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Osman Donia
AmenorrheaAmenorrhea
Osman DoniaOsman DoniaProf. Obstet. Gynaecol.,Prof. Obstet. Gynaecol.,
Osman Donia
Osman Donia
Definitions & ClassificationDefinitions & Classification
Amenorrhea: Absence of menses.
Primary amenorrhea: Non occurrence of menarche by age of:
– 14 with no secondary sex characters
– 16 (18) with secondary sex characters.
Secondary amenorrhea: Absence of menses for 3 successive cycles.
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Amenorrhea
PhysiologicPathologic
Puberty
Menopause
Pregnancy
Lactation
TrueFalse
Cervix
Vaginal T. septa
Imperforate hymen
Hypothalamic
Pituitary
Ovarian
Uterine
General
CNS
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False amenorrheaFalse amenorrhea(Cryptomenorrhea)(Cryptomenorrhea)
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CryptomenorrheaCryptomenorrhea
Due to outflow obstruction. The most common cause is imperforate hymen. Blood accumulate behind the hymen hematocolpos
Hematometra Pelvic hemorrhage. Diagnosis:
– P. amenorrhea with good 2ry sex characters.
– PMS.
– Urinary symptoms.
– Abdominal mass ????.
– Local examination is diagnostic.
Treatment: Cruciate incision under anesthesia Slow evacuation + antibiotics.
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True amenorrheaTrue amenorrhea
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CNS CNS CausesCauses
Psychological troubles:– Psychosis # neurosis.
– Pseudocyesis.
– Anorexia nervosa.
Chronic stresses. Weight loss. Exercise:
– Loss of body fat.
– Stress of competition.
– Hyperthermia and dehydration.
– Euphoria of winning causing increased opiates.
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Hypothalamic causesHypothalamic causes
Destruction:– Trauma– Inflammation.– Tumors.– Infiltrations.
Drugs:– Estrogens.– CNS affecting drugs.
Dysfunction & congenital disorders:– Chiari Frommel syndrome.– Del Castillo syndrome.– Kallmann syndrome.– Laurence Moon Biedl syndrome.– Frohlich syndrome.
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Destruction:– Infiltrations.
– Tumors.
– Sheehan syndrome.
Drugs:– Estrogens.
– Prolactin inducing drugs.
Dysfunction and congenital disorders:– Levi Lorain syndrome.
– Empty sella syndrome.
– Prolactinomas.
Pituitary causesPituitary causes
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Congenital:– Turner.– Androgen insensitivity syndrome.
Traumatic:– Surgical removal.– Irradiation.
Inflammatory:– Mumps.– PID.– TB.
Neoplasia:– Benign.– Malignant.
Dysfunctions:– PCO.– Resistant ovary syndrome.
Ovarian causesOvarian causes
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Congenital:– Mullerian agenesis.– Uterine atresia– Severe hypoplasia.
Traumatic:– Surgical removal.– Irradiation.
Inflammatory:– Asherman syndrome.– TB.
Neoplastic:– Obstructing the cervix.
Dysfunctions:– Insensitive endometrium.
Uterine causesUterine causes
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DM:– Glucose metabolism.– Ketosis.– Immunological.
Thyroid:– Hyper.– Hypo.
Adrenal:– Addison.– Cushing.
Debilitating diseases.
General causesGeneral causes
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1- Cryptomenorrhea: All congenital causes.
2- True:– Psychological disturbances before menarche.
– Congenital diseases in the hypothalamus or pituitary.
– Ovarian dysgenesis and removal or destruction before menarche (T.B, irradiation).
– Uterine aplasia or severe hypoplasia, T.B or removal before menarche.
– General cause before menarche.
The most common causes of primary amenorrhea:– Gonadal dysgenesis.
– Mullerian agenesis.– Complete AIS.
Causes of 1ry amenorrheaCauses of 1ry amenorrhea
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Physiological:– Pregnancy, lactation, after menopause.
Cryptomenorrhea: Any acquired cause. True:
– Psychogenic disorders after menarche, Chiari Frommel and Del Castillo syndromes, drugs, OCs, destruction by trauma, infections, tumors after puberty.
– Sheehan syndrome, Simmond's disease, destruction and tumors after puberty.
– Ovarian failure, PCO and ovarian tumors.
– Intrauterine synechia, hysterectomy or T.B endometritis after puberty.
– Any general cause after puberty.
Causes of 2ry amenorrheaCauses of 2ry amenorrhea
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History:History:– Age, occupation, residence, habits and education.
– Primary or secondary amenorrhea.
– History of psychogenic disorders.
– History of neurological disturbances.
– History of endocrinological disorders.
– Past history of operations, pelvic infections, T.B, long drug course or irradiation.
– Family history of similar condition, familial disease.
Diagnosis of amenorrheaDiagnosis of amenorrhea
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Examination:– Psyche, height, weight and span measure. Nutritional status
should be also evaluated.
– Secondary sexual characters.
– Evidence of neurological disorders specially central lesions.
– Evidence of endocrinological disorders with special reference to galactorrhea and hirsutism.
– Evidence of general disease as heart, chest, renal or hepatic disorder.
– Abdominal masses (ovarian, adrenal, renal hepatosplenomegaly or ascites).
– External genital anomaly or hypoplasia.
– Pelvic examination (PV or PR) for uterine and ovarian abnormalities.
Diagnosis of amenorrheaDiagnosis of amenorrhea
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Diagnosis of amenorrheaDiagnosis of amenorrhea
CNSHypothalamus
Pituitary
Ovary
UterusOutflow tract
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Special investigations – Step I:– Search for specific disease if suspected.
– Pregnancy test.
– TSH assay.
– Prolactin assay.
– Progesterone challenge test:
» If (+)ve withdrawal Normal outflow tract and well estrogenized cases The cause is anovulation.
» If (-)ve withdrawal Hypoestrogenic state or uterine cause step II.
Diagnosis of amenorrheaDiagnosis of amenorrhea
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Special investigations – Step II:– Give estrogen + Progesterone:
» If (-)ve withdrawal Uterine cause.
» If (+)ve withdrawal Normal outflow tract and uterus, and there is ovarian failure Step III
Special investigations – Step III:– Measure FSH:
» If high Ovarian cause.
» If low central cause.
Diagnosis of amenorrheaDiagnosis of amenorrhea
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Treatment of the cause
Treatment of amenorrheaTreatment of amenorrhea
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Osman Donia