rps138 slide amenorrhea
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AMENORRHEAAMENORRHEAAMENORRHEAAMENORRHEA
Prof.DR.Dr.H.M.Thamrin Tan un , S .OG(K)Dr.M.Rusda Harahap, Sp.OG
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e n ons
r mary amenorr ea
Failure of menarche to occur when expected in.
No menarche by age 16 years with signs of pubertal
development.
No onset of pubertal development by age 14 years.
Secondary amenorrhea
Absence of menstruation for 3 or more months in apreviously menstruating women of reproductive
.
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- -Ovary-uterus I nt eract ion
Neural cont rol Chemical cont rol
( -) (+ ) ( -)
H othalamus
Gn-RH
Ant . pit uit ary ?FSH, LH
Ovaries ProgesteroneEstrogen
Uterus
Menses
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Inadequate hormonal stimulation of the endomeriumnovu a ory amenorr ea
- Euestrogenic
- ypoes rogen c
Ovulatory amenorrhea
- - -
- XY-Females ( e.g T.F.S)
- Dama ed endometrium e. Ashermans s ndrome
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Amenorrhea
Normal androgens Hypothalamic-pituitary High androgens PCOS
loss or gain, exercise,pseudocyesis)
H er rolactinemia
tumour
Cushings syndrome
Feminizing ovarian tumour Non-gonadal endocrine
hyperplasia (late onset)
, Systemic illness
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AN APPROACH FOR DIAGNOSIS
HISTORY
ULTRASOUND EXAMINATION
Exclude Pregnancy
Exclude Cryptomenorrhea
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ryptomenorr ea
Outflow obstruction to menstrual blood- Imperforate hymen
- ransverse ag na sep um w unc on ng u erus- Isolated Vaginal agenesis with functioning uterus
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- I nterm it t ent abdominal pain
- oss e cu y w m c ur on- Possible low er abdominal sw ell ing
- Bulging blu ish membrane at t he int roit us or absent
vagina (only dimple)
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I mperforate hymen
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Once Pregnancy and cryptomenorrhea are
The pat ient is a bioassay for
Four categories of pat ients are ident if ied
1. Amenorrhea w it h absent or poorsecondary sex Characters
. menorr ea w norma rysex characters
. androgen excess
.and vagina
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AMENORRHEAAbsent or poor secondary sexCharacteristics
FSH Serum level
Low / normal High
H o onadot ro ic Gonadal
hypogonadim dysgenesis
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Norm al secondary sex Character ist ics
- FSH, LH, Prolactin, TSH- Provera 10 mg PO daily
x 5 days
+ Bleeding No bleeingProlactinTSH
- Mild hypothalamicdysfunction
Work-up(Endocrinologist)
- PCO ( LH/FSH) ev ew resu
And history (next sl ide)
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Hypothalamic-pituitary
Failure
Ovarian
failure
If < 25 yrs or primaryhead CT- scan or MRI
amenorrhea karyoptypeIf < 35 yrs R/O
autoimmune disease
- evere ypo a am cdysfunction
?? Ovar ian biopsy
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Utero-vaginal absence
Karyotype
46-XX46-XY
MullerianAgenesis
AndogenInsenit ivi ty
. Gonadal regressioon
. Testocular enzyme
(MRKH syndrom e)(TSF syndrome)defenciecy. Leydig cell agenisis
Normal breast sNormal breast s
& sexual haira sen sexuahair
sen reas s& sexual hair
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Normal FSH, LH; -ve bleedinghistory is suggestive of amenorrheatrumatica
Ashermans syndrome History of pregnancy associated D&C
Rarely after CS , myomectomy T.B
endometritis, bilharzia agnos s : or ys erescopy
Treatment : lysis of adhesions; D&C or
catheter)
ome w prescr e a cyc e o s rogen an
Progesterone challenge Before HSG or Hysterescopy
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Ashermans syndrome
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Signs of androgen excess
Testosterone, DHEAS, FSH, and LH
DHEAS 500-700 mug/dLDHEAS >700 mug/dLTEST. >200 ng/dL
Serum 17-OH
Progesterone level
U/S ? MRI or CT
Late CAHrenahyperfunctionOr adrenal
tumor
Lower elevations PCOS (High LH / FSH)
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Amenorrhea
PRIMARY AMENORRHEA
SECONDARY AMENORRHEA
.
. Hypogonadotrophic 34%
Hypogonadism.
.
. Premature ovarian failure 29%
. Weight related amenorrhoea 19%. PCOS 17%
. Congenital lesions
(other than dysgenesis) 4%
. Hyperprolactinaemia 14%
. Exercise related amenorrhoea 2%
. Hypopituitarism 2%
. Hypopituitarism 3%
. Hyperprolactinaemia 3%
.
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Gonadal dysgeneis
Chromosomally incompetent- Classic turners syndrome (45XO)
- urner variants (45XO/46XX),(46X-abnormal X)
- Mixed gonadal dygenesis (45XO/46XY) romosoma y compe en
- 46XX (Pure gonadal dysgeneis)
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Gonadal dysgenesis
Turners Variant Dysgenesis Dysgenesis
phenotype Female Female Female Ambiguous
Gonad Streak Streak Streak - Streak
- Testes
Hight Short - Short
- Normal
Tall Short
Classical Nil
stigmata
karyotype XO XX/XO or 46-XX(Pure) XO/XYa norma 46-XY (Swyer)
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Turners syndrome
.
Associated abnormalities, webbed neck,coarctation ofthe aorta,high-arched pallate, cubitus valgus, broads e - e c es w w e y space n pp es, owhairline on the neck, short metacarpal bones and
renal anomalies. High FSH and LH levels.
Bilateral streaked gonads.
- ,
- 20% mosaic forms (46XX/45X0)
Treatment: HRT
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None-dysgenesis ovarian failure
Steroidogenic enzyme defects (17-hydroxylase) Ovarian resistance s ndrome
Autoimmune oophoritis
Postinfection e . Mum s
Postoopherectomy
Postchemotherapy
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Premat ure ovar ian failure
Serum estradiol < 50 pg/ml and FSH > 40 IU/ml onrepeated occasions
o secon ary amenorr ea
Few cases reported, where high dose estrogen or
Sometimes immuno therapy may reverse autoimmueovarian failure
Rarely spont. ovulation (resistant ovaries) Treatment: HRT (osteoporosis, atherogenesis)
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Polycyst ic ovary syndrome
The most common cause of chronic anovulation Hyperandrogenism ; LH/FSH ratio
Insulin resitance is a major biochemical feature
(
blood insulin level
hyperandrogenism ) ong erm r s s: es y, rsu sm, n er y,type 2 diabetes, dyslipidemia, cardiovasularrisks endometrial h er lassia and cancer
Treatment depends on the needs of the patientand preventing long term health problems
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Hypogonadism
Normal hight
Normal external and internalni l r n inf n il
Low FSH and LH
MRI to R/O intra-cranial pathology. 30-40% anosmia (kallmanns
syndrome)
Sometimes constitutional dela
Treat according to the cause (HRT),potentially fertile.
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Const it ut ional pubertal delay
Under stature and delayedbone age
( X-ray Wrist joint)
Positive family history
follow up
Prognosis is good
(late developer) No drug therapy is required
Reassurance ? HRT
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Sheehans syndrome
Pituitary inability to secrete gonadotropins Pituitar necrosis followin massive obstetric
hemorrhage is most common cause in women
Diagnosis : History and E2,FSH,LH+ other pituitary deficiencies (MPS test)
reatment :
Replacement of deficient hormones
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-Anorexia Nervosa
1o or 2o Amenorrhea is often first sign
A body mass index (BMI)
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-amenorrhoea
Common in women who participatein sports (e.g. competitive athletes,
Eating disorders have a higher
prevalence in female athletes than-
Hypothalamic disorder caused byabnormal gonadotrophin-releasing
ormone pu sa y, resu ng nimpaired gonadotrophin levels,particularly LH, and subsequentlyow oes rogen eve s
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amenorrhea
Post-pill amenorrhea is not an entity Depot medroxyprogesterone acetate
Up to 80 % of women will have amenorrheaafter 1 year of use. It is reversible
A minority of women taking the progestogen-onl ill ma have reversible lon term
amenorrhoea due to complete suppression ofovulation
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hyperplasia
Autosomal recessive trait Most common form is due to 21-
y roxy ase e c ency
Mild forms Closely resemble PCO
severe androgen excess
High 17-OH-progesterone blood
level Treatment : cortisol replacement
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Cushings syndrome
Clinical suspicion : Hirsutism,truncal obesity, purple striae, BP
dexamethasone suppression test
(1 mg PO 11 pm ) and obtaineserum cor so eve a am :
< 5 g/ dl excludes cushings
24 hours total urine free cortisol
level to confirm diagnosis 2 forms ; adrenal tumour or ACTH
site)
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-Mayer-Roki t ansky-Kuster-Hauser syndrome
15% of 1ry amenorrhea
Normal breasts and Sexual Hairdevelo ment & Normal lookin externalfemale genitalia
Normal female range testosterone level
ovaries
Karyotype 46-XX
- ,anomalies
Treatment : STERILE ? Vaginal creation
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Test icular feminizat ion syndrome
X-linked trait
Absent cytosol receptors
Normal looking female external
genitalia Absent uterus and upper vagina
Karyotype 46, XY
Treatment : gonadectomy afterpuberty + HRT
? Vagina creation i atation VVaginoplasty )
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of Amenorrhea
. Attempts to restore ovulatory function
. If this is not possible HRT (oestrogen and
progesterone) is given to hypo-estrogenic
amenorrheic women (to prevent osteoporosis; atherogenesis). Periodic progestogen should be taken by euestrogenic
amenorrheic women v i i l
. If Y chromosome is present gonadectomy is indicated
. any cases requ re requen re-eva ua on
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Hormonal t reatmentPr imary Amenorrhea w it h absentsecondary sexual character ist ics
To achieve pubertal developmentremar n mg - + provera mg -
X 3 months; 2.5mg premarin X 3 months and
1.25mg premarin X 3 months
Maintenance therapy
0.625mg premarin + provera OR ready HRT
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ummary -
complex, a carefully conducted physical examination with thehistory, and Looking to the patient as a bioassay for
endocrine abnormalities, should permit the clinician to narrow
the diagnostic possibilities and an accurate diagnosis can beo a ne qu c y.
Management aims at restoring ovulatory cycles if possible,
protect endometrium from unopposed estrogen.
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FOR YOUR ATTENTI ON
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