amenorrhoea for undergraduates
TRANSCRIPT
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