Amenorrhea

1. Amenorrhea Dr Jack Biko

2. introduction • A symptom and not a Condition • Absence of menstrual bleeding • Maturation of H-P-O axis • Outflow tract

3. Causes • Hypothalamic • Pituatory • Ovarian • Other

4. 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

5. Amenorrhea • Transient, intermittent or permanent • Dysfunction of hypothalamus, pituatory gland, ovaries, uterus or vagina • Thyroid gland • Adrenal gland

6. Hormonal events

7. 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

8. Teens with • Secondary sexual characteristics present • No menstruation • Cyclical pains • THINK MULLERIAN ANOMALIES / OBSTRUCTION OF OUTFLOW TRACT

9. Primary Amenorrhea • Is there normal development of secondary sexual characteristics? YES • Think • Pregnancy • Mullerian anomaly – outflow tract, uterine • Androgen insensitivity

10. Primary amenorrhea • CNS pathology • Ovarian - Genetic abnormality • Obstruction of outflow tract

11. Are there secondary sexual characteristics?

12. Primary Amenorrhea • Is there normal development of secondary sexual characteristcs? NO Think hypogonadism or hypogonadotropism

13. 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

14. Imperforate Hymen

15. Amenorrhea with Immature Secondary Characteristics FSH Serum level /Low normal High Hypogonadotropic hypogonadism Gonadal dysgenesis

16. 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)

17. 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

18. Amenorrhea • Evaluation • Pregnancy test • Physical exam to determine presence of uterus • FSH • Karyotype

19. 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

20. Secondary Amenorrhea • Pregnancy! • CNS disorders • Pituitary gland • Thyroid • Ovary • Uterus • Systemic disorders • Renal failure, liver disorders, DM • Medications: anti-psychotics, reserpine

21. Secondary Amenorrhea • CNS disorders • Chronic hypothalamic anovulation • Stress • Increased exercise levels • Anorexia nervosa • Head trauma • Space-occupying lesions

22. Secondary Amenorrhea • Hyperprolactinemia: Prolactinoma • Medications • Renal failure • Pituatory injury • Pituitary resection • Sheehan’s syndrome • Thyroid disorders • Hyper- or hypothyroidism

23. Secondary Amenorrhea • Ovulation disorders • Polycystic ovarian syndrome • Premature ovarian failure • Uterine abnormalities • Asherman’s syndrome • Cervical stenosis • Drug-induced amenorrhea • Hormonal contraceptives • GnRH analogues

24. PCOS • First described in 1935 • Findings of polycystic ovaries reported more than 100yrs previously • A syndrome – no single feature or test is diagnostic

25. 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.

26. Diagnostic Criteria; Rotterdam 2003 • Based on Consensus • Oligo or anovulation • Hyperandrogenism – clinical or biochemical • Polycystic ovaries Exclude other causes of androgen excess

27. Intra-uterine adhesions • Asherman’s syndrome • Previous D&C • Previous endometritis • Endometrial TB

28. Asherman’s Syndrome

29. Treatment • Hysteroscopic resection • High dose oestradiol

30. Hysteroscopy

31. Amenorrhea History • Nutrition/exercise habits, weight change • Sexual/contraceptive practice • History of uterine/cervical surgery • Physical exam • Height/weight • Hirsutism • Galactorrhea • Estrogen status of tissues • Laboratory • BhCG PRL & TSH  progesterone challenge  FSH  if high karyotype

32. Secondary Amenorrhea • Treatment goals • Discovery and treatment of underlying disorder • Hormone replacement • Menses every 1-3 months • Pregnancy • Ovulation induction • FSH/LH

33. Case studies

34. 12 year old • No periods • No pain • No secondary sexual characteristics

35. 15 yr old • No periods • Cyclical pains • Has secondary sexual characteris

36. 24 yr old • G3P0 • TOP x 3 • No periods for 6 months now

37. 33 yr old • Amenorrhea for 4 yrs • Para 0 • No cyclical pains • Normal secondary sexual characteristics

38. Amenorrhea • 26 yr Gravida 0 with menarche at age 14 presents with one-year history of amenorrhea. • Obese • Hirsutism

39. Thank you