7/26/2019 143278103 Amenorrhea Ppt
1/41
AMENORRHEAAMENORRHEA
Prof.DR.Dr.H.M.Thamrin Tanjung, Sp.OG(K)Dr.M.Rusda Harahap, Sp.OG
7/26/2019 143278103 Amenorrhea Ppt
2/41
Defnitions
Primary amenorrhea
Failure of menarche to occur when expected in
relation to the onset of pubertal development.
No menarche by age 16 years with signs of pubertal
development.
No onset of pubertal development by age 14 years.
Secondary amenorrhea
Absence of menstruation for 3 or more months in a
previously menstruating women of reproductive
age.
7/26/2019 143278103 Amenorrhea Ppt
3/41
CNS-Hypothalamus-Pituitary
Ovary-uterus InteractionNeural control Chemical control
Dopamine
-!
Norepiniphrine
"!
En#orphines
-!
Hypothalamus
Gn-RH
Ant$ pituitary
%SH& 'H
Ovaries
(terus
Pro)esteroneEstro)en
Menses
?
7/26/2019 143278103 Amenorrhea Ppt
4/41
Pathophysiolo)y o*
Amenorrhea
Inadequate hormonal stimulation of the endomeriumAnovulatory amenorrhea
- Euestrogenic
- Hypoestrogenic
Inability of endometrium to respond to hormonesOvulatory amenorrhea
- Uterine absence - Utero-vaginal agenesis- XY-Females ( e.g T.F.S)
- amage! en!ometrium ( e.g "s#erman$s syn!rome)
7/26/2019 143278103 Amenorrhea Ppt
5/41
Euestro)enic Anovulatory
AmenorrheaNormal androgens Hypothalamic-pituitary
dysfunction (stress !eight
loss or gain e"ercisepseudocyesis#
Hyperprolactinemia
$emini%ing ovarian tumour
Non-gonadal endocrinedisease (thyroid adrenal#
&ystemic illness
High androgens 'O&
)usculini%ing ovariantumour
ushing*s syndrome
ongenital adrenalhyperplasia (late onset#
7/26/2019 143278103 Amenorrhea Ppt
6/41
Hypoestro)enicAnovulatoryAmenorrhea
Normal androgens- Hypothalamic-pituitary failure
- &evere dysfunction - Neoplasticdestructive infiltrative infectious + trumatic conditions involving hypothalamus or
pituitary- Ovarian failure
-,onadal dysgenesis - 'remature ovarian failure
- n%yme defect - .esistant ovaries - .adiotherapy chemotherapy
High androgens
- )usculini%ing ovarian tumour- ushing*s syndrome
- ongenital adrenal hyperplasia(late onset#
7/26/2019 143278103 Amenorrhea Ppt
7/41
A)NO..HOA
AN APPROACH FOR DIAGNOI H%ST&'Y
HYS%"* EX"+%,"T%&,
U*T'"S&U, EX"+%,"T%&,
Eclu!e regnancy
Eclu!e ryptomenorr#ea
7/26/2019 143278103 Amenorrhea Ppt
8/41
ryptomenorrhea
!utflow obstruction to menstrual blood
- Imperforate hymen- Transverse Vaginal septum with functioning
uterus- Isolated Vaginal agenesis with functioning
uterus
- Isolated Cervical agenesiswith functioninguterus
- Intermittent a+#ominal pain- Possi+le #i,culty ith micturition
- Possi+le loer a+#ominal sellin)
-.ul)in) +luish mem+rane at the introitus ora+sent
va)ina only #imple!
7/26/2019 143278103 Amenorrhea Ppt
9/41
Imper*orate hymen
7/26/2019 143278103 Amenorrhea Ppt
10/41
Once Pre)nancy an# cryptomenorrheaare e/clu#e#:
0he patient is a +ioassay *or En#ocrine a+normalities
%our cate)ories o* patients arei#entife#
1$ Amenorrhea ith a+sent orpoor secon#ary se/Characters
2$ Amenorrhea ith normal2ry
se/ characters3$ Amenorrhea ith si)ns o* an#ro)en e/cess
4$ Amenorrhea ith a+sentuterus
an# va)ina
7/26/2019 143278103 Amenorrhea Ppt
11/41
%SH Serum level
'o 5normal
Hi)h
Hypo)ona#otropichypo)ona#im 6ona#al#ys)enesis
AMENORRHEAA+sent or poor secon#ary se/
Characteristics
7/26/2019 143278103 Amenorrhea Ppt
12/41
AMENORRHEANormal secon#ary se/
Characteristics
- $&H /H 'rolactin 0&H-'rovera 12 mg 'O daily
" 3 days
4 5leeding No bleeing'rolactin0&H
$urther
6or7-up
(ndocrinologist#
- )ild hypothalamic
dysfunction
- 'O (/H8$&H# .evie! $&H result
And history (ne"t slide#
7/26/2019 143278103 Amenorrhea Ppt
13/41
%SH
'o 5 normalHi)h
Hypothalamic-pituitary%ailureOvarian*ailure
If 9 :3 yrs or primary
amenorrhea 7aryoptype
If 9 ;3 yrs .8O
autoimmune disease
77 Ovarian+iopsy
head CT- scan or MRI
- Severe #ypot#alamic
!ysunction
- %ntracranial pat#ology
7/26/2019 143278103 Amenorrhea Ppt
14/41
Amenorrhea
(tero-va)inal a+sence
8aryotype
49-::
Mullerian
A)enesisMR8H syn#rome!
An#o)en
Insenitivity0S%syn#rome!
$ 6ona#al
re)ressioon$ 0estocular en;yme
#e*enciecy$ 'ey#i) cella)enisis
49-:
7/26/2019 143278103 Amenorrhea Ppt
15/41
Normal %SH& 'H> -ve +lee#in)history is suggestive of amenorrhea
trumaticaAshermans syndrome
istory of pregnancy associated !"C
Rarely after C# $ myomectomy T%&endometritis$ 'ilhar(ia
!iagnosis ) #* or hysterescopy
Treatment ) lysis of adhesions+ !"C orhysterescopy , estrogen therapy . I/C!or catheter0
#ome will prescri'e a cycle of 1strogen and
2rogesterone challenge &efore #* orysterescopy
7/26/2019 143278103 Amenorrhea Ppt
16/41
Asherman?s syn#rome
7/26/2019 143278103 Amenorrhea Ppt
17/41
Amenorrhea
Si)ns o* an#ro)en e/cessTestosterone, DHEAS, FSH, and LH
DHEAS 500-700 mug/dLDHEAS 700 mug/dLTEST! "00 ng/dL
Serum #7-$H
%rogesterone &e'e&
Late (AHAdrena&
)*+erunt.on
/S ? R1 or (T
$'ar.an$r adrena&
tumor
Lo2er e&e'at.ons %($S 3H.g) LH / FSH4
7/26/2019 143278103 Amenorrhea Ppt
18/41
Amenorrhea
'.I)A.< A)NO..HA
= Ovarian failure ;>?
= Hypogonadotrophic ;@?
Hypogonadism=
= 'O& 1?
= ongenital lesions
(other than dysgenesis# @?= Hypopituitarism ;?
= Hyperprolactinaemia ;?
= 6eight related ;?
&ONBA.< A)NO..HA
= 'olycystic ovary syndrome ;2?
= 'remature ovarian failure :C?
= 6eight related amenorrhoea 1C?
= Hyperprolactinaemia 1@?
= "ercise related amenorrhoea :?
= Hypopituitarism :?
7/26/2019 143278103 Amenorrhea Ppt
19/41
6ona#al #ys)eneis
Chromosomally incompetent
- Classic turners syndrome 34560
- Turner variants 3456738550$385-a'normal 50 - Mi9ed gonadal dygenesis 34567385:0
Chromosomally competent
- 3855 2ure gonadal dysgeneis0
- 385: #wyers syndrome0
7/26/2019 143278103 Amenorrhea Ppt
20/41
6ona#al #ys)enesis
(&ass.
Turners
Turner
6ar.ant
True gonada&
D*sgenes.s
.ed
D*sgenes.s
+)enot*+e Fema&e Fema&e Fema&e Am8.guous
Gonad Strea9 Strea9 Strea9 - Strea9- Testes
H.g)t S)ort - S)ort
- :orma&
Ta&& S)ort
Somat.st.gmata
(&ass.a& :.&
9ar*ot*+e ;$ ;;/;$ ora8norma& ;
7/26/2019 143278103 Amenorrhea Ppt
21/41
0urner?s syn#rome
#e9ual infantilism and short stature%
Associated a'normalities$ we''ednec;$coarctation of the aorta$high-arched pallate$cu'itus valgus$ 'road shield-li;e chest with
wildely spaced nipples$ low hairline on the nec;$short metacarpal 'ones and renal anomalies%
igh aryotype - ?@ 34$ 5@- B@ mosaic forms 38557345@0
Treatment) RT
7/26/2019 143278103 Amenorrhea Ppt
22/41
osa. 3
7/26/2019 143278103 Amenorrhea Ppt
23/41
Ovarian #ys)enesis
7/26/2019 143278103 Amenorrhea Ppt
24/41
None-#ys)enesis ovarian
*ailure #teroidogenic en(yme defects D-
hydro9ylase0
6varian resistance syndrome Autoimmune oophoritis
2ostinfection eg% Mumps0
2ostoopherectomy 2ostradiation
2ostchemotherapy
7/26/2019 143278103 Amenorrhea Ppt
25/41
Premature ovarian *ailure
#erum estradiol E 4@ pg7ml and
7/26/2019 143278103 Amenorrhea Ppt
26/41
Polycystic ovary syn#rome
The most common cause of chronic anovulation
yperandrogenism + =7
7/26/2019 143278103 Amenorrhea Ppt
27/41
7/26/2019 143278103 Amenorrhea Ppt
28/41
Hypo)ona#otrophic
Hypo)ona#ismNormal hight
D Normal e"ternal and internalgenital organs (infantile#
D /o! $&H and /HD ).I to .8O intra-cranial pathology=
D ;2-@2? anosmia (7allmann*ssyndrome#
D &ometimes constitutional delayD 0reat according to the cause (H.0#
potentially fertile=
7/26/2019 143278103 Amenorrhea Ppt
29/41
Constitutional pu+ertal #elay
Common cause B@0
/nder stature and delayed'one age
5-ray Hrist Goint0
2ositive family history
!iagnosis 'y e9clusion andfollow up
2rognosis is good
late developer0
o drug therapy isreJuired K Reassurance .RT0
7/26/2019 143278103 Amenorrhea Ppt
30/41
Sheehan?s syn#rome
2ituitary ina'ility to secrete gonadotropins
2ituitary necrosis following massive
o'stetric hemorrhage is most commoncause in women
!iagnosis ) istory and 1B$
7/26/2019 143278103 Amenorrhea Ppt
31/41
@ei)ht-relate# amenorrhoea
Anore"ia Nervosa 1o or :o Amenorrhea is often first sign
A body mass inde" (5)I# 91 7g8mEmenstrual irregularity and amenorrhea
Hypothalamic suppression Abnormal body image intense fear of !eight
gain often strenuous e"ercise
)ean age onset 1;-1@ yrs (range 12-:1 yrs#
/o! estradiol
ris7 of osteoporosis
5ulemics less commonly have amenorrheadue to fluctuations in body !t but any
disordered eating pattern (crash diets# can
cause menstrual irregularity=
0reatment F body !t= ('sychiatrist referral#
7/26/2019 143278103 Amenorrhea Ppt
32/41
E/ercise-associate#
amenorrhoea Common in women who participate
in sports e%g% competitiveathletes$ 'allet dancers0
1ating disorders have a higherprevalence in female athletes thannon-athletes
ypothalamic disorder caused 'ya'normal gonadotrophin-releasinghormone pulsatility$ resulting inimpaired gonadotrophin levels$particularly =$ and su'seJuentlylow oestrogen levels
7/26/2019 143278103 Amenorrhea Ppt
33/41
Contraception relate#
amenorrhea 2ost-pill amenorrhea is not an entity
!epot medro9yprogesterone acetate
/p to ?@ of women will have amenorrhea after
year of use% It is reversi'le oestrogen deLciency0 A minority of women ta;ing the progestogen-only
pill may have reversi'le long term amenorrhoeadue to complete suppression of ovulation
7/26/2019 143278103 Amenorrhea Ppt
34/41
7/26/2019 143278103 Amenorrhea Ppt
35/41
Cushin)?s syn#rome
Clinical suspicion : Hirsutism,truncal obesity, purple striae,BP
If Suspicion is high :
dexamethasone suppression test! mg P" !! pm # and obtaineserum cortisol le$el at % am :
& ' (g) dl excludes cushing*s
+ hours total urine free cortisolle$el to confirm diagnosis
+ forms adrenal tumour or .C/Hhypersecretion pituitary or ectopicsite#
7/26/2019 143278103 Amenorrhea Ppt
36/41
(tero-va)inal A)enisisMayer-Roitansy-8uster-Hauser
syn#rome 13? of 1ry amenorrhea
Normal breasts and &e"ual Hair
development + Normal loo7ing e"ternal
female genitalia Normal female range testosterone level
Absent uterus and upper vagina + Normal
ovaries
Garyotype @>-
13-;2? renal s7eletal and middle earanomalies
0reatment F &0.I/ Jaginal creation
( Bilatation ! Jaginoplasty#
7/26/2019 143278103 Amenorrhea Ppt
37/41
An#ro)en insensitivity
0esticular *emini;ation syn#rome
5-lin;ed trait
A'sent cytosol receptors
ormal 'reasts 'ut no se9ual
hair ormal loo;ing female e9ternal
genitalia
A'sent uterus and upper vagina
>aryotype 38$ 5:
Male range testosterone level
Treatment ) gonadectomy afterpu'erty , RT
. Vaginal creation dilatation
V#Vaginoplasty 0
7/26/2019 143278103 Amenorrhea Ppt
38/41
6eneral Principles o*mana)ement o* Amenorrhea
%"ttempts to restore ovulatory unction
%% t#is is not possible H'T (oestrogen and
progesterone) is given to #ypo-estrogenicamenorr#eic /omen (toprevent osteoporosis; atherogenesis)
%erio!ic progestogen s#oul! be ta0en by euestrogenic
amenorr#eic /omen (to avoid endometrial cancer)%% Y c#romosome is present gona!ectomy is in!icate!
%+any cases re1uire re1uent re-evaluation
l
7/26/2019 143278103 Amenorrhea Ppt
39/41
Hormonal treatmentPrimary Amenorrhea itha+sent secon#ary se/ual
characteristics
0o achieve pubertal development
remarin 2mg 3-42 5 provera 36mg 32-42
X 7 mont#s8 4.2mg premarin X 7 mont#s an!
3.42mg premarin X 7 mont#s
)aintenance therapy 6.942mg premarin 5 provera &' rea!y H'T
preparation &' 76:g oral contraceptive pill
7/26/2019 143278103 Amenorrhea Ppt
40/41
Summary
"lt#oug# t#e /or0-up o amenorr#ea may seem to be
comple; a careully con!ucte! p#ysical eamination /it# t#e
#istory; an! *oo0ing to t#e patient as a bioassay or en!ocrine
abnormalities; s#oul! permit t#e clinician to narro/ t#e!iagnostic possibilities an! an accurate !iagnosis can be
obtaine! 1uic0ly.
+anagement aims at restoring ovulatory cycles i possible;
replacing estrogen /#en !eicient an! rogestogegen toprotect en!ometrium rom unoppose! estrogen.
Fre1uent re-evaluation an! reassurance o t#e patient.
7/26/2019 143278103 Amenorrhea Ppt
41/41
0HAN8