www.obg.edu.ly
Download
Report
Transcript www.obg.edu.ly
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 changes•thelarche (breast devel): avg.
age 10.8 yrs; indication of estrogen
exposure•adrenarche (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 causes•anatomic
lesions (can appear with or without
secondary sex changes•drugs affecting
prolactin levels (stimulators and
inhibitors)•stress, exercise, and eating
disorders•PCOS•functional 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 17ahydroxylase 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.