AmenorrheaAmenorrhea DI WEN DI WEN M.D., Ph.D., M.D., Ph.D.,

Professor & ChairmanProfessor & Chairman

Department Of Obstetrics & GynecologyDepartment Of Obstetrics & Gynecology

Renji Hospital Affiliated to SJTU School of MedicineRenji Hospital Affiliated to SJTU School of Medicine

AmenorrheaAmenorrhea

• Amenorrhea is the absence of Amenorrhea is the absence of menstruation.menstruation.

• PrimaryPrimary

– Absence of menses by age 16 with Absence of menses by age 16 with normal secondary sexual normal secondary sexual characteristics.characteristics.

– Absence of menses by age 14 without Absence of menses by age 14 without secondary sexual development.secondary sexual development.

• SecondarySecondary

– Absence of menses for 6 months in a Absence of menses for 6 months in a previously menstruating female.previously menstruating female.

Events of PubertyEvents of Puberty

• Thelarche Thelarche (breast development)(breast development)

– Requires estrogenRequires estrogen

• Pubarche/adrenarche Pubarche/adrenarche (pubic hair (pubic hair development)development)

– Requires androgensRequires androgens

Events of PubertyEvents of Puberty

• MenarcheMenarche

Requires:Requires:

– GnRH from the hypothalamusGnRH from the hypothalamus

– FSH and LH from the pituitaryFSH and LH from the pituitary

– Estrogen and progesterone from Estrogen and progesterone from the ovariesthe ovaries

– Normal outflow tractNormal outflow tract

P1P1

P5P5

P4P4

P3P3

P2P2

Tanner’sTanner’s

Classification of amenorrheaClassification of amenorrhea

• hypothalamic amenorrheahypothalamic amenorrhea

• pituitary amenorrheapituitary amenorrhea

• ovarian amenorrheaovarian amenorrhea

• uterine amenorrheauterine amenorrhea

EtiologyEtiology

• hypothalamic amenorrheahypothalamic amenorrhea– Psychological stressPsychological stress

– 5a-Reductase deficiency5a-Reductase deficiency

– Anorexia nervosa, weight lossAnorexia nervosa, weight loss

– Increased exercise levelsIncreased exercise levels

– Kallmann syndromeKallmann syndrome

– drug-induced amenorrhea drug-induced amenorrhea

– Space-occupying lesion of CNSSpace-occupying lesion of CNS

EtiologyEtiology

• pituitary amenorrheapituitary amenorrhea– tumortumor

– Empty sella syndromeEmpty sella syndrome

– Sheehan syndromeSheehan syndrome

EtiologyEtiology

• ovarian amenorrheaovarian amenorrhea– Gonadal dysgenesisGonadal dysgenesis

– Turner syndrome: low hair line, web Turner syndrome: low hair line, web neck, shield chest, and widely neck, shield chest, and widely spaced nipplesspaced nipples

– Swyer syndrome Swyer syndrome

– resistant ovary syndromeresistant ovary syndrome

– Premature ovarian failurePremature ovarian failure

Tunner stagingTunner staging

Acanthosis nigransAcanthosis nigrans

StriaeStriae

Typical features of Turner SyndromeTypical features of Turner Syndrome

EtiologyEtiology

• uterine amenorrheauterine amenorrhea

– Absence of uterusAbsence of uterus

– Asherman syndromeAsherman syndrome

• anatomic abnormalities of the anatomic abnormalities of the reproductive tract reproductive tract – Imperforate HymenImperforate Hymen

Imperforate HymenImperforate Hymen

Mayer-Rokitansky-Kuster-Hauser SyndromeMayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis)(utero-vaginal agenesis)

• 15% of primary amenorrhea 15% of primary amenorrhea

• Normal secondary development & Normal secondary development & external female genitaliaexternal female genitalia

• Normal female range testosterone Normal female range testosterone levellevel

• Absent uterus and upper vagina Absent uterus and upper vagina & normal ovaries& normal ovaries

• Karyotype 46-XXKaryotype 46-XX

• 15~30% renal, skeletal and middle 15~30% renal, skeletal and middle ear anomaliesear anomalies

Androgen InsensitivityAndrogen Insensitivity

• Normal breasts but no sexual Normal breasts but no sexual hairhair

• Normal looking female Normal looking female external genitaliaexternal genitalia

• Absent uterus and upper Absent uterus and upper vaginavagina

• Karyotype 46, XYKaryotype 46, XY

• Male range testosterone levelMale range testosterone level

• Treatment : gonadectomy Treatment : gonadectomy after puberty + HRTafter puberty + HRT

DiagnosisDiagnosis

• History History

• Physical examinationPhysical examination– Physical examination begins Physical examination begins

with vital signs, including with vital signs, including height and weight, and with height and weight, and with sexual maturity ratings sexual maturity ratings

• Laboratory evaluationLaboratory evaluation

VE- preg test

TSH ,PROLACTIN’, Prog.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 hysteroscopy asherman

2wk

FSH norm.

repeatRepeat+serum ,est.level

PROFhypothalamic-pituitary failure

anovulation

TreatmentTreatment

• treatment varies depending upon the treatment varies depending upon the causes of the amenorrhea. Treatment causes of the amenorrhea. Treatment options include:options include:

– Dietary changes, including an increase in Dietary changes, including an increase in fat and calories in order to stimulate fat and calories in order to stimulate estrogen production. estrogen production.

– Counseling for eating disorders. Counseling for eating disorders.

– Using stress reduction techniques to Using stress reduction techniques to help regulate the period. help regulate the period.

– Hormonal supplements, like the Hormonal supplements, like the birth control pillbirth control pill or or patchpatch, or , or hormone replacement therapyhormone replacement therapy. .

– Surgery to remove cysts, fibroids or Surgery to remove cysts, fibroids or tumorstumors

DI WEN DI WEN M.D., Ph.D.M.D., Ph.D.

Professor & ChairmanProfessor & Chairman

Department of Obstetrics & GynecologyDepartment of Obstetrics & Gynecology

Renji Hospital Affiliated to SJTU School of MedicineRenji Hospital Affiliated to SJTU School of Medicine

Thanks for Your AttentionThanks for Your Attention