Transcript Amenorrhea (and Dysfunctional Uterine Bleeding)

Amenorrhea
(and Dysfunctional Uterine
Bleeding)
Dr. ELHAM GHANBARI JOLFAEI
OB&MD
Gynecologiest
Amenorrhea:
“absence of menses”
“Normal cycle is 28 days 
This occurs in 15% of cycles ◦
98% have cycles between 24-35 days 
Average duration 4-6 days (2-8 normal) 
Average blood loss per cycle = 30 ml. 
> 80 ml. Leads to risk for anemia ◦
PRIMARY AMENORRHEA
Patient has never menstruated 
No period by age 14 with no secondary sexual ◦
characteristics
No period by age 16 regardless of secondary ◦
sexual characteristics
SECONDARY AMENORRHEA
Previously established cycles cease 
ALWAYS RULE OUT
PREGNANCY
Then evaluate the four parts of the system
REASONS FOR AMENORRHEA
Pregnancy
Menopause
Thyroid/Prolactin Disorders
Anovulation
Outflow obstruction
CNS/hypothalamic dysfunction
Drugs/Stress/Nutrition
Chromosomal/Abnormal Sexual Differentiation
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ALWAYS RULE OUT
No matterPREGNANCY!!!!!!!
WHAT!!!
STEP ONE –
will diagnose pregnancy, thyroid disorder,
hypoprolactinemia and anovulation
LABS 
Beta hcg ◦
TSH ◦
Prolactin ◦
MEDS 
Progestin challenge ◦
{If galactorrhea, obtain MRI of pituitary/sella 
turcica}
STEP TWO – will diagnose outflow
tract obstruction
Give estrogen “priming”, followed by 
progestin
Estrogen x 21 days ◦
Add progesterone for the last 5 days ◦
STEP 3- will determine if lack of
estrogen is due to ovarian failure
vs. altered CNS/pituitary axis
FSH
(LH)
UTERUS – VAGINA – I.
OUTFLOW TRACT
Asherman’s – secondary amenorrhea 
Imperforate hymen – primary 
amenorrhea
Vaginal septum – primary amenorrhea 
Agenesis – primary amenorrhea 
Testicular feminization – primary 
amenorrhea
II. OVARY
Chromosomes Normal- 
Menopause
Radiation/Chemo
Autoimmune Disorder
Infection
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Chromosomes Abnormal- 
Primary Amenorrhea ◦
Premature Menopause ◦
III. ANTERIOR PITUITARY
Prolactin Secreting Tumors 
Sheehan’s Syndrome 
IV. CNS / HYPOTHALAMUS
Weight loss, anorexia, stress, intense 
exercise
Hypothyroidism – TRH/drugs which affect 
dopamine
Anovulation 
Hypothalamic Suppression 
ALWAYS, ALWAYS, ALWAYS
RULE OUT 
PREGNANCY
CASE STUDY
17 year old female with primary 
amenorrhea. She is of normal weight and
has mature secondary sexual
characteristics.
CASE STUDY
15 year old with three months of 
secondary amenorrhea. She underwent
normal pubertal development and had
menarche at age 12 with regular cycles for
three years. She is on the track team.
CASE STUDY
42 year old G3P3 with 5 months 
amenorrhea. Normal weight. Has been
experiencing hot flashes.
CASE STUDY
28 year old G2P2 with 8 months of 
amenorrhea. Has been gaining weight lately,
feels cold all of the time, and complains of
constipation and fatigue.
CASE STUDY
35 year old G0 with amenorrhea for 9 
months. Overweight. Slightly hirsute.