Amenorrhea

1. Amenorrhea Khalid Akkour, MD FRCSC

3. Definitions & Classification • Amenorrhea: Absence of menses. • Primary amenorrhea: Non occurrence of menarche by age of: • 14 with no secondary sex characters • 16 (18) with secondary sex characters. • Secondary amenorrhea: Absence of menses for 3 successive cycles.

4. Amenorrhea Pathologic Physiologic False True CNS Puberty Imperforate hymen Hypothalamic Menopause Vaginal T. septa Pituitary Pregnancy Cervix Ovarian Lactation Uterine General

5. False amenorrhea(Cryptomenorrhea)

6. Cryptomenorrhea • Due to outflow obstruction. • The most common cause is imperforate hymen. • Blood accumulate behind the hymen  hematocolpos  Hematometra  Pelvic hemorrhage. • Diagnosis: • P. amenorrhea with good 2ry sex characters. • PMS. • Urinary symptoms. • Abdominal mass ????. • Local examination is diagnostic. • Treatment: Cruciate incision under anesthesia  Slow evacuation + antibiotics.

7. True amenorrhea

8. CNS Causes • Psychological troubles: • Psychosis # neurosis. • Pseudocyesis. • Anorexia nervosa. • Chronic stresses. • Weight loss. • Exercise: • Loss of body fat. • Stress of competition. • Hyperthermia and dehydration. • Euphoria of winning causing increased opiates.

9. Hypothalamic causes • Destruction: • Trauma • Inflammation. • Tumors. • Infiltrations. • Drugs: • Estrogens. • CNS affecting drugs. • Dysfunction & congenital disorders: • Chiari Frommel syndrome. • Del Castillo syndrome. • Kallmann syndrome. • Laurence Moon Biedl syndrome. • Frohlich syndrome.

10. Pituitary causes • Destruction: • Infiltrations. • Tumors. • Sheehan syndrome. • Drugs: • Estrogens. • Prolactin inducing drugs. • Dysfunction and congenital disorders: • Levi Lorain syndrome. • Empty sella syndrome. • Prolactinomas.

11. Ovarian causes • Congenital: • Turner. • Androgen insensitivity syndrome. • Traumatic: • Surgical removal. • Irradiation. • Inflammatory: • Mumps. • PID. • TB. • Neoplasia: • Benign. • Malignant. • Dysfunctions: • PCO. • Resistant ovary syndrome.

12. Uterine causes • Congenital: • Mullerian agenesis. • Uterine atresia • Severe hypoplasia. • Traumatic: • Surgical removal. • Irradiation. • Inflammatory: • Asherman syndrome. • TB. • Neoplastic: • Obstructing the cervix. • Dysfunctions: • Insensitive endometrium.

13. General causes • DM: • Glucose metabolism. • Ketosis. • Immunological. • Thyroid: • Hyper. • Hypo. • Adrenal: • Addison. • Cushing. • Debilitating diseases.

14. Causes of 1ry amenorrhea 1- Cryptomenorrhea: All congenital causes. 2- True: • Psychological disturbances before menarche. • Congenital diseases in the hypothalamus or pituitary. • Ovarian dysgenesis and removal or destruction before menarche (T.B, irradiation). • Uterine aplasia or severe hypoplasia, T.B or removal before menarche. • General cause before menarche. • The most common causes of primary amenorrhea: • Gonadal dysgenesis. • Mullerian agenesis. • Complete AIS.

15. Causes of 2ry amenorrhea • Physiological: • Pregnancy, lactation, after menopause. • Cryptomenorrhea: Any acquired cause. • True: • Psychogenic disorders after menarche, Chiari Frommel and Del Castillo syndromes, drugs, OCs, destruction by trauma, infections, tumors after puberty. • Sheehan syndrome, Simmond's disease, destruction and tumors after puberty. • Ovarian failure, PCO and ovarian tumors. • Intrauterine synechia, hysterectomy or T.B endometritis after puberty. • Any general cause after puberty.

16. Diagnosis of amenorrhea • History: • Age, occupation, residence, habits and education. • Primary or secondary amenorrhea. • History of psychogenic disorders. • History of neurological disturbances. • History of endocrinological disorders. • Past history of operations, pelvic infections, T.B, long drug course or irradiation. • Family history of similar condition, familial disease.

17. Diagnosis of amenorrhea • Examination: • Psyche, height, weight and span measure. Nutritional status should be also evaluated. • Secondary sexual characters. • Evidence of neurological disorders specially central lesions. • Evidence of endocrinological disorders with special reference to galactorrhea and hirsutism. • Evidence of general disease as heart, chest, renal or hepatic disorder. • Abdominal masses (ovarian, adrenal, renal hepatosplenomegaly or ascites). • External genital anomaly or hypoplasia. • Pelvic examination (PV or PR) for uterine and ovarian abnormalities.

18. Diagnosis of amenorrhea CNS Hypothalamus Pituitary Ovary Uterus Outflow tract

19. Diagnosis of amenorrhea • Special investigations – Step I: • Search for specific disease if suspected. • Pregnancy test. • TSH assay. • Prolactin assay. • Progesterone challenge test: • If (+)ve withdrawal  Normal outflow tract and well estrogenized cases  The cause is anovulation. • If (-)ve withdrawal  Hypoestrogenic state or uterine cause  step II.

20. Diagnosis of amenorrhea • Special investigations – Step II: • Give estrogen + Progesterone: • If (-)ve withdrawal  Uterine cause. • If (+)ve withdrawal  Normal outflow tract and uterus, and there is ovarian failure  Step III • Special investigations – Step III: • Measure FSH: • If high  Ovarian cause. • If low  central cause.

21. Treatment of amenorrhea Treatment of the cause

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