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1、Dr.Mohammed Abdalla Obst.Gyn.Specialist,Egypt ,Domiat G. Hospital,H,ASSESSMENT OF A CASE OF AMENORRHEA,AMENORRHEA,Amenorrhea is the absence or abnormal cessation of the menses. A patient is diagnosed with primary amenorrhea if she has not reached menarche by age 15.1 She meets the criteria for secon
2、dary amenorrhea if established menses have ceased for longer than 6 months,Etiology of Amenorrhea,Primary Gonadal failure(43%) Congenital absence of uterus and vagina(15%) Constitutional delay(14%) Secondary Chronic anovulation(39%)Hypothyroidism / hyperprolactinemia(20%) Weight loss/anorexia(16%),T
3、HE ASSESSMENT,Primary amenorrhea,vagina,no,yes,congenital uterovaginal agenesis imperforate hymen complete transverse vaginal septum,Pubic hair,Estrogenized,breasts have developed,the (MPA) challenge,abnormal ovaries,abnormal hormonal stimulation of normal ovaries,FSH Level,Chromosome Analysis,no,no
4、,yes,complete androgen insensitivity syndrome (CAIS),+,-,high,low,Secondary Amenorrhea,Secondary amenorrhea is the absence of menstrual periods for 6 months in a woman who had previously been regular, or for 12 months in a woman who had irregular periods.,incidence,1% of women of reproductive age.,T
5、he most common cause of secondary amenorrhea in reproductive age women is pregnancy and this should always be excluded by physical exam and laboratory testing for the pregnancy hormone - HCG.,History,A good history can reveal the etiologic diagnosis in up to 85% of cases of amenorrhea.,Galactorrhea,
6、hot flashes, breast atrophy and decreased libido,Certain medications,A large amount of weight loss or gain,Anorexia nervosa,Cushings disease and hypothyroidism,Sheehans syndrome.,Ashermans syndrome,Amenorrhea following cervical conization,Following discontinuation of oral contraception,History,Physi
7、cal examination,Signs of androgen excessThe breast exam may reveal galactorrheaEstrogen deficiency may be suggested on pelvic exam by a smooth vagina that lacks the normal rugae (wrinkles) and a dry endocervix with no mucous,what the doctor will do next?,If the history and physical exam are suggesti
8、ve of a certain etiology :,for the sake of efficiency and cost-effectiveness, the workup can sometimes be more directed. ( in 85% of cases .),Some patients will not demonstrate any obvious etiology for their amenorrhea on history and physical exam. These patients can be worked up in a logical manner
9、 using a stepwise approach.,the first tests to perform after pregnancy is ruled out are : a progesterone withdrawal test TSH (thyroid stimulating hormone) prolactin level.,Preg.test,TSH ,PROLACTIN, Prog.challenge test,withdrawal bleeding,without withdrawal bleeding,hypoestrogenic,compromised outflow
10、 tract.,+ve.est,progest.challenge test,-ve.est,progest .challenge test,FSH30-40,Normal FSH,HSG OR hysteroscopy asherman,2wk,FSH norm.,repeat,Repeat+serum ,est.level,PROF,hypothalamic-pituitary failure,anovulation,-VE,Ovarian failure (premature menopause),chromosomal anomalies,autoimmune disease,If t
11、he woman is under 30, a karyotype should be performed to rule out any mosaicism involving a Y chromosome.,it is prudent to screen for thyroid, parathyroid, and adrenal dysfunction,If a Y chromosome is found the gonads should be surgically excised.,Laboratory evidence of autoimmune phenomenon is much
12、 more prevalent than clinically significant disease,autoimmune related dysfunction,The most common association is with thyroid disease, but the parathyroids and adrenals can also be affected. Several studies have shown laboratory evidence of immune problems in about 15-40% of women with premature ov
13、arian failure. In general, ovarian biopsy is not indicated in patients with premature ovarian failure since no clinically useful information will be obtained.,Hypothalamic-pituitary failure,Patients who do not bleed after the progestin challenge but do after estrogen/progestin and have normal or low
14、 FSH and LH levels,Hypothalamic-pituitary failure,Some medications (e.g. phenothiazines) as well as extremes of weight loss, stress or exercise can cause this type of secondary amenorrhea.A pituitary or hypothalamic tumor would be a rare finding in these patients who were all screened with prolactin
15、 levels at the beginning of the diagnostic evaluation. However, if there is no cause apparent from the history, it would be prudent to obtain a baseline CT (or MRI) evaluation of the sellar region to rule out a space occupying lesion.,Hypothalamic-pituitary failure,Patients with normal prolactin lev
16、els and normal imaging studies have hypothalamic amenorrhea of uncertain etiology.,If the amenorrhea and lack of withdrawal bleeding persists, prolactin levels should be measured annually since a small microadenoma could be present that is escaping laboratory and radiographic detection.,Hypothalamic
17、-pituitary failure,In this condition, as well as in the other hypothalamic amenorrhea situations, the patients can be significantly hypo estrogenic (a low estrogen situation similar to menopause). If the state is persistent, hormone replacement therapy should be considered for protection against osteoporosis. One approach is to get an estradiol level and if it is less than 30 pg/ml, counsel the patient that hormonal replacement therapy is indicated,
