Upload
mainehoona
View
219
Download
0
Embed Size (px)
Citation preview
7/28/2019 Amenorrhoea( no menses)
1/21
Amenorrhoea
Is the absence of menstruation.Its a symptom and not a disease.
7/28/2019 Amenorrhoea( no menses)
2/21
Physiological Pathological
Primary
-before puberty
Secondary
-during pregnancy
-during lactation
-following menopause
Concealed(cryptomenorrhoea)
Congenital
Acquired
Real
PrimarySecondary
-imperforate hymen-transverse vaginal
septum
-atresia of upper
third of vagina and
cervix
-stenosis of
cervix
-secondary
vaginal
atresia
7/28/2019 Amenorrhoea( no menses)
3/21
At least 5 basic factors involved in the onset
and continuation of normal menstruation:-
Normal female chromosomal pattern
Co-ordinated hypothalamus-pituitary-
ovarian axis
Responsive endometrium
Active support of thyroid and adrenal
glands
Anatomical patency of outflow tract
7/28/2019 Amenorrhoea( no menses)
4/21
PRIMARY AMENORRHOEA
7/28/2019 Amenorrhoea( no menses)
5/21
The causes are grouped as follows:-
Disorders of hypothalamic-pituitary-
ovarian axis
Developmental defect of genital tract
Abnormal chromosomal pattern
Dysfunction of thyroid and adrenal cortex
Metabolic disorders
Systemic illness
Unresponsive endometrium
7/28/2019 Amenorrhoea( no menses)
6/21
Hypothalamus Anterior
pituitary Ovary Endometrium
Hypothalamic causes:-
-Chronic illness
-Anorexia
-Excessive exercise
-Stress
Pituitary causes:-
-hyperprolactinaemia
-hypothyroidism
-breastfeeding
-kallmans syndrome
Ovarian causes:-
-Polycystic ovarian
syndrome
-premature ovarian
failure
-chemotherapy &radiotherapy
-Depot
medroxyprogesterone
acetate ( DMPA)
-menopause
Uterine
causes:-
-Pregnancy
-cervical
stenosis
GnRH LH
FSH
Oestrogen
Progesterone
7/28/2019 Amenorrhoea( no menses)
7/21
Disorders of hypothalamo-
pituitary ovarian axis
Hypogonadotrophic hypogonadism e.g.
delayed puberty, Kallmans syndrome,
CNS tumours and rarely polycystic ovarian
disease.
Hypergonadotrophic hypogonadism e.g.
premature ovarian failure, individuals with
17 alpha hydroxylase deficiency andgalactosemia.
7/28/2019 Amenorrhoea( no menses)
8/21
Developmental defect of genital
tract
Imperforate hymen
Transverse vaginal hymen
Atresia of upper third of vagina and cervix
Complete absence of vagina
Absence of uterus
7/28/2019 Amenorrhoea( no menses)
9/21
Abnormal chromosomal pattern
Turners syndrome
Androgen insensitivity syndrome
7/28/2019 Amenorrhoea( no menses)
10/21
Clinical featuresFamily history of female relatives with late onset
of menses is suggestive of constitutional delay.Androgen insensitivity is also suggestive offamily history.
Excessive exercise and any change in weightshould be inquired.
Chronic illness or medications should be askedabout.
An imperforate hymen or vaginal septum with ahistory of amenorrhoea and cyclical abdominalpain.
7/28/2019 Amenorrhoea( no menses)
11/21
Examination The important feature is the presence or absence of
secondary sexual characteristics like breast
development, pubic and axillary hair. Absence of thesefeatures suggests Turners, hypothalamic cause orhypothyroidism.
Check weight and height to calculate BMI
Note any features of Turners (webbed neck,shortstature etc)
Prolactinoma..abnormal visual fields
Hypothyroidism
Androgen excess (hirsutism and acne)
7/28/2019 Amenorrhoea( no menses)
12/21
Investigations
Should be initiated in a girl who has no menses
by the age of 16 if no secondary sexual
characteristics are presentAND at 14 if there is
no secondary sex development.
Urine pregnancy test to rule out possible
pregnancy.
Thyroid function and prolactin levels.
Serum gonadotrophin, testosterone and
oestradiol levels. FSH & LH levels.
Karyotyping
Ultrasound scan
7/28/2019 Amenorrhoea( no menses)
13/21
Management
Reassure girls with constitutional delaythat they will menstruate spontaneously.
Thyroxine for hypothyroidism
Bromocriptine or surgery for prolactinoma.Exercise should be limited in exercise-
induced-amenorrhoea and weight gain
should be encouraged if body mass indexis < 19.
Osteoporosis should be prevented by
giving combined oral contraceptive pills.
7/28/2019 Amenorrhoea( no menses)
14/21
Vaginal reconstruction for complete agenesis ofvagina.
In Turners or other gonadal dysgenesis, shortterm use of oestrogen and progesterone isprescribed at least for development of breasts.
In androgen insensitivity syndrome(AIS), theectopic gonads are to be removed after thesecondary characters are well developed.
For hypothalamo-pituitary-ovarian defects aretreated by induction of menstruation orovulation.
7/28/2019 Amenorrhoea( no menses)
15/21
SECONDARY AMENORRHOEAis the absence of menstruation for 6 months or more
after previously regular menses.
7/28/2019 Amenorrhoea( no menses)
16/21
COMMON CAUSES
Hypothalamus
-stress
-Sudden weight
change
-Anti-Ht drugs
Pituitary
- Adenoma
(hyperprolactinoma)
- Sheehans
syndrome
Ovary
-Polycystic
ovarian disease
-Premature
ovarian failure
Uterine
-Intrauterine
adhesions
Systemic
-Malnutrition
-Hypothyroidism
-Diabetes
7/28/2019 Amenorrhoea( no menses)
17/21
History
Preceded by hypomenorrhoea oroligomenorrhoea
Sudden change in environment/ weight loss,emotional stress
Intake of antihypertensives Acne, change in voice, hirsutism.
Inappropriate galactorrhoea
Prolonged lactation
Medical history of TB
Family history of premature menopause
7/28/2019 Amenorrhoea( no menses)
18/21
Examination
Nutritional status
Look for signs of polycystic ovarian syndrome
(hirsutism, obesity and acne), hypothyroidism
and prolactinoma (check visual fields). Marked obesity
In abdominal examination- presence of striae
and masses. In pelvis examination for enlargement of clitoris
and adnexal masses.
7/28/2019 Amenorrhoea( no menses)
19/21
Investigations
oA pregnancy test is usually indicated.
o LH, FSH, testosterone, estradiol to check forpolycystic ovarian syndrome, androgen
secreting tumour and premature ovarianfailure.
o T3 & T4 levels to check for hypothyroidism.
o Serum prolactin levels, CT/MRI for cases ofsuspected prolactinoma.
7/28/2019 Amenorrhoea( no menses)
20/21
ManagementCombined oral contraceptive pill for
polycystic ovaries. If obesity becomes aproblem, weight loss usually restores
menses and fertility.
For premature ovarian failure, hormone
replacement therapy to prevent
osteoporosis. Fertility is only possible byovum donation and in vitro fertilization
( IVF).
7/28/2019 Amenorrhoea( no menses)
21/21
Exercise induced amenorrhoea advice
on change in lifestyle and diet.
Prolactinomas managed by bromocriptine
or cabergoline. Surgery is only indicative if
resistant to medications.
Thyroxine replacement for hypothyroidism.
Contraceptive related amenorrhoea is
restored by expectancy.