1. Amenorrhea
Dr Jack Biko

2. introduction A symptom and not a Condition
Absence of menstrual bleeding
Maturation of H-P-O axis
Outflow tract

3. Causes
Hypothalamic
Pituatory
Ovarian
Other

4. Amenorrhea Primary Secondary
Absence of menses by age 16 with normal secondary sexual characteristics
Absence of menses by age 14 without secondary sexual development
Secondary
Absence of menses for 6 months in a previously menstruating female, not on contraceptives
There is a 5% lifetime incidence for some form of amenorrhea.
Physiologic causes of amenorrhea are:
Prepubertal status, pregnancy, lactation, and menopause

5. Amenorrhea Transient, intermittent or permanent
Dysfunction of hypothalamus, pituatory gland, ovaries, uterus or vagina
Thyroid gland
Adrenal gland

6. Hormonal events

7. Events of Puberty Thelarche (breast development)
Requires estrogen
Pubarche/adrenarche (pubic hair development)
Requires androgens
Menarche
Requires:
GnRH from the hypothalamus
FSH and LH from the pituitary
Estrogen and progesterone from the ovaries
Normal outflow tract

8. Teens with Secondary sexual characteristics present No menstruation
Cyclical pains
THINK MULLERIAN ANOMALIES / OBSTRUCTION OF OUTFLOW TRACT

9. Primary Amenorrhea
Is there normal development of secondary sexual characteristics?
YES
Think
Pregnancy
Mullerian anomaly – outflow tract, uterine
Androgen insensitivity
With androgen insensitivity, there will typically be more breast development than pubic hair development.

10. Primary amenorrhea CNS pathology Ovarian - Genetic abnormality
Obstruction of outflow tract

11. Are there secondary sexual characteristics?

12. Think hypogonadism or hypogonadotropism
Primary Amenorrhea
Is there normal development of secondary sexual characteristcs? NO
Think hypogonadism or hypogonadotropism

13. Mayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis)
15% of primary amenorrhea
Normal secondary development & external female genitalia
Normal female range testosterone level
Absent uterus and upper vagina & normal ovaries
Karyotype 46-XX
15-30% renal, skeletal and middle ear anomalies

14. Imperforate Hymen

15. Amenorrhea with Immature Secondary Characteristics
FSH Serum level
/Low normal
High
Hypogonadotropic
hypogonadism
Gonadal
dysgenesis

16. Gonadal Dysgenesis Chromosomally abnormal
- Classic turner’s syndrome (45XO)
- Turner variants (45XO/46XX),(46X-abnormal X)
- Mixed gonadal dygenesis (45XO/46XY)
Chromosomally normal
- 46XX (Pure gonadal dysgeneis)
- 46XY (Swyer’s syndrome)

17. Androgen Insensitivity
Normal breasts but no sexual hair
Normal looking female external genitalia
Absent uterus and upper vagina
Karyotype 46, XY
Male range testosterone level
Treatment : gonadectomy after puberty + HRT

18. Amenorrhea Evaluation Pregnancy test
Physical exam to determine presence of uterus
FSH
Karyotype

19. Amenorrhea Treatment Cyclic estrogen/progestin
Remove gonadal streaks if XY or mosaic
Increased (52%) risk of gonadoblastomas, dysgerminomas, and yolk sac tumors
Pulsatile GnRH for ovulation induction in select patients
Surgical resection of intrauterine, cervical, and vaginal septa

20. Secondary Amenorrhea Pregnancy! CNS disorders Pituitary gland Thyroid
Ovary
Uterus
Systemic disorders
Renal failure, liver disorders, DM
Medications: anti-psychotics, reserpine

21. Secondary Amenorrhea CNS disorders Chronic hypothalamic anovulation
Stress
Increased exercise levels
Anorexia nervosa
Head trauma
Space-occupying lesions

22. Secondary Amenorrhea Pituitary resection Sheehan’s syndrome
Hyperprolactinemia: Prolactinoma
Medications
Renal failure
Pituatory injury
Pituitary resection
Sheehan’s syndrome
Thyroid disorders
Hyper- or hypothyroidism

23. Secondary Amenorrhea Ovulation disorders Polycystic ovarian syndrome
Premature ovarian failure
Uterine abnormalities
Asherman’s syndrome
Cervical stenosis
Drug-induced amenorrhea
Hormonal contraceptives
GnRH analogues

24. PCOS First described in 1935
Findings of polycystic ovaries reported more than 100yrs previously
A syndrome – no single feature or test is diagnostic

25. Endocrinology of PCOS Hyper-production of androgens by theca cells.
Abnormal ovarian steroid-genesis
Failure of follicular maturation.
Lack of progesterone production due to corpus luteum absence.
Subsequent increase of LH level.

26. Diagnostic Criteria; Rotterdam 2003
Based on Consensus
Oligo or anovulation
Hyperandrogenism – clinical or biochemical
Polycystic ovaries
Exclude other causes of androgen excess

27. Intra-uterine adhesions
Asherman’s syndrome
Previous D&C
Previous endometritis
Endometrial TB

28. Asherman’s Syndrome

29. Treatment
Hysteroscopic resection
High dose oestradiol

30. Hysteroscopy

31. Amenorrhea History Nutrition/exercise habits, weight change
Sexual/contraceptive practice
History of uterine/cervical surgery
Physical exam
Height/weight
Hirsutism
Galactorrhea
Estrogen status of tissues
Laboratory
BhCG PRL & TSH  progesterone challenge  FSH  if high karyotype
Karyotype for patients with premature ovarian failure <30yo
If hirsutism is present, consider PCOS, congenital adrenal hyperplasia, Cushing’s, or ovarian tumors: check free testosterone

32. Secondary Amenorrhea Treatment goals
Discovery and treatment of underlying disorder
Hormone replacement
Menses every 1-3 months
Pregnancy
Ovulation induction
FSH/LH
Purpose for inducing menses at least every 3 months is to prevent endometrial hyperplasia and cancer

33. Case studies

34. 12 year old
No periods
No pain
No secondary sexual characteristics

35. 15 yr old
No periods
Cyclical pains
Has secondary sexual characteris

36. 24 yr old
G3P0
TOP x 3
No periods for 6 months now

37. 33 yr old Amenorrhea for 4 yrs Para 0 No cyclical pains
Normal secondary sexual characteristics

38. Amenorrhea
26 yr Gravida 0 with menarche at age 14 presents with one-year history of amenorrhea.
Obese
Hirsutism

39. Thank you