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FINAL YEAR
AMENORRHEA
“ABSENCE OF MENSTURATION”
TYPES OF AMENORRHEA
PHYSIOLOGICAL PATHOLOGICAL
PRIMARY SECONDARY
PHYSIOLOGICAL
BEFORE MENARCHE ADOLOSCENCE PREGNANCY LACTATION MENOPAUSE
PATHOLOGICAL
PRIMARY
“ Girls failing to have their menarche by age of 16”
CAUSES OF PRIMARY AMENORRHEA
ABSENT SECONDARY SEX CHARACTER NORMAL SECONDARY SEX CHARACTER HETEROSEXUAL DEVELOPMENT CONSTITUTIONAL DELAY
ABSENT SECONDARY SEX CHARACTER• SHORT STATURE1. Hypothalamic pituitary dysfunction HYDROCEPHALUS CRANIOPHARYNGIOMA PANHYPOPITUITARISM
2. Ovarian Failure TURNER’S SYNDROME MOSAIC TURNER MIXED GONADAL DYSGENESIS
• NORMAL STATURE1.Hypothalamic pituitary dysfunction ISOLATED GnRH DEFICIENCY OLFACTOGENITAL SYNDROME HYPERPROLACTNEMIA
2. Ovarian Failure TRUE GONADAL AGENESIS PREMATURE MENOPAUSE GALACTOSAEMIA
NORMAL SECONDARY SEX CHARACTERS
1. Anatomical Abnormalities
2. Androgen Insensitivity
3. Resistant ovary syndrome
4. Polycystic Ovarian disease
5. Prolactinoma
HETEROSEXUAL DEVELOPMENT
1. Congenital adrenal hyperplasia
2. 5 alpha reductase deficiency
3. Ovarian / adrenal tumours
4. Absent anti Mullerian factor
5. True hermaphrodite
CONSTITUTIONAL DELAY
SECONDARY AMENORRHEA
“THE MENSTURATION STOPS FOR ATLEAST SIX MONTHS AFTER THE WOMAN HAS
MENSTURATED REGURARLY OR AT LEAST ONCE”
10 times more common than primary Amenorrhea Commonest cause is pregnancy
CAUSES OF SECONDARY AMENORRHEA
1. Physiological
2. Social Factors
3. Pregnancy related conditions
4. Gynaecological conditions
5. Drugs
6. Andrgenizing conditions
7. Medical/Surgical conditions
8. Other causes
MANAGEMENT
NORMAL SECONDARY SEX CHARACTERS
SECONDARY AMENORRHOEA
“TREATMENT”
ABSENT SECONDARY SEX CHARACTERS SHORT STATURE
Note: when conception is desired ovulation can induced by human menopausal gonadotrophin injections.
CAUSE TREATMENT DOSE
Hypothalamic pituitary dysfunction
Growth Hormone 0.2 micro gram/kg/day
For secondary sex development
0.01mg ethinyl estradiole bd for 3 weeks, every month for several month
Once they are developed
Combine oral contraceptives as hormonal replacement therapy.
NOTE: In mixed Gonadal genesis Gonads are removed because malignancy
arising from them is 30%
CAUSE TREATMENTOVARIAN FAILURE(turner’s syndrome and mixed gonadal dysgenesis)
SEXUALLY MATURE by LOW DOSE ESTROGENS
OCPs as HRT
NORMAL STRATURECAUSE TREATMENT DOSE
ISOLATED GnRH deficiency
Same as hypogonadrophic hypogonadism association with short strature except for the need of growth hormone
HYPER PLOCATENEMIA
Bromocriptine 2.5mg bd
PITUITARY ADENOMA
Ruled out on CT scan sometimes require surgical treatment
TRUE GONADAL AGENESIS
Treated as turner syndrome & induced with XY genotype would require gonadectomy
NORMAL SECONDARY SEX CHARACTERS
CAUSES TREATMENT
ANATOMICAL ABNORMALITIES SURGICAL RECONSTRUCTION
ANDROGEN INSENSTIVITY VAGINOPLASTY + GONADECTOMY FOLLOWED BY OCP’s
RESISTANT OVARIAN SYNDROME OCP’s FOLLOWED BY OVULATION INDUCTION BY CLOMIPHENE CITRATE
PCO’s WEDGE RESECTION OR LAPROSCOPIC OVARIAN DRILLING FOLLOWED BY OVULATION INDUCTION BY CLOMIPHENE CITRATE
HETEROSEXUAL DEVELOPMENT
CAUSES TREATMENT
CONGENITAL ADRENAL HYPERPLASIA
Steroid therapy and fertility is restored with clomephene citrate
OVARIAN/ADRENAL TUMOUR
Surgical Resection
SECONDARY AMMENORRHAE T/M
CAUSES TREATMENT
ADRENAL/OVARIAN TUMOUR
SURGICAL RESECTION
CONG ADRENAL HYPERPLASIA
STEROIDS + OVULATION INDUCTION
PELVIC TB ANTI TB MEDICATION
PIT ADENOMA BROMOCRIPTINE AND SURGERY
ASHERMAN’S SYNDROME BREAK IU ADHESIONS WITH UTERINE SOUND, FOLLOWED BY IUCD INSERTIONMODEREN TECHNIQUE CAUTERY UNDERDIRECT VISION THROUGH HYSTEROSCOPEOCP’s
OVULATION INDUCTION1.NON HYPERPROLACTINEMIAC AMENORRHEA
2. HYPERPROLACTINEMIAC AMENORRHEA
DRUGS DOSE
CLOMIPHENE CITRATE 50 mg daily on any day and continued for 5 days and dose is increased by 50mg every month till menstruation is achieved
GONADOTROPHINS (LH/FSH) INJECTIONS 75 I.ULH/75 I.UFSH one injection on any day.
BROMOCRIPTINE 1.25mg once a day for 1 week, 1.25 bd for next week followed by 2.5 mg bd