1. Osman Donia Amenorrhea Prof. Obstet. Gynaecol.,

2. Osman Donia

3. Definitions & Classification n n Amenorrhea: Absence of menses. n n Primary amenorrhea: Non occurrence of menarche by age of: – –14 with no secondary sex characters – –16 (18) with secondary sex characters. n n Secondary amenorrhea: Absence of menses for 3 successive cycles.

4. Osman Donia Amenorrhea PhysiologicPathologic Puberty Menopause Pregnancy Lactation TrueFalse Cervix Vaginal T. septa Imperforate hymen Hypothalamic Pituitary Ovarian Uterine General CNS

5. Osman Donia False amenorrhea (Cryptomenorrhea)

6. Osman Donia Cryptomenorrhea n n Due to outflow obstruction. n n The most common cause is imperforate hymen. n n Blood accumulate behind the hymen  hematocolpos  Hematometra  Pelvic hemorrhage. n n Diagnosis: – –P. amenorrhea with good 2ry sex characters. – –PMS. – –Urinary symptoms. – –Abdominal mass ????. – –Local examination is diagnostic. n n Treatment: Cruciate incision under anesthesia  Slow evacuation + antibiotics.

7. Osman Donia True amenorrhea

8. Osman Donia CNS Causes n n Psychological troubles: – –Psychosis # neurosis. – –Pseudocyesis. – –Anorexia nervosa. n n Chronic stresses. n n Weight loss. n n Exercise: – –Loss of body fat. – –Stress of competition. – –Hyperthermia and dehydration. – –Euphoria of winning causing increased opiates.

9. Osman Donia Hypothalamic causes n n Destruction: – –Trauma – –Inflammation. – –Tumors. – –Infiltrations. n n Drugs: – –Estrogens. – –CNS affecting drugs. n n Dysfunction & congenital disorders: – –Chiari Frommel syndrome. – –Del Castillo syndrome. – –Kallmann syndrome. – –Laurence Moon Biedl syndrome. – –Frohlich syndrome.

10. Osman Donia n n Destruction: – –Infiltrations. – –Tumors. – –Sheehan syndrome. n n Drugs: – –Estrogens. – –Prolactin inducing drugs. n n Dysfunction and congenital disorders: – –Levi Lorain syndrome. – –Empty sella syndrome. – –Prolactinomas. Pituitary causes

11. Osman Donia n n Congenital: – –Turner. – –Androgen insensitivity syndrome. n n Traumatic: – –Surgical removal. – –Irradiation. n n Inflammatory: – –Mumps. – –PID. – –TB. n n Neoplasia: – –Benign. – –Malignant. n n Dysfunctions: – –PCO. – –Resistant ovary syndrome. Ovarian causes

12. Osman Donia n n Congenital: – –Mullerian agenesis. – –Uterine atresia – –Severe hypoplasia. n n Traumatic: – –Surgical removal. – –Irradiation. n n Inflammatory: – –Asherman syndrome. – –TB. n n Neoplastic: – –Obstructing the cervix. n n Dysfunctions: – –Insensitive endometrium. Uterine causes

13. Osman Donia n n DM: – –Glucose metabolism. – –Ketosis. – –Immunological. n n Thyroid: – –Hyper. – –Hypo. n n Adrenal: – –Addison. – –Cushing. n n Debilitating diseases. General causes

14. Osman Donia 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. n n The most common causes of primary amenorrhea: – –Gonadal dysgenesis. – –Mullerian agenesis. – –Complete AIS. Causes of 1ry amenorrhea

15. Osman Donia n n Physiological: – –Pregnancy, lactation, after menopause. n n Cryptomenorrhea: Any acquired cause. n n 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 amenorrhea

16. Osman Donia n 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 amenorrhea

17. Osman Donia n n 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 amenorrhea

18. Osman Donia Diagnosis of amenorrhea CNS Hypothalamus Pituitary Ovary Uterus Outflow tract

19. Osman Donia n n 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 amenorrhea

20. Osman Donia n n 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 n n Special investigations – Step III: – –Measure FSH: » »If high  Ovarian cause. » »If low  central cause. Diagnosis of amenorrhea

21. Osman Donia Treatment of the cause Treatment of amenorrhea

22. Osman Donia