ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦
 NOTE
Bromocreptine not contraindicated to use during
pregnancy while cabergoline is contra-indicated "
class C drug " .

٢٠ amenorrhea-1 - ٢٠٢٢ ،‫ كانون األول‬٦