Amenorrhoea

Amenorrhoea

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  By Dr. Md RaziAhmad, MD(Moalejat) Assist. Prof. dept. of Niswa wa Qabalat GTCH, Patna AMENORRHEA
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  AMENORRHEA Is the absenceor abnormal cessation of the menses PHYSIOLOGIAL AMENORRHEA PATHOLOGIAL AMENORRHEA
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  CONTROL OF MENSTRUALCYCLE HYPOTHALAMUS PITUITARY ENDOCRINE OVARIAN OUTFLOW TRACT AXIS
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  CLASSIFICATION OF AMENORRHEA AMENORRHEA PHYSIOLOGICALPATHOLOGICAL Pre-puberty Pregnancy related Menopause Primary Secondary
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  AMENORRHEA A patient isdiagnosed amenorrhea if she has menarche by age 16 with with primary not reached normal secondary sexual characteristics.  Secondary amenorrhea if established menses have ceased for longer than 6 months without any physiological reasons. PATHOLOGICAL AMENORRHEA
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  ETIOLOGY OF AMENORRHEA PITUITARY ENDOCRINE OVARIAN OUTFLOWTRACT AXIS Congenital absent of uterus and vagina Vaginal atresia Imperforate hymen Asherman’s syndrome Pituitary adenoma Sheehan’s syndrome Hypothalamic-hypogonadism HYPOTHALAMUS Weight related amenorrhea (anorexia nervosa) Hypothyroidism Gonadal dysgenesis Gonadal failure PCOS
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  Etiology of Amenorrhea Primary Gonadal failure (43%)  Congenital absence of uterus and vagina (15%)  Constitutional delay (14%) Secondary  Chronic anovulation (39%)  Hypothyroidism / hyperprolactinemia (20%)  Weight loss/anorexia (16%)
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  Primary Amenorrhea Primary amenorrheais the failure to start menstruation by age of 16 in a girl with normal secondary sexual characteristics OR by the age of 14 where there is a failure to develop secondary sexual characteristics
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  HYPOTHALAMUS-PITUITARY OVARIAN Primary Amenorrhea - ETIOLOGY- CHROMOSOME MUTATION Androgen insensitivity (testicular feminization) Hypothalamic failure (Kallmann’s syndrome) Turner’s syndrome Gonadal dysgenesis Absent of uterus Absent of vagina OUTFLOW TRACT Imperforate hymen
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  Primary Amenorrhea - ETIOLOGY- OUT FLOW TRACT DISORDERS (Imperforate hymen) Imperforate hymen represents one form of failure of complete canalization of the vagina. Most frequent obstructive anomaly of the female genital tract. Presentation: primary amenorrhea associated with cyclical abdomen pain – abdominal swelling and urinary retention. Signs: Bluish bulging membrane at the introitus
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  GONADAL DYSGENESIS (Turner’ssyndrome) Primary Amenorrhea - ETIOLOGY - Chromosomal abnormalities ( 45XO female) Associated with streak ovarian tissue and primary amenorrhea. Presentation: primary amenorrhea associated with features of Turner’s syndrome – short stature, webbed neck, increased carrying angle at the elbow and sexual infantilism.
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  ANDROGEN INSENSITIVITY (Testicularfeminization) Primary Amenorrhea - ETIOLOGY - A syndrome found in patient with X, Y chromosome but resistant to androgens (androgen insensitivity. Has male karyotype (45XY) with female appearance. Presentation: Female appearance with normal breast development and external genitalia. Primary amenorrhea , absent uterus Gonad - testes Phenotype female Genotype female XY
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  HYPOTHALAMIC FAILURE (Kallmann’ssyndrome) Primary Amenorrhea - ETIOLOGY - Congenital disorder characterized by: 1) Hypogonadotropic hypogonadism 2) Eunuchoidal features 3) Anosmia or hyposmia 4) Primary amenorrhea Caused by defect in synthesis and/or release of gonadorelin (LH releasing hormone) G
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  Secondary Amenorrhea Secondary amenorrheais the absence of menstrual periods for 6 months in a woman who had previously been regular, or for 12 months in a woman who had irregular periods without any physiological reasons.
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  Secondary Amenorrhea - Physiological- 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.
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  HYPOTHALAMUS-PITUITARY OVARIAN OUTFLOW TRACT Secondary Amenorrhea -ETIOLOGY - ENDOCRINE Hypothyroidism Cushing’s Adrenal tumour Ovarian tumour (androgen) Pituitary tumour Sheehan’s syndrome Hypothalamic dysfunction Premature ovarian failure PCOS Surgical removal Asherman’s syndrome Hysterectomy
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  Secondary Amenorrhea - ETIOLOGY- 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 and ovulation The classical picture – AMENORRHEA, OBESE, SUBINFERTILITY and HIRSUITISM
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  HYPOTHALAMIC CAUSES Secondary Amenorrhea -ETIOLOGY - Hypothalamic dysfunction is a common cause (30%). It is more often seen as a result of stress, weight loss and eating disorders It may be due to tumour, infarction, thrombosis or inflammation.
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  PITUITARY CAUSES Secondary Amenorrhea -ETIOLOGY - Pituitary failure - It is usually the acquired type as the result of trauma, treatment of pituitary tumour or infarction after massive blood loss ( Sheehan’s syndrome ) Pituitary tumour  hyperprolactinaemia which cause secondary amenorrhea.
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  Secondary Amenorrhea - ETIOLOGY- 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.
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  ANATOMICAL CAUSES Secondary Amenorrhea -ETIOLOGY - 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
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  PREMATURE OVARIAN FAILURE SecondaryAmenorrhea - ETIOLOGY - Premature ovarian failure occurs in about 1% before the 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
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  DRUGS CAUSING HYPERPROLACTINAEMIA SecondaryAmenorrhea - ETIOLOGY - 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
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  THE ASSESSMENT HISTORY EXAMINATION INVESTIGATIONS
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  ASSESSMENT The most commoncause 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.
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  History A good historycan reveal the etiologic diagnosis in up to 85% of cases of amenorrhea. ASSESSMENT
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  Weight change A large amount of weight loss (anorexia nervosa) Hot flashes , decreased libido  premature menopause Certain medications Contraception Associate symptoms - Cushing's disease , hypothyroidism CLINICAL ASSESSMENT - HISTORY - ASK ABOUT Menstrual cycle  age of menarche and previous menstrual history Previous pregnancies - severe PPH (Sheehan’s syndrome) Previous gynaecological surgery Chronic illness
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  CLINICAL ASSESSMENT - EXAMINATION- CHECK FOR BODY MASS INDEX (BMI)  weight loss-related amenorrhea BLOOD PRESSURE  elevated in Cushing and PCOS ANDROGEN EXCESS  hirsuitism (PCOS) – virilization (tumour) Secondary sexual characteristic Features of Turner’s syndrome Breast examination  may revealed galactorrhea, Abdominal (haemato mera) and pelvic masses (ovarian tumour) Inspection of genitalia  imperforate hymen, cervical stenosis Vaginal examination  blind vagina, vaginal atresia, absent of uterus
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  If the historyand physical exam are suggestive of a certain etiology The workup can sometimes be more directed CLINICAL ASSESSMENT - INVESTIGATIONS -
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  Some patients willnot demonstrate any obvious etiology for their amenorrhea on history and physical examination These patients can be worked up in a logical manner using a stepwise approach. CLINICAL ASSESSMENT - INVESTIGATIONS -
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       BLOOD TESTS ULTRASOUND CT scanof pituitary KAROTYPING LAPAROSCOPY INVESTIGATING PRIMARY AMENORRHEA
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  INVESTIGATING PRIMARY AMENORRHEA SITE OFDISORDER DIAGNOSIS INVESTIGATIONS HYPOTHALAMUS Hypothalamic-hypogonadism FSH, LH and estradiol - Low PITUITARY Pituitary adenoma Prolactin – High FSH, LH and estradiol - Low OVARY Gonadal dygenesis (Turner’s syndrome) FSH and LH – High Estradiol – Low Karyotype – 45 XO MULLERIAN TRACT Absent uterus (Testicular feminization) PCT – negative Karyotyping – 46 XY GENITAL TRACT Imperforate hymen FSH, LH, estardiol – normal PCT – negative Examination – imperforate hymen
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  Primary amenorrhea vagina no yes congenitaluterovaginal agenesis imperforate hymen complete transverse vaginal septum Pubic hair Estrogenized Progesterone challenge abnormal ovaries FSH Level Chromosome Analysis breasts have developed no no yes complete androgen insensitivity syndrome + - high low abnormal hormonal stimulation of normal ovaries (Hypothalamic-hypogonadism)
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  INVESTIGATING SECONDARY AMENORRHEA The mostcommon 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.
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      Progesterone challenge test TSH(thyroid stimulating hormone) FSH, LH Prolactin level INVESTIGATING SECONDARY AMENORRHEA Once pregnancy has been excluded
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  FSH, LH andThyroid function test Progesterone challenge test WITHDRAWAL BLEEDING NO WITHDRAWAL BLEEDING HYPOESTROGENIC COMPROMISED OUTFLOW TRACT Negative E-P challenge test Normal FSH Asherman’s syndrome (HSG or hysteroscopy) Normal or Low FSH Ovarian Failure Hypothalamic-pituitary failure ANOVULATION Positive E-P challenge test Very high FSH FSH normal + high LH  PCOS High prolactin  pituitary tumour NEGATIVE PREGNANCY TEST INVESTIGATING SECONDAY AMENORRHEA
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  Ovarian failure (premature menopause) chromosomal anomalies autoimmune disease Ifthe woman is under 30, a karyotype should be performed to rule out any mosaicism involving a Y chromosome. it is prudent to screen for thyroid, parathyroid, and adrenal dysfunction If a Y chromosome is found the gonads should be surgically excised. Laboratory evidence of autoimmune phenomenon is much more prevalent than clinically significant disease SECONADARY AMENORRHEA
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  Hypothalamic-pituitary failure  who donot bleed after the progestin Patients challenge  But do bleed after estrogen/progestin and  Have normal or low FSH and LH levels SECONDARY AMENORRHEA
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  INVESTIGATING SECONDARY AMENORRHEA SITE OFDISORDER DIAGNOSIS INVESTIGATIONS HYPOTHALAMUS Hypothalamic – failure Weight-related amenorrhea FSH, LH and estradiol - Low PITUITARY Pituitary adenoma Sheehan syndrome Prolactin – High FSH, LH and estradiol – Low FSH, LH and estrogen - Low ENDOCRINE Hypothyroidism TSH – raised ; T4 – low or N OVARY Premature menopause PCOS FSH, LH – high ; E2 – low FSH – Normal ; LH - High MULLERIAN TRACT Asherman’s syndrome PCT – negative HSG / Hystereoscopy
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  TREATMENT OF AMENORRHEA The needfor treatment depends on Underlying causes Need for regular periods Trying to conceive (fertility Need for contraception)
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  TREATMENT OF AMENORRHEA Underlying causes PITUITARYTUMOUR  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  appropriate treatment ASHERMAN’s syndrome  breaking down adhesion + insert IUCD
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  TREATMENT OF AMENORRHEA TRYING TOCONCEIVE The 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
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  TREATMENT OF AMENORRHEA WANT REGULARPERIOD The use of 1): COMBINED ORAL CONTRACEPTIVE 2): HRT NEED CONTRACEPTION Confirmed ovarian failure will not required contraception Women requiring contraception  oral contraceptives are method of choice
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  AMENORRHEA