amenorrhoea for undergraduates

AMENORRHOEA

Presented by :-

CHAITANYA SHEORANUniversity college of medical science

Delhi, INDIA

Amenorrhea

Absence Of Menstruation.

ORIGIN from Greek

Classification of amenorrhea

AMENORRHEA

PHYSIOLOGICAL PATHOLOGICAL

Pre-pubertyPregnancy

relatedMenopause

Primary

Secondary

The Hypothalamic-Pituitary-Ovarian Axis

http://www.shen-nong.com/eng/images/exam/missedperiods/img_mp1a.gif

Clinically

Primary Secondary

ETIOLOGY OF AMENORRHEA

HYPOTHALAMUS

PITUITARY

ENDOCRINE

OVARIAN

OUTFLOW TRACTAXIS

Congenital absent of uterus and vagina

Vaginal atresia

Imperforate hymen

Asherman’s syndrome

Pituitary adenoma

Sheehan’s syndrome

Hypothalamic-hypogonadism

Weight related amenorrhea(anorexia nervosa)

HypothyroidismGonadal dysgenesis

Gonadal failure

PCOS

Common causes of Amenorrhea

Primary  » Gonadal failure (45%) » Congenital absence of uterus and vagina (20%)» Constitutional delay (15%)

Secondary  Chronic anovulation (40%)

» Hypothyroidism / hyperprolactinemia (20%) »Weight loss/anorexia (16%)

Constitutional pubertal delay

• Common cause (15%) Positive family history

• Under stature and delayed bone age ( X-ray Wrist joint)

• Diagnosis by exclusion and follow up

• Prognosis is good(late developer)

• No drug therapy is required – Reassurance (? HRT)

Evaluation Categories

• 1-Breast Absent – Uterus Present

• 2-Breast Present – Uterus Absent

• 3-Breast Present – Uterus Present

• 4-Breast Absent – Uterus Absent

46 XX

Typical features of Turner Syndrome 1st common cause (45% of causes )

•A craniopharyngioma is a benign tumor that develops near the pituitary gland .

• most commonly in childhood and adolescence and •in later adult life.compresses the pituitary stalk or gland , the tumor can cause partial or complete pituitary hormone deficiency.

• Family history: Consider watchful waiting

• Request: FSH, LH- Raised: Karyotype: 45 XO Turner syn

46 XX Premature ovarian failure

- Low: Constitutional delayConsider: anorexia

exerciseillnesscoeliac diseasehypothalamic/pituitary

Secondary sexual charactersabsent 14y

Utero-vaginal Agenisis Mayer-Rokitansky-Kuster-Hauser syndrome

• Second most common cause of Primary amenorrhea.

• Normal breasts and axillary/pubic hair growth.• Normal looking external genitalia

• Karyotype 46-XX

• Renal abnormalities in 15-30 % cases.

• Treatment : Vaginal creation (Dilatation VS Vaginoplasty)

• Normal breasts but no sexual hair

• Normal looking female external genitalia

• Absent uterus and upper vagina

• Karyotype 46, XY

• Male like testosterone level

• Treatment : gonadectomy after puberty + HRT

Androgen insensitivityTesticular feminization syndrome

• Absent/abnormal then karyotype:- 46 XX Mullerian agenesis- 46 XY Androgen insensitivity

• Present •+ no outflow obstruction

- As for 2o amenorrhoea

Secondary sexual characteristics Present by 16 yearsUltrasound uterus

1-Rule out pregnancy!

2-Exclude cryptomenohrea

✴1-Pregnancy

✴2-Cryptomenorrhea : imperforated hymen, vaginal septum,

✴3- Secondary Amenorrhea :hypothalamic, pituitary ,other endocrionpathy

Very rare

Gonadal agenesisGonadal destructionCongenital enzyme defects

classification

Classify according to level of serum FSH

• Hypergonadotropic primary amenorrhea • Eugonadrotropic primary amenorrhea• Hypogonadotropic primary amenorrhea

Hypergonadotropic primary amenorrhoea

Abnormal sex chromosome :-Turner syndrome Normal sex chromosome:-gonadal dysgenesis

Eugonadotropic primary amenorrhoea

• Androgen insensitivity syndrome(testicular feminisation)

• Rokitansky-kuster-hauser syndrome• PCOS• Cryptomenorrhoea

Hypogonadotropic primary amenorrhoea

Hypothalamic causes• Hypothalamic hypogonadsim (kallman’s

syndrome)• Psychogenic causes, weight loss, stress,

anorexia nervosa, malnutritionPituitary causes• Short stature, obesity, mental retardation• Craniopharyngiomas

Hypothalamic (Kallmann’s syndrome) • Hypogonadotropic hypogonadism

• Congenital disorder characterized by:

• 1) Anosmia or hyposmia• 2) Primary amenorrhea

• Caused by defect in synthesis and/or release of gonadorelin (LH releasing hormone)

CNS; HP Disorder

Gonadal Failure

History and physical examination completed for a patient with primary amenorrhea

Secondary sexual characteristics present

No Yes

Measure FSH and LH levels

Uterus absent or abnormal

Uterus present or normal

Karyotype analysis Outflow obstruction

FSH and LH < 5 IU/ L

Hypogonadotropic hypogonadism

Hypergonadotropichypogonadism

Karyotype analysis 46, XY 46, XX

Mullerian Agenesis

Androgen Sensitivity Syndrome

NoYes

Evaluate for secondary amenorrheaImperforate

hymen or transverse vaginal septum

Perform ultrasonography of uterus

Evaluation of Primary Amenorrhea

FSH > 20 IU/ L and LH > 40 IU/ L

Secondary amenorrhoea

In women of reproductive age, pregnancy is the most common cause of secondary amenorrhoea.

Pregnancy

Etiology of secondary Amenorrhoea

• Physiological :- pregnancy, lactation• Pathological:-

• genital tract• Ovarian• Pituitary• Hypothalamus• Nutrition• Suprarenal causes• Thyroid

Outflow tract ( uterine target organ)

Asherman's Syndrome

Ovary

PCOS

Premature Ovarian Failure

Resistance Ovarian Syndrome

Radiation & Chemotherapy .

(Hypergonadotropic Hypogonadism)

POLYCYSTIC OVARIAN SYNDROME (PCOS)

PCOS accounts for 90% of cases of oligoamenorrhea

Also known as Stein-Leventhal syndrome

The etiology is probably related to insulin resistance,with a failure of normal follicular development andovulation

The classical picture – AMENORRHEA, OBESE,SUBINFERTILITY and HIRSUITISM

HYPOTHALAMIC CAUSES

Hypothalamic dysfunction is a common cause (30%).

It is more often seen as a result of stress, weight lossand eating disorders

It may be due to tumour, infarction, thrombosis or inflammation.

Pituitary failure - It is usually the acquired type as the result of trauma, treatment of pituitary tumour orinfarction after massive blood loss ( Sheehan’s syndrome )

Pituitary tumour hyperprolactinaemia which cause secondary amenorrhea.

PITUITARY CAUSES

ENDOCRINE CAUSES

Thyroid disorder and Cushing’s disease interfere with the normal functioning of the hypothalamic -pituitary – ovarian axis present with amenorrhea.

High level of thyroxine inhibit FSH release.

Androgen – secreting tumours of the ovaries cause secondary amenorrhea.

ANATOMICAL CAUSES

Usually due to previous surgery.

Commonest example: 1). Hysterectomy 2). Endometrial ablation 3). Asherman’s syndrome (damage to the endometrium with adhesion formation) 4). Stenosis of the cervix following cone biopsy

PREMATURE OVARIAN FAILURE

Premature ovarian failure occurs in about 1% beforethe age of 40.

Premature ovarian failure may be due to: 1). Chemotherapy and radiotherapy. 2). Autoimmune disease following viral infection 3). Following surgery for conditions such as endometriosis

DRUGS CAUSING HYPERPROLACTINAEMIA

Hyperprolactinaemia accounts for 20% of cases of amenorrhea.

Prolactin inhibits GnRH release from the hypothalamus

Drugs that may cause hyperprolactinaemia: 1). Phenothiazines 2). Methyldopa 3). Cimetidine 4). Butyrophenones 5). Antihistamines

Classic 45-XO Mosaic (46-XX / 45-XO)

Turner’s syndrome premature ovarian failure

anorexia nervosaa nervosa

• A psychological disease characterized by

• Intense fear of gaining weight or being fat, despite being underweight

• Disturbance in one’s experience of body weight, size, and shape

• the refusal to maintain normal body weight, and amenorrhea

THE ASSESSMENT

HISTORY

EXAMINATION

INVESTIGATIONS

The most common cause of secondary amenorrhea in reproductive age women is pregnancy and this should always be excluded by physical exam and laboratory testing for the pregnancy hormone - HCG.

History

A good history can reveal the etiologic diagnosis in up to 85% of cases of

amenorrhea.

Hot flashes , decreased libido premature menopause

Certain medications

Weight change A large amount of weight loss (anorexia nervosa)

Associate symptoms - Cushing's disease , hypothyroidism Contraception

Previous gynaecological surgery

CLINICAL ASSESSMENT- HISTORY -

ASK ABOUTMenstrual cycle age of menarche and previous menstrual history

Previous pregnancies - severe PPH (Sheehan’s syndrome)

Chronic illness

Secondary sexual characteristic

Features of Turner’s syndrome

ANDROGEN EXCESS hirsuitism (PCOS) – virilization (tumour)

Abdominal (haemato mera) and pelvic masses (ovarian tumour) Breast examination may revealed galactorrhea,

Inspection of genitalia imperforate hymen, cervical stenosis

CLINICAL ASSESSMENT- EXAMINATION -

CHECK FORBODY MASS INDEX (BMI) weight loss-related amenorrhea

BLOOD PRESSURE elevated in Cushing and PCOS

Vaginal examination blind vagina, vaginal atresia, absent of uterus

• Progesterone challenge test • TSH (thyroid stimulating hormone)• FSH, LH • Prolactin level

INVESTIGATING

Once pregnancy has been excluded

FSH, LH and Thyroid function test Progesterone challenge test

WITHDRAWAL

BLEEDING

NO WITHDRAWAL

BLEEDING

HYPOESTROGENIC COMPROMISED OUTFLOW TRACT

Negative E-Pchallenge test

Normal FSH

Asherman’s syndrome

(HSG or hysteroscopy)

Normal or Low FSH

Ovarian FailureHypothalamic-pituitary

failure

ANOVULATIONPositive E-P

challenge test

Very high FSH

FSH normal + high LH PCOSHigh prolactin pituitary tumour

NEGATIVE PREGNANCY TEST

INVESTIGATING SECONDAY AMENORRHEA

1. Provera 10 mg PO once daily 7-10 days or

2. Norethindrone 5 mg PO once daily for 7-10 days or

3. Progesterone 200 mg IM for one dose .

Progesterone Challenge Test :

1. Premarin 1.25 mg orally daily for 21 days

2. Oral Contraceptive for 2 Cycles

3. Estradiol 2 mg orally daily for 21 days and Follow with 7-10 days of Progesterone

Estrogen progesterone challenge test

Asherman syndrome(intrauterine synechea)

Excessive curretageUterine infectionEndometrial TBDysfunctional uterine bleedingUterine packing in PPH

TREATMENT OF AMENORRHEA

The need for treatment depends on

Underlying causes

Need for regular periods

Trying to conceive (fertility)

Need for contraception)

TREATMENT OF AMENORRHEA

Underlying causesPITUITARY TUMOUR Bromocryptine / Surgery

ANDROGEN producing tumour of ovary Surgery

TESTICULAR FEMINIZATION removed gonad + HRT

TURNER’S syndrome HRT

IMPERFORATE HYMEN surgical incision

THYROID disease – appropriate medical treatment

EATING DISORDERS referred to psychiatrist

PCOS HRT/ surgery

ASHERMAN’s syndrome breaking down adhesion + insert IUCD

TREATMENT OF AMENORRHEA

TRYING TO CONCEIVEThe prognosis for women with confirmed ovarian failure is poor.

ANOVULATION response well with ovulation induction treatment

PCOS ovulation may resume with weight reduction – fertility drugs - use of gonadotrophins or ovarian drilling.

HYPERPROLACTINAEMIA respond to treatment with dopamine agonist.

HYPOTHALAMIC DYSFUNCTION maintenance of normal weight and change of lifestyle

ASHERMAN’S syndrome breaking down adhesion + insert IUCD

TREATMENT OF AMENORRHOEA WANT REGULAR PERIOD

The use of

1): COMBINED ORAL CONTRACEPTIVE 2): HRT

NEED CONTRACEPTIONConfirmed ovarian failure will not required contraception

Women requiring contraception oral contraceptives aremethod of choice

THANK YOU