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PRIMARY AMENORRHEA
1. No menstruation by the age of 14 years
accompanied by failure to grow properly or
develop secondary sexual characteristics.
2. No menstruation by age of 16 when growth and
sexual development are normal.
SECONDARY AMENORRHOEA
OLIGOMENORRHEA
Menses occurring at intervals longer than 35 days
apart.
No consensus has been reached regarding the point
at which oligomenorrhea becomes amenorrhea. Some
authors suggest the absence of menses for 6 months
constitutes amenorrhea, but the basis for this
recommendation is unclear. For a post menarchal girl
or a reproductive-aged woman to experience a
menstrual cycle interval of more than 90days is
unusual. Practically this should be an indication to
seek the cause.
CLINICAL APPROACH
Amenorrhea is a normal feature in
prepubertal, pregnant, and postmenopausal
females.
In females of reproductive age, diagnosing
amenorrhea is a matter of first determining
whether pregnancy is the etiology. In the
absence of pregnancy, the challenge is to
determine the exact cause of absent menses.
Pathophysiology
The menstrual cycle is an orderly progression of
coordinated hormonal events that stimulates growth of
a follicle to release an egg and prepare for implantation
if fertilization occurs; failure of which results in the
decidua of the endometrium is sloughed in a flow of
menses in preparation for another cycle.
The menstrual cycle can be divided into 3 physiologic
phases: follicular, ovulatory, and luteal. Each phase
has distinct hormonal milieu. Consideration of the
target organs of these reproductive hormones
(hypothalamus, pituitary, ovary, uterus) is helpful for
identifying the disease process responsible for the
patients amenorrhea.
CAUSES OF AMENORRHOEA
A. Disorder of outflow tract and or
uterus
B. Disorders of ovary
C. Disorders of Anterior Pituitary
D. Disorders of Hypothalamus
FEATURES:
MANAGEMENT:INCISE MEMBRANE
Imperforate hymen
2.
ABSENCE OR HYPOPLASIA OF
VAGINA:
FEATURES:
MANAGEMENT:
Create a functional vagina by surgery or dilators
Mayer-Rokitansky-Kuster-Hauser Syndrome
(utero-vaginal agenesis)
3. TESTICULAR FEMINIZATION:
(Androgen Insensitivity)
Phenotype is woman. Genotype is
man (xy) testes are present.
Inherited by an X-linked recessive
gene (familial)
Resulting in absence of cytosol
androgen receptor
FEATURES:
i.
MANAGEMENT:
These patients are female.
The gonads must be removed after puberty
then HRT (hormone replacement Therapy)
started
Rare cases of incomplete test. feminization
do occur have variable degress of
masculinization
4. ASHERMANS SYNDROME:
Sec. amenorrhea following destruction of the
endometrium by overzealous curettage
multiple Synechiae show up on
Hysterography.
MANAGEMENT:
Under G.A. breakdown intraut. Adhesions
through hysteroscopeinsert an IUCD to
deter reformation hormone therapy (E2 + P)
5. INFECTION
e.g. Tuberculosis. Ut. Schistosomiasis.
Sarcoidosis
2. GONADAL AGENESIS:
(Failure of gonadal develop): no
other cong. abn.
3. RESISTANT OVARY SYNDROME
A rare condition
Normal ovarian develop and
potential
FSH
It may resolve spontaneously
If hot flushes Rx. With estrogen
4. PREMATURE MENOPAUSE:
Ovarian failure.due to
i. Auto-immune dis. (associated with
dis. ??)
ii. Viral infection (e.g. mumps)
iii. Cytotoxic drugs
5.
Addisons
PCOs:
Mostly present with classical Stein-Leventhal
syndrome (of oligomenorrhea, obesity,
hirsutism, and infertility)
However a substantial group will have sec.
amenorrhea with no obesity or hirsutism
Diagnosis is made by finding LH/FSH ratio
Confirmation is made by laparoscopy.
USS +
C. DISORDERS OF PITUITARY
1. Pituitary Tumor causing
Hyperprolactinemia
40% of women with hyperprolactinemia
will have a pituitary adenoma
Pit. Fossa XR is necessary in all cases of
amenorrhea particular 20.
FEATURES:
Erosion of clinoid process
Enlarge of pituitary fossa
Double flooring of fossa
If any of above features seen
CT san or MRI + Assessment of visual fields
MANAGEMENT:
2.
3. CRANIOPHARYNGIOMA
4. SHEEHANS SYNDROME
Necrosis of ant. pituitary due to severe
PPH
Pan or partial hypopituitarism
It is rare problem today due to better
obstetric care and adequate blood
transfusion
D. DISORDERS OF HYPOTHALAMUS
CAUSES:
POST-PILL AMENORRHOEA:
INVESTIGATION OF AMENORRHOEA
1. S. Prolactin level and Thyroid
Function Tests
2. Karyotypingif chrom. anomaly is
suspected on clinical grounds
3. Progesterone withdrawal test.to
check endog. estrogen.
e.g. Provera (medroxy-prog) if
bleeding PV=reactive endom. and
patent outflow tract.
4. USS:
Of uterus and ovaries can be useful to investigating and
monitor Rx. Of these women
DDX
Anorexia Nervosa
Anxiety Disorders
Congenital Adrenal Hyperplasia
Cushing Syndrome
Depression
Follicle Stimulating Hormone Abnormalities
Lutenizing Hormone Deficiency
Ovarian Insufficiency
Pregnancy Diagnosis
Prolactinoma