Amenorrhea In the name of GOD
AmenorrheaIn the name of GOD
Deffination Amenorrhea is the absence or cessation of
menses and may result from a wide variety of pathological condition:
AnatomicalEndocrineOrganic
Primary Amenorrhea : secondary sexual development fails to begin by age 14,or begins but fails to progress.
Secondary Amenorrhea : once menstural cycles have been established ,amenorrhea for an interval equivalent to 3 previous cycles,or 6 months.
The Normal Menstrual Cycle1.Functional Hypothalamus to synthesize and
release GnRHin a pulstile pattern.2.Pitutitary gonadotrophs must have the capacity
to synthesize and secret gonadotropinsin response to GnRH.
3.Ovaries must contain follicles responsive to pituitiary FSH & LH stimulation.
4.Normal genital outflow tract and FunctionalEndometrium capable of respance to estrogen & progestrone.
Hypothalamus
Pitutitary
Ovaries
Genital outflow tract
Functional Endometrium
Genital Tract AbnormalitiesCongenital:
vaginal/mullerian agenesisandrogen insensitivity syndrome(AIS)imperforate hymentransverse vaginal septumcervical atresia
Acquired:asherman syndromecervical stenosis/obstraction
Abnormal Genital Tract Anatomy
A history of primary amenorrhea and absent or blind vaginaimperforate hymen , transverse vaginal septum , cervical atresia
a the time of menarche with complaint of cyclic perineal,pelvic or abdominal pressure or pain.
Imperforate Hymen
Abnormal Genital Tract Anatomy
Vaginal/mullerian agenesis
Asymtomatic and Normal breast and pubic hair development but absent vagina.
androgen insensitivity syndrome(AIS)
Normal breast and pubic hair development,absent or sparse growth of pubic hair and shot blind vagina.
Abnormal Genital Tract Anatomy
asherman syndrome
Dysmenorrhea and spotting
cervical stenosis/obstraction
Dysmenorrhea and hypomenorrhea,subfertility or recurrentearly pregnancy loss
Hypothalamus
Pitutitary
Ovaries
Genital outflow tract
Functional Endometrium
Congenital
Acquiredcervical stenosis/obstraction
asherman syndrome
cervical atresia
vaginal/mullerian agenesis
androgen insensitivity syndrome
imperforate hymen
transverse vaginal septum
Ovarian Disorders
Gonadal dysgenesis(30-40 %)Turner syndrome (45 XO)Swyer syndrome (46 XY)
No significant secondary sexual development
Premature ovarian failure (POF)Have significant secondary sexual development
Other:17- α hydroxylase deficencyAromatase deficencyGonadotropin-resistant ovary syndrome
Primaryamenorrhea
Secodaryamenorrhea
Normal Genital Tract Anatomy
Increased FSH: ovarian failure(Gonadal dysgenesis,Premature ovarian failure)
Hypothalamus
Pitutitary
Ovaries
Genital outflow tract
Functional Endometrium
Congenital
Acquiredcervical stenosis/obstraction
asherman syndrome
cervical atresia
vaginal/mullerian agenesis
androgen insensitivity syndrome
imperforate hymen
transverse vaginal septum
Gonadal dysgenesis
Premature ovarian failure
Other
Pituitary Disorders
Pituitary tumorsFunctional tumors (Prolactin,GH,TSH,ACTH)
Empty Sella syndromeSheehan syndrome
Normal Genital Tract Anatomy
1- TSH
hypo and hyper thyroidism
2-Prolactinprolactin-secreting pituitary adenomaother pituitary and hypothalamic tumorsdrugsbreast or chest wall stimulationhypothyroidismOCPothers…
3-FSHdecreased or normal
Hypothalamus
Pitutitary
Ovaries
Genital outflow tract
Functional Endometrium
Congenital
Acquiredcervical stenosis/obstraction
asherman syndrome
cervical atresia
vaginal/mullerian agenesis
androgen insensitivity syndrome
imperforate hymen
transverse vaginal septum
Gonadal dysgenesis
Premature ovarian failure
Other
Pituitary tumorsFunctional tumors (Prolactin,GH,TSH,ACTH)
Empty Sella syndromeSheehan syndrome
•Hypothalamic Disorders
The most common cause of amenorrhea
Congenital:Kallmann syndrome
Aquired:PCOSHypothalamic amenorrheaHypothalamic tumorsHyperprolactinemia
Normal Genital Tract Anatomydecreased or normal FSH:pituitary & hypothalamic disorders(PCOS,Hypothalamic Amenorrhea)
PCOS: 1, ovulatory dysfunction
2, clinical evidence of hyperandrogenism(hirsutism,acne,androgenic alopecia)3, exclusion of other disorders(hyperprolactinema,CAH,thyroid abnormalities)+ obesity& insulin resistant
Normal Genital Tract Anatomy
Hypothalamic Amenorrhea:absence of obesity or evidence of hyperandrogenism of PCOS.
Determination of Estrogen Status???????? serum estradiol cervical mucus progestin challenge test
Hypothalamus
Pitutitary
Genital outflow tract
Functional Endometrium
Congenital
Acquiredcervical stenosis/obstraction
asherman syndrome
cervical atresia
vaginal/mullerian agenesis
androgen insensitivity syndrome
imperforate hymen
transverse vaginal septum
Gonadal dysgenesis
Premature ovarian failure
Other
Pituitary tumorsFunctional tumors (Prolactin,GH,TSH,ACTH)
Empty Sella syndromeSheehan syndrome
PCOSHypothalamic amenorrhea
Hypothalamic tumorsHyperprolactinemia
Congenital disorders (Kallmann syndrome)
Ovaries
Evaluation of AmenorrheaMedical History
Physical examination
Diagnostic evaluation: TSHProlactinFSH
Medical History
Puberty : acceleration of growth
thelarcheadrenarchemenarrche
Medical History Vaginal dryness or hot flushes: estrogen deficency Progressive hirsutism or virilization: hyperandrogenism Bilateral galactorrhea: hyperprolactinemia Cyclic pelvic or lower abdominal pain or urinary
complaints: developmental anpmalies …
Physical Examination Short stature(less than 60 inches): gonadal dysgenesis Sexual infantilism/webbing of the neck,low set ear &
posterior hairline,widely spaced nipples,short fourth metacarpal,cubitus valgus : turner
Acne and hirsutism: hyperandrogenism Obesity or an increased waist to hipe ratio: insulin
resistant & chronic anovulation …
Treatment (genital tract abnormalities)
Vaginal/mullerian agenesis: vaginal dilation & operative treatment.
AIS: operative treatment & removed the testes. Imperforate hymen: cruciate incision. Transverse vaginal septum and cervical atresia:
surgical management. cervical stenosis: uterine sounding & cervical
dilation Asherman syndrome: high-dose exogenous
estrogen treatment.
Treatment(ovarian disorders)
Gonadal dysgenesis: 1-GH 2-Sex hormone replacement therapy
(low doses of estrogen & progestin)
POF: estrogen/progestin hormone replacement therapy
Treatment(pituitary disorders)
Pituitary tumors:* Medical treatment(Bromocriptine & Cabergoline)* Sugery treatment.
Empty sella syndrome: like pituitary adenoma.
Sheehan syndrome: hormone replacement therapy.
Treatment(hypothalamic disorders)
PCOSDesire pregnancy: 1-weight loss
2-Clomiphene citrate3-Metformin4-Gonadotropins
Not desire pregnancy : OCP Hypothalamic amenorrheaDesire pregnancy: 1-redused physical activity & increased weight
2-Clomiphene citrate3- Gonadotropins & HCG
Not desire pregnancy : OCP
Negative Pregnancy.test
TSH ,PROLACTIN, Progesterone challenge test
withdrawal bleeding
without withdrawal bleeding
hypoestrogenic compromised outflow tract
+ve.est/progest challenge test
-ve.est/progest challenge test
FSH>30-40Normal FSH
HSG OR hysteroscopyAsherman’s
FSH norm.
repeatRepeat+serum estrogen level
PreOvFailure
hypothalamic-pituitary failure
anovulation
tHaNkS…
References:Danforth’s OBSTETRICS & GYNECOLOGYBerek & Nonak’s GYNECOLOGY
By: Drtabatabai