Dr. Hazem Al-Mandeel, M.D Assistant Professor & Consultant Obstetrics & Gynecology College of...
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![Page 1: Dr. Hazem Al-Mandeel, M.D Assistant Professor & Consultant Obstetrics & Gynecology College of Medicine King Saud University OB/GYN Rotation-course 481.](https://reader035.fdocuments.net/reader035/viewer/2022081722/56649efb5503460f94c0e5a4/html5/thumbnails/1.jpg)
Dr. Hazem Al-Mandeel, M.DAssistant Professor & ConsultantObstetrics & GynecologyCollege of MedicineKing Saud University
OB/GYN Rotation-course 481 GYN
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1ry Amenorrhea: is the lack of onset of menses by age 16 in female with 2ry sexual characteristics
ORby age of 14 in female without 2ry sexual
development
2ry Amenorrhea: is the cessation of menses for a period of 6 months in a female who previously had initiation of menses
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• Gonadal Failure 43%• Congenital Absence of the vagina 14%• Constitutional delay 10%
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• Chronic anovulation 39%• Hypothyroidisim/Hyperprolactinemia 20%• Weight loss/anorexia 16%
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Primary Sexual characteristics
Absent
Present
PE
5 -Reductase def.17-20 Desmolase def.17 Hydroxylase Def.(All XY Karyotype)
UterusAbsent
Normal
FSHHigh
Normal
•Kallman’s Syndrome•Physiologic Delay
Karyotype
•XX•Y line
•Turner (XO)
HCG+
Pregnancy
HCG -ve
Primary
No
Yes
PE
SecondaryR/O
Asherman’sCx Stenosis
Normal
TSH, PRL, FSH
Mullerian AbnAISTrue
Hemaphrodite
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TSH, PRL, FSH
TSH
Normal
AbnormalHypoThyroidismHyperThyroidism
Prolactin High Hyperprolactenemia
Normal
FSH High•Ovarian Failure
•Radiation•Chemo•Infection•Autoimune
•Galacrosemia•Idiopathic
Normal
Estrogen
LowNormal
CNS Exam
PCOSIdiopathicOvarian NeoplasmsObesityCushing’sCAH
Pituitary Hypothalamic Lesions:
TumorsInfectionInfarctionFailure
Toxic
Chronic Disease
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1-TURNER SYNDROME: 45XO2-Mosaicism of Turner’s: XO/XX not always short,
they will have menses , get pregnant then develop premature menopause
3-Structural abnormalities of the X chromosome: deletion of the short arm of the X chromosome Short stature deletion of the long arm normal Ht., 2ry Amenorrhea, & streak gonads
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1ry amenorrhea No breast development Normal ♀♀ genital organs (external /internal)Streak gonads (ovaries are replaced by nonfunctioning tissue)Short statureWebbed neck (Short broad neck) with a low hair lineCubitus vulgusShield chest / Widely spaced nipplesHigh arched palateShort 4th metacarpalCoarctation of the aorta or VSDHorse shoe kidney or single kidneyLymphedema
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4-Pure gonadal dysgenesis : 46XX, mutation in an autosomal gene accelerated germ cell loss streak gonads. Features: genetalia with normal mullerian ♀
structures
5- Pure gonadal dysgenesis : 46 XY. Features: normal ♀genitalia and mullerian structures with streak gonads ↑ risk of malignancy
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6- 17-α hydroxylase deficiency (rare) ovarian synthesis of estrogens 1ry AmenSexual immaturity cortisol ↑ ACTH ↑ Na K ↑ BP ↑ Progestrone as it is not converted to cortisol
7- Galactosaemia (rare) galactosaemia is toxic to oocytes
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Anosmia & Hypogonadotropic Hypogonadism X linked ----Mutation in the KAL geneMore common in > ♂ ♀
Midline defects Cleft lip & PalateSomatic defects color blindness, renal agenesis,
retinitis pigmentosa, neurosensory deafness Lack 2ry sexual chct & the ability to smellHT & bone age appropriate for age
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CNS tumors GnRH pulses LH & FSH estradiol
Hypothalamic Lesions Craniopharyngioma granuloma, aqueduct stenosis , & encephalitis CNS tumors interfere with the –ve feedback of Dopamine on Prolactin ↑ Prolactin Other causes of HypoGonadotropic Amen
hypothyroidism
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Functional GnRH deficiency May present with or without Breast developmentPhysical stress delay menarcheEach year of athelitic training before menarche
delayed menarche 5 MOsteoporosis could occur with prolonged periods of
Amenorrhea, low body Wt
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1. HYPOTHALAMIC CAUSES: CNS lesions (tumors) Stress, Excessive exercise & low body Wt
2. PITUITARY CAUSES: Hyperprolactinemia Hypothyroidism ↑ TRH ↑ prolactin
3. OVARIAN CAUSES: Polycystic ovarian disease/syndrome
4. OUTFLOW TRACT OBSTRUCTION: Imperforate hymen Transverse vaginal septum
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XY Karotype produce MIF Mullerian structures are absentComplete/ Partial absence of androgen receptorsX-linked recessive or dominant Female external genitalia with Short blind vaginaTestosterone normal range♂
Breast development due to peripheral conversion of androgens to estrogens
Sexual hair is absent due to absence of androgen receptorsGonadectomy after puberty ↑ risk of malignancy
(gonadoblastoma, dysgerminoma)
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Autosomal recessive Formation of the external genitalia requires 5♂ α REDUCTASE testosterone dihydrotestosteroneFormation of the internal wolfiane structures respond directly
to testosteroneExternal genitalia with mild musculinization♀
Absent uterusAt puberty testosterone secretion virilization
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Etiology ?Failure of mullerian duct development absence of the upper
vagina, cx & uterus (uterine reminants may be found)The ovaries & fallopian tubes are presentNormal 46XX with normal exrenal genitalia♀
Pt present with 1ry amenorroea47% have asociared urinary tract anomalies12% skeletal anomaliesRx psychological counseling surgical treatments: vaginoplasty, excision of utrine
reminant (if it has fuctioning endometrium)
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The least common presentation of 1ry AmenorrheaAll patients are 46 XYTestosterone or NFSH/LH ↑
A.17-20 DESMOLASE DEFICIENCY The enzyme required for the synthesis of Androgens
androgens estrogen The testes produce MIF therefore no mullerian structures ♀ external genitalia Insufficient estrogens for breast development
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B. 17 α HYDROXYLASE DEFICIENCYSimilar to 17-20 desmolase deficiency. Cortisol synthesis also ↑ BP, hypernatraemia & hypokalaemia
C. AGONADISM Degeneration of the testes (in utero) after the production of
the MIF
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WHAT IS 2RY AMENORRHEA?Cessation of menses for a period of 6 months or 3
consecutive menstrual cycles in a who previously had initiation of ♀
mensesWHAT IS THE PREVELANCE OF AMENORRHEA?1.8-3%WHAT IS THE CLASSIFICATON OF 2RY AMENORRHEA?HypergonadotropicHypogonadotrpicEuogonadotrpicHperprolactinemiaAnatomic defects
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Stress ↑ β-endorphins GnRH FSH LH EstrogensExercise Excessive streneous exercise e.g.: runners Mechanism Similar to stress Wt. loss “Anorexia nervosa” More frequent in
adolescent & young adults 0.5-1% of women aged 15 –30 years 15% < Ideal Body Wt. Functional “Non of the above causes” No LH pulses or
persistent pulse frequency of “Luteal Phase ” 2ry to neurotransmitter abnormality of the CNS (? ↑
Opioid activity)
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IS IT OF ANY CONCERN IF THESE YOUNG WOMEN BECOME AMENORRHEIC ?
HYPOESTROGENISM is the main concern
WHY IS IT MORE WORRYING THAN THE MENOPAUSAL WOMEN ?During adolescence estrogen plays a critical role in
determining PEAK BONE DENSITY which reached in the 2nd decade of life
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IS THERE ANY EVIDENCE OF ITS EFFECT ON THE BONES?Amenorrheic Athletes Bone Mineral Density (BMD) in
lumbar spines, femur, tibia Athletes with menstrual irregularities BMD but less
than athletes with regular cyclesAnorexia nervosa Pt BMD (0.64)Anorexia nervosa Pt may have osteoporotic fractures
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SHEHAN’S SYNDROMEPituitary failure following sever post partum
hemorrhageDeficiency of all pituitary hormonesFSH & LH Failure of ovarian follicular development estrogen AmenorrheaRx HRT
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In training intensity to a level where regular menses resume
HRT Cyclic estrogen / progestrone; e.g.: Premarin continuously + Medroxyprogestrone acetate for 12 days
OCP better compliance Anorexia nervosa Psychiatric Rx + HRT Long term follow up Frequent relapses after attaining
ideal body wt.Functional Amennorhea HRT / ovulation induction
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Polycystic Ovarian Disease / SyndromeAmenorrhea / anovulatory cyclesEnlarged polycystic ovariesInfertilityHyperinsulinemia / ObesityHyperandrogenism / hirsutism↑ LHAcyclic estrogen production / unopposed by
progesrtrone ↑ risk of endometrial hyperplasia/CaInheritable disorder with a complex inheritance pattern
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WHAT IS PREMATURE OVARIAN FAILURE (POF) ?2ry Amenorrhea ↑ FSH & LH Estrogen Before the age of 40 yearsWHAT IS THE INCIDENCE OF POF ?1%WHAT IS THE CAUSE?Unknown / autoimmune / genetic factorsAssociated autoimmune disease 39%
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WHAT ARE THE PATHOLOGICAL CHARACTERISTICS OF POF ?Ovarian sclerosis & lack of folliclesResistant ovary syndrome
HOW TO MANAGE POF?R/O other autoimmune diseases RH factor ANA, Antithyroid Antibodies, Antichromosomal Antibodies,
glucose, cortisol, Ca , Ph, TSHHRT to prevent osteoprosisSpontaneous pregnancy can occur in 8% of women with POF on HRT
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The most common pituitary cause of 2ry AmenorrheaCauses -Pituitary adenoma -Idiopathic -Loss of inhibition by dopamine Hypothalamic or pituitary stalk lesions -Hypothyroidism -PCOS -Medications phenothiazines , haloperidol monoamineoxidase inhibitors, TCA, H2 receptors blockers
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Galactorrhea 1/3 of Pt Amenorrhea/ Hyperprolactinemia Pt at risk of osteoporosis due to estrogenTREATMENT - Hypothyroidism L-Thyroxin If still amenorrheic after RX Parlodel + Thuroxin -If no substitute for the medications that cause hyperprolactinemia HRT -Hypothalamic or pituitary stalk lesions Surgical excision
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PITUITARY ADENOMA (PROLACTINOMA) *Macroadenoma > 10 mm Respond to medical Rx
Dopamine agonist (bromocriptin) size of the tumor & prolactin level
Pt not responding to medical Rx or not tolerating it Surgery/ Irradiation
*Microadenoma < 10mm remain stable in size Rx Bromocriptin prolactin level to normalize the
menstrual cycle
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IDIOPATHIC HYPERPROLACTINEMIA Rx Dopamine agonist Bromocriptin or PergolideSide effects of dopamine agonists -Postural hypotension -Nausea -Headache -Nasal stuffinessStarting with a low dose & gradually ↑ it helps to avoid
the side effects
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Uncommon cause of 2ry AmenorrheaAsherman’s Syndrome Hx of D/C for RPOC after
abortion / puerperium or previous uterine infectionIntrauterine AdhesionsNormal hormonesNegative progestrone chalange testDx HSG / HYSTROSCOPYRx Hystroscopic resection of the adhesions followed
by estrogen therapy