Amenorrhea

1. Amenorrhea OsmanDonia Prof. Obstet. Gynaecol., Osman Donia

2. Osman Donia

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. Osman Donia

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

5. False amenorrhea(Cryptomenorrhea) Osman Donia

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. Osman Donia

7. True amenorrhea Osman Donia

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. Osman Donia

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. Osman Donia

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

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

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. Osman Donia

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

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. Osman Donia

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. Osman Donia

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. Osman Donia

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. Osman Donia

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

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. Osman Donia

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. Osman Donia

21. Treatment of amenorrhea Treatment of the cause Osman Donia

22. Osman Donia

23. Thank You Osman Donia