Amenorrhea (1)

7/27/2019 Amenorrhea (1)

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Amenorrhea

Khalid A. Yarouf

4MedStudents.com


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Outline

Definitions.

Hx.

P/E.Clinical approach to 1 amenorrhea.

Clinical approach to 2 amenorrhea.


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Definitions

1 Amenorrhea:

= No menses by age 14 + absence of 2 sexualcharacteristics.

= No menses by age 16 + presence of 2 sexualcharacteristics.

2 Amenorrhea:

= No menses for 3 months if previous menseswere regular.

= No menses for 6 months if previous menses

were irregular


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Hx:

Obstetric Hx: Gravidity, parity.

Gyne Hx: regularity of periods, duration,

dysmenorrhea, menorrhagia, LMP.


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P / E:

Tanner staging.

Breast present ?

Uterus present ?PV exam.

Rule out possibility of pregnancy.


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Clinical approach to 1

amenorrhea:No 2 sexual characteristics:

Clinical findings:

Absence of 2 sexual characteristics (e.g.

breasts) must result from inadequateestrogen. Possible causes are:

1. Gonadal Hyper-gonadotropic

hypogonadism:

Pathophysiology: Normal hypothalamic-

pituitary axis (indicated by FSH), butend organ is unresponsive (absence of

ovarian follicles no estrogen).


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Cont

Cause is gonadal dysgenesis:

Commonest cause of 1 amenorrhea (30%).

Causes: Turners synd (46,X), structurally

abnormal X chromosome, mosaicism with /

without Y chromosome, pure gonadal

dysgenesis (46,XX & 46,XY).


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Cont

2. CentralHypo-gonadotropic

hypogonadism:

Pathophysiology:

a. Failure of GnRH secretion from

hypothalamus:

Many pts with amenorrhea also have anosmia

(Kallmanns synd).

b. Failure of FSH secretion from anterior

pituitary.


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Causes: CNS tumor, craniopharyngioma

FSH .

Dx:

FSH differentiates between gonadal & central

causes.

Karyotype is very useful as well.

Brain CT / MRI to rule out a tumor in case

of central cause.


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Cont

Mx:

In both conditions, give estrogen

stimulate 2 sexual development.Cyclic progestins

prevent endometrial hyperplasia.

FSH Karyotype Dx

45,X Gonadal dysgenesis

46,XX Hypothalamic-pituitaryinsufficiency


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2 sexual characteristics (e.g. breasts) arepresent:

Adequate estrogen must be produced by gonads

to stimulate breast development. Genotype isnormal 46,XX in most cases.

Causes:

1. Intact hymen.

2. Transverse obstructing vaginal septum.3. Cervical agenesis: rare.

4. Uterine absence.


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4. Mllarian agenesis:

Idiopathic failure of mllarian ducts to descend

into pelvis to form upper genital tract. Pts

usually have bilateral rudimentary uterineanlagen, Fallopian tubes & ovaries.

20% of cases of 1 amenorrhea.


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Dx Testosterone level & karyotype

should be obtained.

Testosterone Karyotype Dx

@ normal

levels

46,XX Mllarian

agenesis

@ male

levels

36,XY Androgen

insensitivity


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Cont

Mx:

Neovagina may need to be created. Its

effective in allowing normal vaginal

intercourse.

Breasts developed, but no pubic and

axillary hair 10% of cases of 1 amenorrhea.


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Present with evidence of gonadal secretion (breast

development) but no manifestation of androgen

secretion reflects absence of androgen

receptors (complete androgen insensitivity synd=testicular feminization synd is misnomer).

Genotype is 46,XY. The Y chromosome has led to

production of Mllarian Inhibitory Factor (MIF),

hence pts have only vaginal dimple & no uterus ortubes.


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Cont

Testes, which are often intra-abdominal,produce normal male levels of testosterone.Breast development is due to enzymatic

conversion of testosterone to estrogen.Mx:

Gonadal resection once puberty is complete.

Creation of neovagina when pt is prepared to besexually active.

Psychotherapy.


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Clinical approach to 2

amenorrhea -hCG level should be obtained:

rule out pregnancy (commonest cause of 2

amenorrhea).

Progesterone challenge to assess

estrogen status.

Medroxy-progesterone acetate 10 mg OD

X 1 week look for withdrawal bleeding:


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(+)ve test if any bleeding occurs within 2-7days always due to anovulation.

Do S-Prolactin & TSH rule out correctable

cause.e.g. pituitary prolactinomas / hypothyroidism.

Mx: Treat underlying cause.

Periodic cyclic progestins prevent endometrialhyperplasia from unopposed estrogen.

Ovulation induction with Clomiphene citrate if pregnancy is desired.


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Cont

(-)ve test if no bleeding occurs:

hypo-estrogenism / outflow tractobstruction.

Combined Estrogen-Progesterone ChallengeTest (EPCT) clarifies etiology of amenorrhea.

EPCT should be administered to seewhether withdrawal bleeding occurs:

Conjugated estrogen 1.25 mg PO for 21 daysfollowed by medroxy-progesterone acetate 10mg PO X 1 week.


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(+)ve if any bleeding occurs within2-7 days

always due to lack of estrogen.

FSH level should be obtained todistinguish between hypothalamic-pituitary failure ( FSH) or ovarian

failure ( FSH). In the former case,brain imaging should be obtained torule out a tumor.


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Estrogen should be provided to preventsequelae of estrogen deficiency, alongwith cyclic progestins to prevent

endometrial hyperplasia, regardless ofthe specific cause.

(-)ve test if no bleeding occurs: always due to outflow tract obstruction.

Mx: Obtain hystero-salpingo-gram (HSG). identify site of obstruction (e.g. cervical stenosis).

rule out endometrial adhesions (Ashermans synd).

Amenorrhea (1)

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