Amenorroea.ppt - Amenorrhea AMENORRHEA Is the absence or cessation of menstruation PHYSIOLOGIAL AMENORRHEA PATHOLOGIAL AMENORRHEA Pathological

Amenorroea.ppt - Amenorrhea AMENORRHEA Is the absence or...

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Unformatted text preview: Amenorrhea AMENORRHEA Is the absence or cessation of menstruation PHYSIOLOGIAL AMENORRHEA PATHOLOGIAL AMENORRHEA Pathological Amenorrhea •Primary – 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. Events of Puberty • Thelarche (breast development) – Requires estrogen • Pubarche/adrenarche (pubic hair development) – Requires androgens Events of Puberty • Menarche Requires: – GnRH from the hypothalamus – FSH and LH from the pituitary – Estrogen and progesterone from the ovaries – Normal outflow tract Regular and spontaneous menstruation requires: •(1) functional hypothalamic– pituitary–ovarian endocrine axis, •(2) an endometrium competent to respond to steroid hormone stimulation, and •(3) an intact outflow tract from internal to external genitalia. Classification of amenorrhea • Hypothalamic amenorrhea. Disorders of the hypothalamus or central nervous system. • Pituitary amenorrhea. Disorders of the anterior pituitary. • Ovarian amenorrhea. Disorders of the ovary. • Uterine amenorrhea. Disorders of the genital outflow tract and uterus. Etiology • Hypothalamic amenorrhea – Psychological stress – Anorexia nervosa, weight loss – Increased exercise levels – Kallmann syndrome – drug-induced amenorrhea – Space-occupying lesion of CNS Etiology • pituitary amenorrhea – tumor – Empty sella syndrome – Sheehan syndrome Etiology • ovarian amenorrhea – Gonadal dysgenesis – Turner syndrome: low hair line, web neck, shield chest, and widely spaced nipples – Swyer syndrome (XY Female) – resistant ovary syndrome – Premature ovarian failure Etiology • uterine amenorrhea – Absence of uterus – Asherman syndrome • anatomic abnormalities of the reproductive tract – Imperforate Hymen Imperforate Hymen 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 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 Diagnosis • History • Physical examination – Physical examination begins with vital signs, including height and weight, and with sexual maturity ratings • Laboratory evaluation - HISTORY ASK ABOUT Menstrual cycle age of menarche and previous menstrual history Previous pregnancies - severe PPH (Sheehan’s syndrome) Weight change A large amount of weight loss (anorexia nervosa) Hot flashes , decreased libido premature menopause Certain medications Contraception Associate symptoms - Cushing's disease , hypothyroidism Previous gynaecological surgery Chronic illness History • Primary amenorrhea speaks for itself, but cyclic pelvic or lower abdominal pain or urinary complaints can be caused by developmental anomalies resulting in obstructed menstrual flow (cryptomenorrhea), as may be caused by an imperforate hymen, transverse vaginal septum, or cervical atresia. • Onset following curettage or other uterine surgery clearly suggests the possibility of damage to the reproductive tract. • Women with PCOS classically present with infrequent and irregular menses dating from menarche or early adulthood, and gradually progressive hirsutism. • In most with hypothalamic amenorrhea, the onset of amenorrhea temporally relates to events resulting in severe nutritional, physical, or emotional stress. • Women with hyperprolactinemia or premature ovarian failure commonly notice a gradual decrease in their regular intermenstrual interval, followed by increasing oligomenorrhea, and finally, amenorrhea, one sometimes accompanied by galactorrhea, and the other by hot flushes. • Questions relating to past medical history, general health, and lifestyle can identify a severe or chronic illness such as diabetes, renal failure, or inflammatory bowel disease, previous head trauma, or evidence of physical or psychological stress. • Headaches, seizures, vomiting, behavioral changes, or visual symptoms may suggest a CNS disorder. INVESTIGATING SECONDAY AMENORRHEA NEGATIVE PREGNANCY TEST FSH, LH and Thyroid function test Progesterone challenge test WITHDRAWAL NO WITHDRAWAL BLEEDING BLEEDING HYPOESTROGENIC ANOVULATION FSH normal + high LH PCOS High prolactin pituitary tumour Positive E-P challenge test Normal or Low FSH Hypothalamic-pituitary failure COMPROMISED OUTFLOW TRACT Negative E-P challenge test Very high FSH Normal FSH Ovarian Failure Asherman’s syndrome (HSG or hysteroscopy) CLINICAL ASSESSMENT - EXAMINATION CHECK FOR BODY MASS INDEX (BMI) weight loss-related amenorrhea BLOOD PRESSURE elevated in Cushing and PCOS ANDROGEN EXCESS hirsuitism (PCOS) – virilization (tumour) Secondary sexual characteristic Features of Turner’s syndrome Breast examination may revealed galactorrhea, Abdominal (haemato mera) and pelvic masses (ovarian tumour) Inspection of genitalia imperforate hymen, cervical stenosis Vaginal examination blind vagina, vaginal atresia, absent of uterus INVESTIGATING PRIMARY AMENORRHEA SITE OF DISORDER DIAGNOSIS INVESTIGATIONS HYPOTHALAMUS Hypothalamic-hypogonadism FSH, LH and estradiol - Low PITUITARY Pituitary adenoma Prolactin – High FSH, LH and estradiol - Low OVARY Gonadal dygenesis (Turner’s syndrome) FSH and LH – High Estradiol – Low Karyotype – 45 XO MULLERIAN TRACT Absent uterus (Testicular feminization) PCT – negative Karyotyping – 46 XY GENITAL TRACT Imperforate hymen FSH, LH, estardiol – normal PCT – negative Examination – imperforate hymen Treatment • treatment varies depending upon the causes of the amenorrhea. Treatment options include: – Dietary changes, including an increase in fat and calories in order to stimulate estrogen production. – Counseling for eating disorders. – Using stress reduction techniques to help regulate the menses. – Hormonal supplements, like the birth control pill or patch, or hormone replacement therapy. – Surgery to remove cysts, fibroids or tumors General Principles of management of Amenorrhea . Attempts to restore ovulatory function . If this is not possible HRT (oestrogen and progesterone) is given to hypo-estrogenic amenorrheic women (to prevent osteoporosis; atherogenesis) . Periodic progestogen should be taken by euestrogenic amenorrheic women (to avoid endometrial cancer) . If Y chromosome is present gonadectomy is indicated . Many cases require frequent re-evaluation Hormonal treatment Primary Amenorrhea with absent secondary sexual characteristics To achieve pubertal development Premarin 5mg D1-D25 + provera 10mg D15D25 X 3 months; 2.5mg premarin X 3 months and 1.25mg premarin X 3 months Maintenance therapy 0.625mg premarin + provera OR ready HRT preparation OR 30µg oral contraceptive pill Thanks for Your Attention ...
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  • Winter '16
  • Bill Oyieke

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