🔹 treatment varies depending upon the causes of the amenorrhea.
🔹
Treatment options include:
Dietary changes, including an increase in fat and calories in order to
🔹
stimulate estrogen production.
🔹🔹Counseling for eating disorders. treatment
Using stress reduction techniques to help regulate the period.
Hormonal supplements, like the birth control pill or patch, or
🔷
Amenorrhea is the absence of menstruation.
Primary:
- Absence of menses by age 16 with normal
🔹Surgery to remove cysts, fibroids or tumors
hormone replacement therapy. secondary sexual characteristics.
-absence of menses by age 14 without secondary
definition
🔷
sexual development.
secondary:
- Absence of menses for 6 months (or greater than
3times the previous cycle interval) in a previously
🔹
mnstruating female.
pregnancy, lactation or hysterectomy must be
🔹 🔹
excluder
prepubertal and post-menopausal conditions are
🔹 History
Physical examination
- Physical examination begins with vital
also to be excluded as physioiogical causes
signs, including height and weight, and DIAGNOSIS
🔹
with sexual maturity ratings
Laboratory evaluation
🔹 There is a difference of opinion about the age at
which
Primary Amenorrhea should be investigated--> 18 yrs.
🔹
often suggested.
Provided the patient has developed normal sec. sex.
Characteristics and cryptomenorrhoea has been
excluded. While those patient with Primary amenorrhea
and sexual
infantilism should be investigated at= age of 15 years or
2. GONADAl AGENESIS:
CLINICAL APPROACH 🌟
16 years (maybe earlier).
🔹 Events of Puberty :
(Failure of gonadal develop): no other cong. abn.
🔹
1. CHROMOSOM ALABNORMALITIES
Tuner's syndrome(45x0)
Thelarche (breast development)
3. RESISTANTOVARY SYNDROME
- A rare condition
-> gonadal dysgenesis
FEATURES:
🔹
- Requires estrogen
Pubarche/adrenarche (pubic hair development)
-Normal ovarian develop
-FSH 个个
1-Amenorrhoea (10, rarely20)
2-Short stature
🔹
- Requires androgens
Menarche
Requires:
3-Failure of sec. sex. Develop
-It may resolve spontaneously -GnRH from the hypothalamus
4- Webbing of the neck
-If hot flushes--> Rx. With estrogen -FSH and LH from the pituitary
5- high carrying angle
-Estrogen and progesterone from the ovaries
6- Shield chest
4. PREMATURE MENOPAUSE: Ovarian failure.. - Normal outflow tract
7- Coartution of aorta
due to:
8- Renal collecting syst. defect
i- Auto-immune dis. (associated with Addison's dis.??)
9-Streak ovaries present
ii-Viral infection (e.g. mumps)
19-Gonadotrophins high
iii- Cytotoxic drugs
11- low Estrgoens
🔹
Classification of amenorrhea
5. PCOS:
12- Mosaic Chrom. Pattern
Amenorrhea
🔹
-Mostly present with classical Stein-Leventhal
syndrome (of oligomenorrhoea, obesity, hirsuitism, and infertility)
(e.g. XO/XX)--> lead to various degrees of hypothalamic amenorrhea
🔹
gonadal dysgenesis and pituitary amenorrhea
-However a substantial group will have sec-amenorrhoea with no
🔹
sec. amen. + premature menopause
obesity or hirsuitism
--> If Y-Chrom is present in the genotype--
ovarian amenorrhea
-Diagnosis is made by finding incraased LH/FSH ratio uterine amenorrhea
> risk of gonadal malig. makes
-Confirmation is made by laparoscopy.
-USS 土 gonadectomy advisable
Anatomic abnormalities of the reproductive
tract
🔷 CRYPTOMENORRHOEA:
vaginal atresia or imperforate hymen prevent menstrual
loss from escaping.
FEATURES:
prim.Amenohea in a teenage girl with normal sexual development present
complaining of:
i - Intermittent lower abd. pain
ii- Possible difficulty of mict.
iii- Palpable lower abd. swelling (Haematometra)
iv- Bulging, bluish membrane at lowerend of vagina (Haematocolpus)
MANAGEMENT: Incise membrane
🔷 Asherman syndrome
asherman's syndrome: Sec. amenorrhoea following distruction of the endomet. by overzealous curttage -->
hypothalamic amenorrhea
- Psychological stress
multiple synechiae show up hysterography -5a-Reductase deficiency
MANAGEMENT: - Anorexia nervosa, weight loss
Under G.A. breakdown intraut. Adhesions through -Increased exercise levels
🔷
hysteroscope -> insert an UCD to deter reformation ->hormone therapy(E2+P) -Kallmann syndrome
INFECTION -drug-induced amenorrhea
e.g. Tuberculosis. Ut. Schistosomiasis - Space-occupying lesion of CNS
🔷Mayer-Rokitansky-Kuster-Hauser Syndrome pituitary amenorrhea
-tumor
(utero-vaginal agenesis) -Empty sella syndrome
-15% of primaryamenorrhea -Sheehan syndrome
-Normal secondary development & extemal female genitalia
-Normal female range testosterone level Etiology ovarian amenorrhea
-Absent uterus and upper vagina & normal ovaries - Gonadal dysgenesis
-Karyotype 46-XX -Turner syndrome: low hair line, web neck, shield
-15~30% renal, skeletal and middle ear anomalies chest, and widely spaced nipples
-Swyer syndrome
🔷 Androgen Insensitivity (Testicular Feminization)
-resistant ovary syndrome
- Premature ovarian failure
-Normal breasts but no sexual hair DISORDERS OF THE OVARIES
-Normal looking female external genitalia uterine amenorrhea
-Absent uterus and upper vagina -Absence ofuterus
-Karyotype 46, Xy -Asherman syndrome
-Male range testosterone level anatomic abnormalities of the
🔹
-Treatment: gonadectomy after puberty + HRT
Phenotype is woman.
- Growth and developare normal (maybe taller than average).
reproductive tract
- Imperforate Hymen
-Breasts are large but with sparse glandular tissue and pale areola
-Scanty, or no axillaryand pubic hair
- Labia minora underdeveloped
-Blind vagina, absent uterus, rudimentary fallopian tubes
🔹
- Inguinal hernia in 50% of cases
Genotype is man (Karyotype 46, XY)
- Testes are present.
- Testes> in abd. or inguinal canal
- Inherited by an X-linked recessive gene…(familial) Resulting in absence of cytosol androgen
by fatema okoff
receptor
- Normal levels of testosterone are produced.. But no response to androgens (endog. or exogen)
- No spermatogenesis
- There is increase incidence of testicular neoplasia (50%)
🔹
Diagnosis:
🔹 With inguinal hernia
🔹 With 10 amenorrhea and absent uterus
When bodyhair is absent
🔹
MANAGEMENT:
🔹 These patients are female.
The gonads must be removed after puberty
then HRT started
Disorders Of Hypothalamus
-Commonest reason for hypogonadotrophic sec. amenorrhoea pituitary amenorrhea
-Often associated with stress e.g. in migrants, young women when leave home,
university students 🌟1. Pituitary Tumor causing "Hyperprolactinemia"
=40% of women with hyperprolactinemia will have a pituitary adenoma
-Diagnosis byexclusion of pituitary lesions.
-Hormone therapy or ovulation induction is not indicated unless patient wishes to Pit. Fossa X-ray is necessary in all cases of amenorrhoea-particular
become pregnant 20.
🔷A loss
FEATURES:
weight loss associated amenorrhea
of> 10 kg is frequently associated with amenorrhoea 🔹
In coned view:
🔹 Erosion of clinoid process
i- In young women and teen ages girls become obsessed
with their body image and starve themselves." 🔹 Enlarge of pituitary fossa
Double flooring of fossa
🔹
ii- Jogger's amenorrhoea: If any of above features seen CTsan or MRI + Assessment of visual fields
This is seen frequently in women training for marathon
racing, in ballet dancers and other form of athletes. 🔹MANAGEMENT:
Bromocriptine (Dopamine agonist)
-Suppres prolactin sec.
•CAUSES:
-redistribution between proportion of body fat mass and body muscle mass. -Correct estrogen deficiency
-Maybe also mediated by exercise related changes in B-endorphins -Permits ovulation
iii- Anorexia Nervosa
Associated with sec. amenorrhoea(misnomer--> no loss of appetite) 🔹
-decrease Size of most prolactinomas
Surgical removal of tumor
🔷
- if extracellar manifestation (e.g. press. on optic chiasma)or if patient cannot tolerate or
Amenorrhoea And Anosmia: respond to medical RX.
rare cause of amenorrhoea of hypogonadotrophic - hypo-gonadism
🔷
(Counterpart in males is Kallman's syndrome)
Post-pill Amenorrhoea:
🌟
🔹 2. OTHER CAUSE OF INCREASED PROLACT.
Drugs: e.g. phenothiazines, methyl-dopa, metclopramide, anti- histamines, oesttogens
-There is no evidence that Est-prog. Contraceptive pills predispose to
🌟
and morphine.
amenorrhoea.. once pill taking is ceased.
-An irregular men. cycle frequently precedes pill taking 3.CRANIOPHARYNGIOMA
Other intracranial tumor
-If this assumption of amenorrhoea being merely an after-effect of pill
taking many cases of hyperprolactinemia will be missed (1:5) 🌟
🔹 4.SHEEHAN's SYNDROME
Necrosis of ant.pituitary due to severe PPH
🔹 It is rare problem today due to better obstetric care and adequate blood transfusion
-And Premat. ovarian failure will be missed in 1:10 cases - Pan -or partial hypopituitarism
-Once other causes are excluded, this type of ameno. Responds well to ovulation
induction with Clomiphene citrate if preg. is desired
🔹
Treatment options include:
Dietary changes, including an increase in fat and calories in order to
🔹
stimulate estrogen production.
🔹🔹Counseling for eating disorders. treatment
Using stress reduction techniques to help regulate the period.
Hormonal supplements, like the birth control pill or patch, or
🔷
Amenorrhea is the absence of menstruation.
Primary:
- Absence of menses by age 16 with normal
🔹Surgery to remove cysts, fibroids or tumors
hormone replacement therapy. secondary sexual characteristics.
-absence of menses by age 14 without secondary
definition
🔷
sexual development.
secondary:
- Absence of menses for 6 months (or greater than
3times the previous cycle interval) in a previously
🔹
mnstruating female.
pregnancy, lactation or hysterectomy must be
🔹 🔹
excluder
prepubertal and post-menopausal conditions are
🔹 History
Physical examination
- Physical examination begins with vital
also to be excluded as physioiogical causes
signs, including height and weight, and DIAGNOSIS
🔹
with sexual maturity ratings
Laboratory evaluation
🔹 There is a difference of opinion about the age at
which
Primary Amenorrhea should be investigated--> 18 yrs.
🔹
often suggested.
Provided the patient has developed normal sec. sex.
Characteristics and cryptomenorrhoea has been
excluded. While those patient with Primary amenorrhea
and sexual
infantilism should be investigated at= age of 15 years or
2. GONADAl AGENESIS:
CLINICAL APPROACH 🌟
16 years (maybe earlier).
🔹 Events of Puberty :
(Failure of gonadal develop): no other cong. abn.
🔹
1. CHROMOSOM ALABNORMALITIES
Tuner's syndrome(45x0)
Thelarche (breast development)
3. RESISTANTOVARY SYNDROME
- A rare condition
-> gonadal dysgenesis
FEATURES:
🔹
- Requires estrogen
Pubarche/adrenarche (pubic hair development)
-Normal ovarian develop
-FSH 个个
1-Amenorrhoea (10, rarely20)
2-Short stature
🔹
- Requires androgens
Menarche
Requires:
3-Failure of sec. sex. Develop
-It may resolve spontaneously -GnRH from the hypothalamus
4- Webbing of the neck
-If hot flushes--> Rx. With estrogen -FSH and LH from the pituitary
5- high carrying angle
-Estrogen and progesterone from the ovaries
6- Shield chest
4. PREMATURE MENOPAUSE: Ovarian failure.. - Normal outflow tract
7- Coartution of aorta
due to:
8- Renal collecting syst. defect
i- Auto-immune dis. (associated with Addison's dis.??)
9-Streak ovaries present
ii-Viral infection (e.g. mumps)
19-Gonadotrophins high
iii- Cytotoxic drugs
11- low Estrgoens
🔹
Classification of amenorrhea
5. PCOS:
12- Mosaic Chrom. Pattern
Amenorrhea
🔹
-Mostly present with classical Stein-Leventhal
syndrome (of oligomenorrhoea, obesity, hirsuitism, and infertility)
(e.g. XO/XX)--> lead to various degrees of hypothalamic amenorrhea
🔹
gonadal dysgenesis and pituitary amenorrhea
-However a substantial group will have sec-amenorrhoea with no
🔹
sec. amen. + premature menopause
obesity or hirsuitism
--> If Y-Chrom is present in the genotype--
ovarian amenorrhea
-Diagnosis is made by finding incraased LH/FSH ratio uterine amenorrhea
> risk of gonadal malig. makes
-Confirmation is made by laparoscopy.
-USS 土 gonadectomy advisable
Anatomic abnormalities of the reproductive
tract
🔷 CRYPTOMENORRHOEA:
vaginal atresia or imperforate hymen prevent menstrual
loss from escaping.
FEATURES:
prim.Amenohea in a teenage girl with normal sexual development present
complaining of:
i - Intermittent lower abd. pain
ii- Possible difficulty of mict.
iii- Palpable lower abd. swelling (Haematometra)
iv- Bulging, bluish membrane at lowerend of vagina (Haematocolpus)
MANAGEMENT: Incise membrane
🔷 Asherman syndrome
asherman's syndrome: Sec. amenorrhoea following distruction of the endomet. by overzealous curttage -->
hypothalamic amenorrhea
- Psychological stress
multiple synechiae show up hysterography -5a-Reductase deficiency
MANAGEMENT: - Anorexia nervosa, weight loss
Under G.A. breakdown intraut. Adhesions through -Increased exercise levels
🔷
hysteroscope -> insert an UCD to deter reformation ->hormone therapy(E2+P) -Kallmann syndrome
INFECTION -drug-induced amenorrhea
e.g. Tuberculosis. Ut. Schistosomiasis - Space-occupying lesion of CNS
🔷Mayer-Rokitansky-Kuster-Hauser Syndrome pituitary amenorrhea
-tumor
(utero-vaginal agenesis) -Empty sella syndrome
-15% of primaryamenorrhea -Sheehan syndrome
-Normal secondary development & extemal female genitalia
-Normal female range testosterone level Etiology ovarian amenorrhea
-Absent uterus and upper vagina & normal ovaries - Gonadal dysgenesis
-Karyotype 46-XX -Turner syndrome: low hair line, web neck, shield
-15~30% renal, skeletal and middle ear anomalies chest, and widely spaced nipples
-Swyer syndrome
🔷 Androgen Insensitivity (Testicular Feminization)
-resistant ovary syndrome
- Premature ovarian failure
-Normal breasts but no sexual hair DISORDERS OF THE OVARIES
-Normal looking female external genitalia uterine amenorrhea
-Absent uterus and upper vagina -Absence ofuterus
-Karyotype 46, Xy -Asherman syndrome
-Male range testosterone level anatomic abnormalities of the
🔹
-Treatment: gonadectomy after puberty + HRT
Phenotype is woman.
- Growth and developare normal (maybe taller than average).
reproductive tract
- Imperforate Hymen
-Breasts are large but with sparse glandular tissue and pale areola
-Scanty, or no axillaryand pubic hair
- Labia minora underdeveloped
-Blind vagina, absent uterus, rudimentary fallopian tubes
🔹
- Inguinal hernia in 50% of cases
Genotype is man (Karyotype 46, XY)
- Testes are present.
- Testes> in abd. or inguinal canal
- Inherited by an X-linked recessive gene…(familial) Resulting in absence of cytosol androgen
by fatema okoff
receptor
- Normal levels of testosterone are produced.. But no response to androgens (endog. or exogen)
- No spermatogenesis
- There is increase incidence of testicular neoplasia (50%)
🔹
Diagnosis:
🔹 With inguinal hernia
🔹 With 10 amenorrhea and absent uterus
When bodyhair is absent
🔹
MANAGEMENT:
🔹 These patients are female.
The gonads must be removed after puberty
then HRT started
Disorders Of Hypothalamus
-Commonest reason for hypogonadotrophic sec. amenorrhoea pituitary amenorrhea
-Often associated with stress e.g. in migrants, young women when leave home,
university students 🌟1. Pituitary Tumor causing "Hyperprolactinemia"
=40% of women with hyperprolactinemia will have a pituitary adenoma
-Diagnosis byexclusion of pituitary lesions.
-Hormone therapy or ovulation induction is not indicated unless patient wishes to Pit. Fossa X-ray is necessary in all cases of amenorrhoea-particular
become pregnant 20.
🔷A loss
FEATURES:
weight loss associated amenorrhea
of> 10 kg is frequently associated with amenorrhoea 🔹
In coned view:
🔹 Erosion of clinoid process
i- In young women and teen ages girls become obsessed
with their body image and starve themselves." 🔹 Enlarge of pituitary fossa
Double flooring of fossa
🔹
ii- Jogger's amenorrhoea: If any of above features seen CTsan or MRI + Assessment of visual fields
This is seen frequently in women training for marathon
racing, in ballet dancers and other form of athletes. 🔹MANAGEMENT:
Bromocriptine (Dopamine agonist)
-Suppres prolactin sec.
•CAUSES:
-redistribution between proportion of body fat mass and body muscle mass. -Correct estrogen deficiency
-Maybe also mediated by exercise related changes in B-endorphins -Permits ovulation
iii- Anorexia Nervosa
Associated with sec. amenorrhoea(misnomer--> no loss of appetite) 🔹
-decrease Size of most prolactinomas
Surgical removal of tumor
🔷
- if extracellar manifestation (e.g. press. on optic chiasma)or if patient cannot tolerate or
Amenorrhoea And Anosmia: respond to medical RX.
rare cause of amenorrhoea of hypogonadotrophic - hypo-gonadism
🔷
(Counterpart in males is Kallman's syndrome)
Post-pill Amenorrhoea:
🌟
🔹 2. OTHER CAUSE OF INCREASED PROLACT.
Drugs: e.g. phenothiazines, methyl-dopa, metclopramide, anti- histamines, oesttogens
-There is no evidence that Est-prog. Contraceptive pills predispose to
🌟
and morphine.
amenorrhoea.. once pill taking is ceased.
-An irregular men. cycle frequently precedes pill taking 3.CRANIOPHARYNGIOMA
Other intracranial tumor
-If this assumption of amenorrhoea being merely an after-effect of pill
taking many cases of hyperprolactinemia will be missed (1:5) 🌟
🔹 4.SHEEHAN's SYNDROME
Necrosis of ant.pituitary due to severe PPH
🔹 It is rare problem today due to better obstetric care and adequate blood transfusion
-And Premat. ovarian failure will be missed in 1:10 cases - Pan -or partial hypopituitarism
-Once other causes are excluded, this type of ameno. Responds well to ovulation
induction with Clomiphene citrate if preg. is desired
