Amenorrhea Dr Nadia algantary Associated proffessor Faculty of medicine

objective  The student be able to understand definition of primary &secondary ammenorrhea.  Be able to know the practical approach to ammenorrhic patient

Primary Amenorrhea  absence of menarche by age 16 regardless of secondary sex changes   –absence of normal menstruation in a patient without previously established cycles   –no periods by age 14 with no secondary sex changes  -

Secondary amenorrhea  –absence of menses for 3 cycle lengths in oligomenorrhea, or for 6 months after having regular menses  –1-5% of the population

Clinical feature  History  –milestones, development, diet, exercise, wt change  –drug use (antipsychotics, hormones, narcs, anti-HTN’s  –systemic disease (hypothyroidism, adrenal insuff., GH excess)  –past surgery, glactorrhea, hirsutism  –gyn/ob hx (hemorrhage, D&C, infection)  –genetic history

examination    Physical–ht, wt, vitals–signs of thyroid dz (protuberant eyes, enlarged gland, puffy face, heat/cold intolerance)–secondary sex changesthelarche (breast devel): avg. age 10.8 yrs; indication of estrogen exposureadrenarche (pubic/axillary hair development): avg. age 11 and indicates ovarian and adrenal

causes Primary amenorrhea–gonadal failure is most common cause–uterovaginal agenesis is second most common causeAnorexia nervosa is the most common cause of amenorrhea overall in teens

causes  CNS or hypothalamic causesanatomic lesions (can appear with or without secondary sex changesdrugs affecting prolactin levels (stimulators and inhibitors)stress, exercise, and eating disordersPCOSfunctional hypothalamic amenorrhea

causes  Pituitary causesOvarian causes (elevated gonadotropin and low estrogen)–radiation and chemo; premature ovarian failure; ovarian resistance sd; PCOS; infection; vascular injury; Uterine causes (only group in this category who will show normal endocrine findings

 DDx and Tx in Primary Amenorrhea:2nd sex changes present, cervix present Work up–r/o pregnancy–r/o hyperprolactinemia–if prolactin level elevated, evaluate thyroid function– measure FSH and LH–measure 17a- hydroxylase progesterone and progesterone–do a progesterone challenge test

 Treatment–dopamine agonist therapy– combination OCP therapy–estrogen replacement

 DDx and Tx in Primary Amenorrhea:  2nd sex changes present, cervix absent  androgen insensitivity (testicular feminization sd)  mullerian anomalies or agenesis  work up  –karyotype and testosterone level  –if nl body hair and female testosterone levels, uterine agenesis is present and pt is sterile

 karyotype is to r/o male pseudohermaphrodism  IVP should be done to r/o renal anomalies  may need reconstructive surgery  –pts with AI are usually raised as girls (XY)  remove gonads after breast development and epiphyseal closure  replace estrogen

 DDx and Tx in Primary Amenorrhea:  2nd sex changes absent, cervix absent  <1% of primary amenorrhea  –pts are 46XY, but have abnormality in testosterone synthesis  –mullerian inhibiting factor causes internal female organs to regress

 DDx  –17a-hydroxylase deficiency  –17,20 desmolase deficiency  –agonadism  Lab: elevated gonadotropins and low-normal female testosterone levels  Tx: remove testicles and replace estrogen; no need for progesterone

Secondary amenorrhea  Differential  –similar to that of primary amenorrhea with cervix and secondary sex changes present  Work up  –r/o pregnancy  –r/o hyperprolactinemia  –if prolactin level elevated, evaluate thyroid function  –measure FSH and LH  –measure 17a-hydroxylase progesterone and progesterone  –do a progesterone challenge test

pregnancy is most common cause– 49-62% have hypothalamic disorders, including PCO–7-16% have pituitary disorders–10% have ovarian disorders–7% have Ashermans syndrome

Secondary amenorrhea  Treatment  –dopamine agonist therapy  –combination OCP therapy  –estrogen replacement

conclusion  Ammenorrhea is not uncommon problem.  Pregnancy is the most common causes.  Ultrasound and hormonal assay is the..keys to differentiate between the most causes of ammenorrhea.