Amenorrhea Dr Nadia algantary Associated proffessor Faculty of medicine

1. Amenorrhea Dr Nadia algantary Associated proffessor Faculty of medicine

2. objective • The student be able to understand definition of primary &secondary ammenorrhea. • Be able to know the practical approach to ammenorrhic patient

3. Primary Amenorrhea • absence of menarche by age 16 regardless of secondary sex changes • –absence of normal menstruation in a patient without previously established cycles • –no periods by age 14 with no secondary sex changes • -

4. Secondary amenorrhea • –absence of menses for 3 cycle lengths in oligomenorrhea, or for 6 months after having regular menses • –1-5% of the population

6. Clinical feature • History • –milestones, development, diet, exercise, wt change • –drug use (antipsychotics, hormones, narcs, anti-HTN’s • –systemic disease (hypothyroidism, adrenal insuff., GH excess) • –past surgery, glactorrhea, hirsutism • –gyn/ob hx (hemorrhage, D&C, infection) • –genetic history

7. examination • • • Physical–ht, wt, vitals–signs of thyroid dz (protuberant eyes, enlarged gland, puffy face, heat/cold intolerance)–secondary sex changes•thelarche (breast devel): avg. age 10.8 yrs; indication of estrogen exposure•adrenarche (pubic/axillary hair development): avg. age 11 and indicates ovarian and adrenal

8. causes Primary amenorrhea–gonadal failure is most common cause–uterovaginal agenesis is second most common cause􀁑Anorexia nervosa is the most common cause of amenorrhea overall in teens􀁑

9. causes • CNS or hypothalamic causes•anatomic lesions (can appear with or without secondary sex changes•drugs affecting prolactin levels (stimulators and inhibitors)•stress, exercise, and eating disorders•PCOS•functional hypothalamic amenorrhea

10. causes • Pituitary causes􀁑Ovarian causes (elevated gonadotropin and low estrogen)–radiation and chemo; premature ovarian failure; ovarian resistance sd; PCOS; infection; vascular injury; 􀁑Uterine causes (only group in this category who will show normal endocrine findings

11. DDx and Tx in Primary Amenorrhea:2nd sex changes present, cervix present􀁑Work up–r/o pregnancy–r/o hyperprolactinemia–if prolactin level elevated, evaluate thyroid function–measure FSH and LH–measure 17a-hydroxylase progesterone and progesterone–do a progesterone challenge test

12. Treatment–dopamine agonist therapy–combination OCP therapy–estrogen replacement

13. DDx and Tx in Primary Amenorrhea: • 2nd sex changes present, cervix absent • 􀁑androgen insensitivity (testicular feminization sd) • 􀁑mullerian anomalies or agenesis • 􀁑work up • –karyotype and testosterone level • –if nl body hair and female testosterone levels, uterine agenesis is present and pt is sterile

14. karyotype is to r/o male pseudohermaphrodism • •IVP should be done to r/o renal anomalies • •may need reconstructive surgery • –pts with AI are usually raised as girls (XY) • •remove gonads after breast development and epiphyseal closure • •replace estrogen

15. DDx and Tx in Primary Amenorrhea: • 2nd sex changes absent, cervix absent • 􀁑<1% of primary amenorrhea • –pts are 46XY, but have abnormality in testosterone synthesis • –mullerian inhibiting factor causes internal female organs to regress

16. DDx • –17a-hydroxylase deficiency • –17,20 desmolase deficiency • –agonadism • 􀁑Lab: elevated gonadotropins and low-normal female testosterone levels • 􀁑Tx: remove testicles and replace estrogen; no need for progesterone

17. Secondary amenorrhea • 􀁑Differential • –similar to that of primary amenorrhea with cervix and secondary sex changes present • 􀁑Work up • –r/o pregnancy • –r/o hyperprolactinemia • –if prolactin level elevated, evaluate thyroid function • –measure FSH and LH • –measure 17a-hydroxylase progesterone and progesterone • –do a progesterone challenge test

18. pregnancy is most common cause–49-62% have hypothalamic disorders, including PCO–7-16% have pituitary disorders–10% have ovarian disorders–7% have Ashermans syndrome

19. Secondary amenorrhea • Treatment • –dopamine agonist therapy • –combination OCP therapy • –estrogen replacement

20. conclusion • Ammenorrhea is not uncommon problem. • Pregnancy is the most common causes. • Ultrasound and hormonal assay is the ..keys to differentiate between the most causes of ammenorrhea.