Amenorrhea

1. Amenorrhea DI WEN M.D., Ph.D., Professor & Chairman Department Of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine

2. Amenorrhea • Amenorrhea is the absence of menstruation. • 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.

3. Events of Puberty • Thelarche (breast development) • Requires estrogen • Pubarche/adrenarche (pubic hair development) • Requires androgens

4. Events of Puberty • Menarche Requires: • GnRH from the hypothalamus • FSH and LH from the pituitary • Estrogen and progesterone from the ovaries • Normal outflow tract

5. P1 P2 P3 P4 P5 Tanner’s

6. Classification of amenorrhea • hypothalamic amenorrhea • pituitary amenorrhea • ovarian amenorrhea • uterine amenorrhea

7. Etiology • hypothalamic amenorrhea • Psychological stress • 5a-Reductase deficiency • Anorexia nervosa, weight loss • Increased exercise levels • Kallmann syndrome • drug-induced amenorrhea • Space-occupying lesion of CNS

8. Etiology • pituitary amenorrhea • tumor • Empty sella syndrome • Sheehan syndrome

9. Etiology • ovarian amenorrhea • Gonadal dysgenesis • Turner syndrome: low hair line, web neck, shield chest, and widely spaced nipples • Swyer syndrome • resistant ovary syndrome • Premature ovarian failure

10. Tunner staging

11. Acanthosis nigrans

12. Striae

13. Typical features of Turner Syndrome

14. Etiology • uterine amenorrhea • Absence of uterus • Asherman syndrome • anatomic abnormalities of the reproductive tract • Imperforate Hymen

15. Imperforate Hymen

16. 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

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. Diagnosis • History • Physical examination • Physical examination begins with vital signs, including height and weight, and with sexual maturity ratings • Laboratory evaluation

19. VE- preg test TSH ,PROLACTIN’, Prog.challenge test without withdrawal bleeding withdrawal bleeding compromised outflow tract. hypoestrogenic anovulation +ve.est,progest.challenge test -ve.est,progest .challenge test 2wk Normal FSH FSH norm. FSH>30-40 Repeat+serum ,est.level repeat HSG OR hysteroscopyasherman hypothalamic-pituitary failure PROF

20. Treatment • treatment varies depending upon the causes of the amenorrhea. Treatment options include: • Dietary changes, including an increase in fat and calories in order to stimulate estrogen production. • Counseling for eating disorders. • Using stress reduction techniques to help regulate the period. • Hormonal supplements, like the birth control pill or patch, or hormone replacement therapy. • Surgery to remove cysts, fibroids or tumors

21. Thanks for Your Attention DI WEN M.D., Ph.D. Professor & Chairman Department of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine