Amenorrhea.ppt - Amenorrhea Dr Sylvia A Definition primary amenorrhea It is defined as absence of menstruation by the age of 16 years in the presence of

Amenorrhea.ppt - Amenorrhea Dr Sylvia A Definition primary...

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Unformatted text preview: Amenorrhea Dr Sylvia. A Definition primary amenorrhea It is defined as absence of menstruation by the age of 16 years in the presence of, developed secondary sexual characteristics, or 14 years in the absence of secondary sexual characteristics. Menstruation is dependant on proper functioning of a chain made up of Hypothalamus Pitutary Ovary Uterus Amenorrhea occurs if there is weakening or break in one or more of these links. Hypothalamic Amenorrhea Disease or injury in the region of midbrain Encephalitis 2. Menengitis 3. Tumours or fractures of base of skull 4. Isolated gonadotrophin defacing (The olfactory genital syndrome and kalman syndrome) Here hypothalamus lack the ability to produce GnRH, therefore is hypogonadotrophic state. The pituitary gland is normal, (exogenous GnRH leads to normal release of Pit gonadotrophins) Aetiology Damage of hypothalamus and secretory neurons become functionless resulting in less production of GnRh 1. 2. Ceberal cortex influences 1. Anorexia Nervosa: In prepubertal girls leads to failure of the activation of gene which Initiate GnRH release in hypothalamus, growth spurt is not, effected, but secondary sexual characterotic do not , developed. Drugs Phenothiazine derivative Reserpine and ganglion stocking agent All above acts by affecting … by reducing; Prolactin inhibiting factors, which cause high prolactin levels, hypothyroidism. Pitutary Amenorrhea Hypogonadotrophic Hypogonadism Hypergonadotrophic Hypogonadism Hyper-gonadotrophic Hypogonadism Normal Stature Turner syndrome XO. syndrome XX agenesis Gonadalagenesis. Resistant ovarian syndrome due to absent or Defective gonadotrophin receptors, or mutation in receptors Galacto saemia, cause premature or all failure irreversible 1. 2. A. Hypogonadotrophic Hypogonadism Short Statured Short Statured Absent Secondary Sexual Characteristics Causes Congenital Hydrocephalous a) Due to infection in childhood or neonate period infection. It is believed that this damages hypothalamus and renders GnRH secreting neurones function less. Acquired Trauma: To base of Skull. Tumors: a large No. of tumors in the Pit, which may lead to destruction of receptors e.g. crania pharangioma. This tumor arises in childhood and results in destructiong of pituitary gland Empty sella syndrome The sella tursica is found to be empty. There is congenital absence of pitutary gland or part of it, leading to failure in production of gonadotrophin. . Tumours e.g. pituitary prolactin secreting adenomas 1/3rd of women with pituitary prolacting adenomas have galactorrhea (Secondary Amenorrhea) Ovarian Causes Galactosomia Inborn error of galactose metabolism due to deficiency of galactose, phosphate, uridyl, transferase. Galactose metabolite appear to have toxic effect on the follicles, causing their premature destruction. Gonadal Dysgenesis The gonad is dysgenetic, it is abnormal in its formation. There are various forms of malformation but commonest is Turner’s Syndrome with XO chromosome as Karyotype. They have normal phenotype, and internal genital organs are not developed. (full description of turner’s syndrome) Polycystic Ovarian Disease Un-reactive streak like ovaries Enzyme Deficiency Enzyme deficiency in the conversion of cholesterol to aldosterone estradiol and testosterone. 17 – 20 hydroxylase deficiency 46 XY 17 hydroxylase deficiency with Karyotype 46 XY Clinical picture Primary amenorrhea Failure of breast and uterine development Uterine Causes Imperforate Hymen Total or partial vaginal atresia Rudimentary uterus Uterine hypoplasia Destruction of endometrium by tuberculosis Endometrial insensitivity Hetero Sexual Development Congenital adrenal hyperplasia Androgen secreting tumors 5 α reductase deficiency Testicular feminizations (XY female) Partial androgen receptor deficiency True hormaphardite Absent mullerian inhibitor XY female Patient is phenotypically female, with normal breast development The above phenomenon occurs due to peripheral conversion of androgen into oestrogen Physical Feature Presence of normal breast Vulva is normally formed A short vagina of 1.5 cms is present Uterus and tubes are absent Hair Diagnosis Evaluation of primary amenorrhea No secondary sexual characteristics Height Normal Short FSH/LH FSH/LH Low High Low High Hypogonadotrophic hypogonadism Karyotype Intracranial lesion Karyotype XO or variants Premature ovarian failure Resistant ovary syndrome Gonadal agenesis XY agenesis XY enzymatic failure Normal secondary sexual characteristics Ultrasound Uterus Absent Uterus Present Karyotype 46 XX 46 XY Absent uterus and vagina XY female Outflow tract obstructio n Normal anatom y FSH/LH/prolactin Normal LH/FSH LH/FSH Prolactin Hypothalamic PCO Resistan t ovary Prolactinoma SECONDARY AMENORRHOEA DEFINATION CAUSES MANAGEMENT DEFINATION Absence of menses six months and beyond during reproductive age following establishment of normal mensturation CAUSES - 1 PHYSIOLOGICAL; pregnancy, menopause, lactation UTERINE CAUSES; Asherman’s syndrome, cervical stenosis OVARIAN CAUSES; PCO, premature ovarian failure HYPOTHALAMIC CAUSES; (hypogonadotrophic hypogonadism) weight loss, exercise, chronic illness, phsycological distress, idiopathic CAUSES -2 PITUITARY CAUSES; Hyperprolactinaemia, hypopituitarism (Sheehans syndrome CAUSES OF HYPOTHALAMIC-PITUITARY DAMAGE; tumors(craniopharyngioma, dermiod cyst), cranial irradiation, head injury, sarcoidosis, tuberculosis SYSTEMIC CAUSES; chronic debilitating illness, weight loss, endocrine disorder (thyroid disease, Cushing syndrome) CAUSES - 3 GYNAECOLOGICAL SURGERY; hysterectomy, endometrial ablation, oophorectomy, DRUGS danazol, GnRH, OCP, metochopramide, cimetidine, reserpine, tricyclic antidepresent MANAGEMENT -1 HISTORY Pattern of previous menstruation Sign and symptom of pregnancy Symptoms of menopause Lactatinal amenorrhea Social factors Marathon runner Sudden weight gain or loss crash diet, anorexia nervosa History of massive PPH Vigorous endometrial curettage Symptoms of thyroid disease MANAGEMENT - 2 INVESTIGATION Pregnancy test Baseline investigation LH, FSH, Prolactin, thyroid function test, pelvic ultrasound INVESTIGATION OTHER INVESTIGATION X-ray chest and pre-menstural endometrial biopsy (tuberculosis) Serum cortisol (Cushing syndrome) Thyroid tests TREATMENT ACCORDING TO CAUSE THANK YOU ...
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