Amenorrhea
Dr Jack Biko
introduction
• A symptom and not a Condition
• Absence of menstrual bleeding
• Maturation of H-P-O axis
• Outflow tract
Causes
• Hypothalamic
• Pituatory
• Ovarian
• Other
Amenorrhea
• Primary– Absence of menses by age 16 with normal
secondary sexual characteristics– Absence of menses by age 14 without
secondary sexual development
• Secondary– Absence of menses for 6 months in a
previously menstruating female, not on contraceptives
Amenorrhea
• Transient, intermittent or permanent
• Dysfunction of hypothalamus, pituatory gland, ovaries, uterus or vagina
• Thyroid gland• Adrenal gland
Hormonal events
Events of Puberty
• Thelarche (breast development)– Requires estrogen
• Pubarche/adrenarche (pubic hair development)– Requires androgens
• Menarche– Requires:– GnRH from the hypothalamus– FSH and LH from the pituitary– Estrogen and progesterone from the ovaries– Normal outflow tract
Teens with
• Secondary sexual characteristics present• No menstruation• Cyclical pains
• THINK MULLERIAN ANOMALIES / OBSTRUCTION OF OUTFLOW TRACT
Primary Amenorrhea
• Is there normal development of secondary sexual characteristics?
YES• Think– Pregnancy– Mullerian anomaly – outflow tract, uterine– Androgen insensitivity
Primary amenorrhea
• CNS pathology
• Ovarian - Genetic abnormality
• Obstruction of outflow tract
Are there secondary sexual characteristics?
Primary Amenorrhea
• Is there normal development of secondary sexual characteristcs?
NOThink hypogonadism or hypogonadotropism
Mayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis)
• 15% of primary amenorrhea
• Normal secondary development & external female genitalia
• Normal female range testosterone level
• Absent uterus and upper vagina & normal ovaries• Karyotype 46-XX
• 15-30% renal, skeletal and middle ear anomalies
Imperforate Hymen
Amenorrhea with Immature Secondary Characteristics
FSH Serum level
/Low normal
High
Hypogonadotropichypogonadism
Gonadal dysgenesis
Gonadal Dysgenesis
• Chromosomally abnormal
- Classic turner’s syndrome (45XO) - Turner variants (45XO/46XX),(46X-abnormal X) - Mixed gonadal dygenesis (45XO/46XY)
• Chromosomally normal
- 46XX (Pure gonadal dysgeneis) - 46XY (Swyer’s syndrome)
Androgen Insensitivity
• Normal breasts but no sexual hair
• Normal looking female external genitalia
• Absent uterus and upper vagina
• Karyotype 46, XY• Male range testosterone
level• Treatment :
gonadectomy after puberty + HRT
Amenorrhea
• Evaluation
– Pregnancy test– Physical exam to determine presence of uterus– FSH– Karyotype
Amenorrhea
• Treatment
– Cyclic estrogen/progestin
– Remove gonadal streaks if XY or mosaic• Increased (52%) risk of gonadoblastomas, dysgerminomas, and
yolk sac tumors
– Pulsatile GnRH for ovulation induction in select patients
– Surgical resection of intrauterine, cervical, and vaginal septa
Secondary Amenorrhea
• Pregnancy!• CNS disorders• Pituitary gland• Thyroid• Ovary• Uterus• Systemic disorders– Renal failure, liver disorders, DM
• Medications: anti-psychotics, reserpine
Secondary Amenorrhea
• CNS disorders– Chronic hypothalamic anovulation• Stress• Increased exercise levels• Anorexia nervosa
– Head trauma– Space-occupying lesions
Secondary Amenorrhea
• Hyperprolactinemia: Prolactinoma• Medications
• Renal failure• Pituatory injury
• Pituitary resection• Sheehan’s syndrome
• Thyroid disorders– Hyper- or hypothyroidism
Secondary Amenorrhea
• Ovulation disorders– Polycystic ovarian syndrome– Premature ovarian failure
• Uterine abnormalities– Asherman’s syndrome– Cervical stenosis
• Drug-induced amenorrhea– Hormonal contraceptives– GnRH analogues
PCOS
• First described in 1935• Findings of polycystic
ovaries reported more than 100yrs previously
• A syndrome – no single feature or test is diagnostic
Endocrinology of PCOS
•Hyper-production of androgens by theca cells.
•Abnormal ovarian steroid-genesis
•Failure of follicular maturation.
•Lack of progesterone production due to corpus luteum absence.
•Subsequent increase of LH level.
Diagnostic Criteria; Rotterdam 2003
• Based on Consensus
• Oligo or anovulation• Hyperandrogenism – clinical or biochemical• Polycystic ovaries
Exclude other causes of androgen excess
Intra-uterine adhesions
• Asherman’s syndrome
• Previous D&C
• Previous endometritis
• Endometrial TB
Asherman’s Syndrome
Treatment
• Hysteroscopic resection
• High dose oestradiol
Hysteroscopy
AmenorrheaHistory
Nutrition/exercise habits, weight changeSexual/contraceptive practiceHistory of uterine/cervical surgery
Physical examHeight/weightHirsutismGalactorrheaEstrogen status of tissues
LaboratoryBhCG PRL & TSH progesterone challenge
FSH if high karyotype
Secondary Amenorrhea
• Treatment goals– Discovery and treatment of underlying
disorder– Hormone replacement– Menses every 1-3 months– Pregnancy• Ovulation induction• FSH/LH
Case studies
12 year old
• No periods
• No pain
• No secondary sexual characteristics
15 yr old
• No periods• Cyclical pains• Has secondary sexual characteris
24 yr old
• G3P0
• TOP x 3
• No periods for 6 months now
33 yr old
• Amenorrhea for 4 yrs
• Para 0
• No cyclical pains
• Normal secondary sexual characteristics
Amenorrhea
• 26 yr Gravida 0 with menarche at age 14 presents with one-year history of amenorrhea.
• Obese
• Hirsutism
Thank you