evaluation and management of amenorrhea mazen freij , mbbs mrcog assistant professor at juh
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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EVALUATION AND MANAGEMENT OF
AMENORRHEA
Mazen Freij, MBBS MRCOGAssistant Professor at JUH
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Objectives
Know the definition of Amenorrhea and Oligomenorrhea
Understand the endocrine, genetic and anatomical basis for these disorders
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Definitions Primary amenorrhea No menses by age 14, absence of 2º sexual characteristics.
No menses by age 16 , presence of 2º sexual characteristics.
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Secondary amenorrhea No menses for 3 months if previous menses were
regular.
No menses for 6 months if previous menses were irregular
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Oligomenorrhea
Interval of more than 35 days between periods
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Neural control Chemical control
Dopamine (-)
Norepiniphrine (+)
Endorphines (-)
HypothalamusGn-RH
Ant. pituitaryFSH, LH
Ovaries
Uterus
ProgesteroneEstrogen
Menses
–± ?
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AMENORRHOEA AN APPROACH FOR DIAGNOSIS
• HISTORY• PHYSICAL EXAMINATION• BLOOD TESTS• ULTRASOUND EXAMINATION
Exclude PregnancyExclude Cryptomenorrhea
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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
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Imperforated hymen
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Amenorrhea and no breast development.
FSH Serum level
Low / normal
High
Hypogonadotropichypogonadim
Gonadal dysgenesis
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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)
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Amenorrhea Utero-vaginal absence
Karyotype
46-XX
Rokitansky syndrome)
Andogen Insenitivity
(TSF syndrome)
46-XY
Normal breasts& sexual hair
Normal breasts& absent sexual
hair
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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
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Classic turner’s syndrome (45XO) - Turner variants (45XO/46XX),(46X-abnormal X) - Mixed gonadal dygenesis (45XO/46XY)
Gonadal dysgeneis
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• 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
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Mosaic (46-XX / 45-XO) (Classic 45-XO)
Turner’s syndrome
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Ovarian dysgenesis
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Hypogonadotrophic Hypogonadism
Normal hight
Normal external and internal genital organs (infantile)
Low FSH and LH 30-40% anosmia (kallmann’s
syndrome)Treat with HRT
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Constitutional pubertal delay
• delayed bone age ( X-ray Wrist joint)• Positive family history• Diagnosis by exclusion
and follow up
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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)
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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)
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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
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Endocrine causes.
Genetic causes.
Anatomic causes.
Amenorrhea
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TEST
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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?
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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?
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A. Turner Syndrome B. CAH C. Rokitansky Syndrome D. Imperforsted Hymen E. PCOS
The commonest cause for primary amenorrhea is
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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.
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What is the definition of Primary Amenorrhea?
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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
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Thank You