evaluation and management of amenorrhea mazen freij, mbbs mrcog assistant professor at juh...
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EVALUATION AND MANAGEMENT OF
AMENORRHEA
Mazen Freij, MBBS MRCOG
Assistant Professor at JUH
EVALUATION AND MANAGEMENT OF
AMENORRHEA
Mazen Freij, MBBS MRCOG
Assistant Professor at JUH
Objectives
Know the definition of Amenorrhea and Oligomenorrhea
Understand the endocrine, genetic and anatomical basis for these disorders
Definitions
Primary amenorrhea
No menses by age 14, absence of 2º sexual characteristics.
No menses by age 16 , presence of 2º sexual characteristics.
Secondary amenorrhea
No menses for 3 months if previous menses were
regular.
No menses for 6 months if previous menses were irregular
Oligomenorrhea
Interval of more than 35 days between periods
Neural control Chemical control
Dopamine (-)
Norepiniphrine (+)
Endorphines (-)
Hypothalamus
Gn-RH
Ant. pituitary
FSH, LH
Ovaries
Uterus
ProgesteroneEstrogen
Menses
–± ?
AMENORRHOEA AN APPROACH FOR DIAGNOSIS
• HISTORY• PHYSICAL EXAMINATION• BLOOD TESTS• ULTRASOUND EXAMINATION
Exclude PregnancyExclude Cryptomenorrhea
Cryptomenorrhea
Outflow obstruction to menstrual blood
- Imperforate hymen- Transverse Vaginal septum with functioning
uterus- Isolated Vaginal agenesis with functioning
uterus
- Isolated Cervical agenesis with functioning uterus
Imperforated hymen
Amenorrhea and no breast development.
FSH Serum level
Low / normal
High
Hypogonadotropichypogonadim
Gonadal dysgenesis
Amenorrhea and normal breast development.
- FSH, LH, Prolactin, TSH- Provera 10 mg PO daily x 5 days
+ Bleeding No bleeing Prolactin TSH
FurtherWork-up(Endocrinologist)
- Mild hypothalamic dysfunction - PCO (LH/FSH) Review FSH result
And history (next slide)
Amenorrhea Utero-vaginal absence
Karyotype
46-XX
Rokitansky syndrome)
Andogen Insenitivity
(TSF syndrome)
46-XY
Normal breasts& sexual hair
Normal breasts& absent sexual
hair
Amenorrhea
PRIMARY AMENORRHEA
. Ovarian failure
. Hypogonadotrophic Hypogonadism.. PCOS . Congenital lesions (other than dysgenesis) . Hypopituitarism
Hyperprolactinaemia . Weight related
SECONDARY AMENORRHEA
. Polycystic ovary syndrome
. Premature ovarian failure
. Weight related amenorrhoea
. Hyperprolactinaemia
. Exercise related amenorrhoea
. Hypopituitarism
Classic turner’s syndrome (45XO) - Turner variants (45XO/46XX),(46X-abnormal X) - Mixed gonadal dygenesis (45XO/46XY)
Gonadal dysgeneis
• Sexual infantilism and short stature.• Associated abnormalities, webbed
neck,coarctation of the aorta,high-arched pallate, cubitus valgus, broad shield-like chest with wildely spaced nipples, low hairline on the neck, short metacarpal bones and renal anomalies.
• High FSH and LH levels.• Bilateral streaked gonads.• Karyotype - 80 % 45, X0 - 20% mosaic forms (46XX/45X0)• Treatment: HRT
Turner’s syndrome
Mosaic (46-XX / 45-XO) (Classic 45-XO)
Turner’s syndrome
Ovarian dysgenesis
Hypogonadotrophic Hypogonadism
Normal hight
Normal external and internal genital organs (infantile)
Low FSH and LH 30-40% anosmia (kallmann’s
syndrome)Treat with HRT
Constitutional pubertal delay
• delayed bone age ( X-ray Wrist joint)• Positive family history• Diagnosis by exclusion
and follow up
Weight-related amenorrhoeaAnorexia Nervosa 1o or 2o Amenorrhea is often first sign
A body mass index (BMI) <17 kg/m² menstrual irregularity and amenorrhea
Hypothalamic suppression
Low estradiol risk of osteoporosis
Treatment : body wt. (Psychiatrist referral)
Utero-vaginal Agenisis Mayer-Rokitansky-Kuster-Hauser syndrome
Second most common cause of Primary amenorrhea.
Normal breasts and Sexual Hair Normal looking external female genitalia
Karyotype 46-XX
15-30% renal abnormalities.
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 range testosterone level
Treatment : gonadectomy after puberty + HRT
Androgen insensitivityTesticular feminization syndrome
Endocrine causes.
Genetic causes.
Anatomic causes.
Amenorrhea
TEST
A. History of leukemia during infancy B. Short stature C. History of delayed puberty in the family D. All of the above E. None of the above
A 17-year-old girl presents to the clinic for the evaluation of primary amenorrhea.Which would be an important aspect of her clinical history?
FSH of 60 IU/L (normal 0.33–10.54) B. Estradiol of 100 pg/ml (normal 40–410) C. LH of < 0.2 IU/L (normal 0.69–7.15) D. All of the above E. None of the above
After receiving Chemotherapy, which of the following labs results would make you consider the diagnosis of ovarian failure?
A. Turner Syndrome B. CAH C. Rokitansky Syndrome D. Imperforsted Hymen E. PCOS
The commonest cause for primary amenorrhea is
A. Imperforated hymen. B. Turner Syndrome C. Androgen insensitivity. D. Rokitansky syndrome E. Hypogonadotropic hypogonadism
One of the following can be the cause for primary amenorrhea with normal secondary sexual development.
What is the definition of Primary Amenorrhea?
19 year old presented with primary amenorrhea, normal breast development but no pubic hair, absent uterus. The most likely diagnosis is:
A. Rokitansky syndrome B. Turner Syndrome C. Androgen insensitivity D.Hypogonadotropic Hupogonadism
Thank You