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Amenorrhea: DR - Aliya Waheed Senior Registrar Department of Obstetrics and Gynaecology Ziauddin University & Hospitals
Amenorrhea: DR - Aliya Waheed Senior Registrar Department of Obstetrics and Gynaecology Ziauddin University & Hospitals
Dr.Aliya Waheed
Senior Registrar
Department of Obstetrics and Gynaecology
Ziauddin University & Hospitals
Puberty
Physiology of puberty
Onset: 10-16 years
Hypothalamus matures pulsatile release
Gonadotrophin releasing hormone
(GnRH) Pituitary gland FSH & LH
release Ovaries Oestradiol
Secondary sexual characteristics
Signs Of Puberty
Breast development
Pubic & axillary hair
Growth spurt
Onset of menstruation
Physiological amenorrhea
Before menarche
Pregnancy
Lactation
After menopause
Classification
Primary
Amenorrhea
Secondary Amenorrhea
Primary Amenorrhea
Primary Amenorrhea
Failure of spontaneous onset of menstruation
by the age of 16 years.
Primary Amenorrhea
Case 1:
17 years old brought by her mother for
complaints of failure to start menstrual
cycle.
Management?
History:
Withdrawl bleed, cyclical pain, urinary
retention
Past medical and surgical history (cranial,
thyroid, genital tract, chemotherapy,
radiotherapy)
Family history (mother and other sisters)
Personal history: athlete, vigorous exercise
Examination
Height and weight (BMI)
Secondary sexual characteristics, breast and
hair distribution (axillary and pubic)
Thyroid
Systemic examination (perabdominal mass)
Genital tract inspection
U te ru s a b s e n t
U te ru s p re s e n t
K a ry o ty p e
O u t flo w o b s tu c tio n
46XX
46XY
A b s e n t u te ru s a n d v a g in a
X Y fe m a le
N o rm a l a n a to m y
F S H /L H
P ro la c tin
N o rm a l
L H /F S H
F S H /L H
P ro la c tin
H Y p o th a lm ic
PCO
R e s is ta n t o v a ry
P ro la c tin o m a
No secondary sexual
characteristics
N o s e c o n d a r y s e x u a l c h a r a c t e r is t ic s
H e ig h t
N o rm a l
S h o rt
F S H /L H
F S H /L H
Low
H ig h
Low
H ig h
H y p o g o n a d o t r o p h ic
h y p o g o n a d is m
K a ry o ty p e
I n t r a c r a n ia l le s io n
K a r y o t y p in g
* P r e m a t u r e o v a r ia n fa ilu r e
* R e s is t a n t o v a r y
* G o n a d a l a g e n e s is
* X Y a g e n e s is
* X Y e n z y m a t ic fa ilu r e
X O o r v a r ia n t s
Female phenotype
Failure of testicular development, enzymatic failure of the
testis to produce androgens (testosterone), and androgen
receptor absence or failure of function.
Androgen insensitivity ---- structural abnormality with
androgen receptors, due to abnormalities of androgen
receptor genes---non-functional receptors.
Peripheral conversion of androgen to estrogen and
subsequent stimulation of breast growth
Case 2:
35 years old para 3+0 complaint of absent
menstrual cycles for 6 months.
Diagnosis?
Management?
History
Examination
General (BMI, thyroid, Galactorrhoea,
hirsuitism, galactorrhoea)
Systemic (mass)
Local examination
Secondary Amenorrhea
Classification of Secondary
Amenorrhea
Uterine causes:
Ashermans syndrome
Cervical stenosis
Ovarian causes:
PCOS
Premature ovarian failure (genetic, autoimmune,
infective, radio and chemotherapy)
Hypothalamic causes
(hypogonadotrophic hypogonadism):
Weight loss
Exercise
Chronic illness
Psychological distress
Idiopathic
Pituitary causes
Hyperprolactinaemia
Hypopituitarism (Sheehan syndrome)
Cranial irradiations
Head injuries
Tuberculosis
Systemic causes:
Chronic illness
Weight loss
Endocrine disorders
(thyroid disease, cushings disease)
P r o la c t in
FSH
H ig h
N o rm a l / L o w
A s s e s s R x ta k e n
C T s c a n o f p it u it a r y fo s s a
A b n o rm a l
N o rm a l
N e u r o lo g ic a l
o p in io n
C heck TS H
le v e l
N o rm a l o r
Low
H ig h
E s tr o g e n le v e l
I f p r e g n a n c y r e q u ir e d , e v a lu a t e p r o g e s t e r o n e
s t im u la t io n t e s t
H ig h
R e fr a c t o r y
o v a ry
b le e d in g + v e
H ig h
N o rm a l
T h y r o x in e
B r o m o c r ip t in e
C lo m ip h e n e
I f fa ilu r e
b le e d in g - v e
F o llit r o p in /
hC G or G nR H
Low
O v a r ia n
fa liu r e
POLYCYSTIC OVARY
SYNDROME (PCO)
Is the commonest endocrine disorder in
women (prevalence15-20%)
PCO runs in families and affects 50% of
first-degree relatives.
POLYCYSTIC OVARY
SYNDROME
Oligo- and/or anovulation
Hyperandrogenism(clinical and/or
biochemical)
Polycystic Ovaries (ovary with 12 or more
follicles measuring 2-9 mmin diameter and
increased volume(>10cm3 )on TVS.
Symptoms:
Hyperandrogenism(acne,hirsutism,alopecia)
Menstrual disturbances
Infertility
Obesity
Asymptomatic with PCO on U/S
Serum Endocrinology
Fasting Insulin
Androgens
Leutinizing hormone,normal FSH
Sex hormone binding globulin(SHBG)
Oestradiol,oestrone
Prolactin
Case:3
34 years old female married since 5 yrs
para 0+2,presented in OPD with secondary
amenorrohea.
a.Differential diagnosis.
b.What additional information will you obtain
about her complaint?
c.Briefly outline the investigation you will
undertake on her?
KEY(a)
Wt loss,stress anrexia
Hyperprolactinoma-galactorrhea,headaches
Drugs-steroids,antihypertensive
Feature of hyperandrogenismacne,hirsutism,wt gain voice change
Exclude Ashermans syndrome, infection
Symptoms of thyroid dysfunction
Premature menopause-hot flushes,mood
changes
KEY(b)
Exclude pregnancy
Hormonal profile
U/S of pelvis
C.T of brain to rule out prolactinoma
Hysteroscopy
THANKYOU