1. ASSESSMENT OF A CASE OF AMENORRHEA

2. Prof. Ashis Kumar Mukhopadhyay
Professor, G & O
Medical Superintendent-cum-Vice Principal
CSS College of Obstetrics & Gynaecology, Kolkata
National Chairperson, Medical Education Committee of FOGSI

3. AMENORRHEA
Amenorrhea is the absence or abnormal cessation of the menses. A patient is diagnosed with primary amenorrhea if she has not reached menarche by age 14 without the appearance of secondary sex characterististics and by the age 16 with secondary sex characteristics.
She meets the criteria for secondary amenorrhea if established menses have ceased for longer than 6 months or at least 3 of the previous cycle intervals.

4. Concealed (Cryptomenorrhoea)
Types
Physiological
Pathological
Primary
--Before puberty
Secondary
pregnancy
Lactation
Menopause
Concealed (Cryptomenorrhoea)
Congenital
Acquired
Real (True)
Primary
Secondary

5. Five basic factors for normal menstruation
Normal female chromosome 46 XX
Co-ordination of H-P-O axis
Responsive Endometrium
Patent outflow tract
Ancillary glands like Thyroid and Adrenal

6. Causes Disorders of H-P-O axis Hypogonadotropic Hypogonadism
Constitutional delayed puberty
Kallman’s syndrome
CNS tomours like craniopharyngioma
Isolated FSH deficiency
Hypergonadotropic Hypogonadism
Primary Ovarian Failure
17-alpha Hydroxylase deficiency
Gonadal dysgenesis

7. Causes Abnormal chromosomal pattern Turner’s syndrome (45XO)
Mosaicism 45 X/ 46 XX
Pure Gonadal dysgenesis (46 XX or 46 XY)
Androgen Insensitivity Syndrome
Partial deletion of X chromosome:-
Deletion of long arm (Xq-)  Streak Gonads but no somatic abnormalities
Deletion of short arm (Xp-) Somatic features like Turner’s

8. Causes Developmental defect of Genital tract
Imperforate Hymen
Transverse Vaginal Septum
Atresia of upper 1/3rd. Of vagina
Complete absence of vagina
Absent Uterus
Dysfunction of Thyroid and Adrenal Cortex
Adrenogenital syndrome
Cretinism

9. Causes Metabolic disorders Systemic illness Unresponsive Endometrium
Juvenile DM
Systemic illness
Malnutrition
Anaemia
Wt. Loss
Tuberculosis
Unresponsive Endometrium
Congenital
Synaechiae (rare)

10. Etiology of Amenorrhea
Primary  
Gonadal failure (43%) 
Congenital absence of uterus and vagina (15%) 
Constitutional delay (14%)
Secondary  
Chronic anovulation (39%)
 Hypothyroidism / hyperprolactinemia(20%) 
Weight loss/anorexia(16%)

11. THE ASSESSMENT

13. abnormal hormonal stimulation
Primary amenorrhea
breasts have developed
FSH Level no
high
low
vagina no
yes
congenital uterovaginal agenesis imperforate hymen complete transverse vaginal septum
Pubic hair
complete androgen insensitivity syndrome (CAIS)
Estrogenized
the (MPA) challenge + -
Chromosome Analysis
abnormal ovaries
abnormal hormonal stimulation
of normal ovaries

15. Secondary Amenorrhea

16. Incidence
1% of women of
reproductive age.

17. The most common cause of secondary amenorrhea in reproductive age women is pregnancy and this should always be excluded by physical exam and laboratory testing for the pregnancy hormone - HCG.

18. History
A good history can reveal the etiologic diagnosis in up to 85% of cases of amenorrhea.

19. History Galactorrhoea Hot flashes, breast atrophy and decreased libido
Certain medications
A large amount of weight loss or gain
Anorexia nervosa
Cushing's disease  and hypothyroidism
Sheehan's syndrome.
Asherman's syndrome
Amenorrhoea following cervical conization
Following discontinuation of oral contraception
Psychological dysfunction or emotional stress
Family history of apparent genetic anomalies

20. Physical examination Height, Weight and nutrition
Growth and development
Signs of androgen excess
Endocrinal stigma
The breast exam may reveal galactorrhoea
Estrogen deficiency may be suggested on pelvic exam by a smooth vagina that lacks the normal rugae (wrinkles) and a dry endocervix with no mucous.
Size of pelvic organs.

21. What we will do next?

22. If the history and physical exam are suggestive of a certain etiology :
for the sake of efficiency and cost-effectiveness, the workup can sometimes be more directed.
( in 85% of cases .)

23. Some patients will not demonstrate any obvious etiology for their amenorrhea on history and physical exam. These patients can be worked up in a logical manner using a stepwise approach.

24. The first tests to perform after pregnancy is ruled out are :
a progesterone withdrawal test
TSH (thyroid stimulating hormone)
prolactin level.

25. -VE Preg.test TSH ,PROLACTIN’, Prog.challenge test
withdrawal bleeding
anovulation
without withdrawal bleeding
compromised outflow tract.
-ve.est, progest. challenge test
Normal FSH
HSG OR hysteroscopy asherman
hypoestrogenic
+ve.est,progest.challenge test
FSH norm.
Repeat+serum ,est.level
hypothalamic-pituitary failure
FSH>30-40
2wk
repeat
PROF

26. -VE Preg.test anovulation PROF
TSH ,PROLACTIN’, Prog.challenge test
without withdrawal bleeding
withdrawal bleeding
hypoestrogenic
compromised outflow tract.
anovulation
+ve.est,progest.challenge test
-ve.est,progest
.challenge test
2wk
FSH>30-40
FSH norm.
Normal FSH
Repeat+serum ,est.level
repeat
HSG OR hysteroscopy asherman
hypothalamic-pituitary failure
PROF

27. Ovarian failure (premature menopause)
chromosomal anomalies
If the woman is under 30, a karyotype should be performed to rule out any mosaicism involving a Y chromosome.
If a Y chromosome is found the gonads should be surgically excised.
autoimmune disease
it is prudent to screen for thyroid, parathyroid, and adrenal dysfunction
Laboratory evidence of autoimmune phenomenon is much more prevalent than clinically significant disease

28. Autoimmune Related Dysfunction
The most common association is with thyroid disease, but the parathyroids and adrenals can also be affected.
Several studies have shown laboratory evidence of immune problems in about 15-40% of women with premature ovarian failure.
In general, ovarian biopsy is not indicated in patients with premature ovarian failure since no clinically useful information will be obtained.

29. Hypothalamic-pituitary failure
Patients who do not bleed after the progestin challenge but do after estrogen/progestin and have normal or low FSH and LH levels

30. Hypothalamic-pituitary failure
Some medications (e.g. phenothiazines) as well as extremes of weight loss, stress or exercise can cause this type of secondary amenorrhea.
A pituitary or hypothalamic tumor would be a rare finding in these patients who were all screened with prolactin levels at the beginning of the diagnostic evaluation.
However, if there is no cause apparent from the history, it would be prudent to obtain a baseline CT (or MRI) evaluation of the sellar region to rule out a space occupying lesion.

31. Hypothalamic-pituitary failure
Patients with normal prolactin levels and normal imaging studies have hypothalamic amenorrhea of uncertain etiology.
If the amenorrhea and lack of withdrawal bleeding persists, prolactin levels should be measured annually since a small microadenoma could be present that is escaping laboratory and radiographic detection.

32. Hypothalamic-pituitary failure
In this condition, as well as in the other hypothalamic amenorrhea situations, the patients can be significantly hypo estrogenic (a low estrogen situation similar to menopause). If the state is persistent, hormone replacement therapy should be considered for protection against osteoporosis. One approach is to get an estradiol level and if it is less than 30 pg/ml, counsel the patient that hormonal replacement therapy is indicated