Amenorrhea

Dr Jack Biko

introduction

• A symptom and not a Condition

• Absence of menstrual bleeding

• Maturation of H-P-O axis

• Outflow tract

Causes

• Hypothalamic

• Pituatory

• Ovarian

• Other

Amenorrhea

• 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, not on contraceptives

Amenorrhea

• Transient, intermittent or permanent

• Dysfunction of hypothalamus, pituatory gland, ovaries, uterus or vagina

• Thyroid gland• Adrenal gland

Hormonal events

Events of Puberty

• Thelarche (breast development)– Requires estrogen

• Pubarche/adrenarche (pubic hair development)– Requires androgens

• Menarche– Requires:– GnRH from the hypothalamus– FSH and LH from the pituitary– Estrogen and progesterone from the ovaries– Normal outflow tract

Teens with

• Secondary sexual characteristics present• No menstruation• Cyclical pains

• THINK MULLERIAN ANOMALIES / OBSTRUCTION OF OUTFLOW TRACT

Primary Amenorrhea

• Is there normal development of secondary sexual characteristics?

YES• Think– Pregnancy– Mullerian anomaly – outflow tract, uterine– Androgen insensitivity

Primary amenorrhea

• CNS pathology

• Ovarian - Genetic abnormality

• Obstruction of outflow tract

Are there secondary sexual characteristics?

Primary Amenorrhea

• Is there normal development of secondary sexual characteristcs?

NOThink hypogonadism or hypogonadotropism

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

Imperforate Hymen

Amenorrhea with Immature Secondary Characteristics

FSH Serum level

/Low normal

High

Hypogonadotropichypogonadism

Gonadal dysgenesis

Gonadal Dysgenesis

• Chromosomally abnormal

- Classic turner’s syndrome (45XO) - Turner variants (45XO/46XX),(46X-abnormal X) - Mixed gonadal dygenesis (45XO/46XY)

• Chromosomally normal

- 46XX (Pure gonadal dysgeneis) - 46XY (Swyer’s syndrome)

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

Amenorrhea

• Evaluation

– Pregnancy test– Physical exam to determine presence of uterus– FSH– Karyotype

Amenorrhea

• Treatment

– Cyclic estrogen/progestin

– Remove gonadal streaks if XY or mosaic• Increased (52%) risk of gonadoblastomas, dysgerminomas, and

yolk sac tumors

– Pulsatile GnRH for ovulation induction in select patients

– Surgical resection of intrauterine, cervical, and vaginal septa

Secondary Amenorrhea

• Pregnancy!• CNS disorders• Pituitary gland• Thyroid• Ovary• Uterus• Systemic disorders– Renal failure, liver disorders, DM

• Medications: anti-psychotics, reserpine

Secondary Amenorrhea

• CNS disorders– Chronic hypothalamic anovulation• Stress• Increased exercise levels• Anorexia nervosa

– Head trauma– Space-occupying lesions

Secondary Amenorrhea

• Hyperprolactinemia: Prolactinoma• Medications

• Renal failure• Pituatory injury

• Pituitary resection• Sheehan’s syndrome

• Thyroid disorders– Hyper- or hypothyroidism

Secondary Amenorrhea

• Ovulation disorders– Polycystic ovarian syndrome– Premature ovarian failure

• Uterine abnormalities– Asherman’s syndrome– Cervical stenosis

• Drug-induced amenorrhea– Hormonal contraceptives– GnRH analogues

PCOS

• First described in 1935• Findings of polycystic

ovaries reported more than 100yrs previously

• A syndrome – no single feature or test is diagnostic

Endocrinology of PCOS

•Hyper-production of androgens by theca cells.

•Abnormal ovarian steroid-genesis

•Failure of follicular maturation.

•Lack of progesterone production due to corpus luteum absence.

•Subsequent increase of LH level.

Diagnostic Criteria; Rotterdam 2003

• Based on Consensus

• Oligo or anovulation• Hyperandrogenism – clinical or biochemical• Polycystic ovaries

Exclude other causes of androgen excess

Intra-uterine adhesions

• Asherman’s syndrome

• Previous D&C

• Previous endometritis

• Endometrial TB

Asherman’s Syndrome

Treatment

• Hysteroscopic resection

• High dose oestradiol

Hysteroscopy

AmenorrheaHistory

Nutrition/exercise habits, weight changeSexual/contraceptive practiceHistory of uterine/cervical surgery

Physical examHeight/weightHirsutismGalactorrheaEstrogen status of tissues

LaboratoryBhCG PRL & TSH progesterone challenge FSH

if high karyotype

Secondary Amenorrhea

• Treatment goals– Discovery and treatment of underlying

disorder– Hormone replacement– Menses every 1-3 months– Pregnancy• Ovulation induction• FSH/LH

Case studies

12 year old

• No periods

• No pain

• No secondary sexual characteristics

15 yr old

• No periods• Cyclical pains• Has secondary sexual characteris

24 yr old

• G3P0

• TOP x 3

• No periods for 6 months now

33 yr old

• Amenorrhea for 4 yrs

• Para 0

• No cyclical pains

• Normal secondary sexual characteristics

Amenorrhea

• 26 yr Gravida 0 with menarche at age 14 presents with one-year history of amenorrhea.

• Obese

• Hirsutism

Thank you