AMENORRHEA. 2.pptx

AMENORRHEA

1. AMENORRHEA By Merlin BOTEN

2. OBJECTIVES Identify various etiologies of both primary and secondary amenorrhea. Review treatment options available for both primary and secondary amenorrhea. Describe the differential diagnoses of both primary and secondary amenorrhea.

3. PLAN Introduction Definition Background Physiopathology Causes Risk factors Diagnosis Management Complications Prevention Conclusion

4. INTRODUCTION Female menstrual cycle normally comprises a 28 to 30-day cycle, which contains 2 phases, the proliferative phase and the secretory phase. At the end of the cycle, the uterine lining starts shedding off, which is a normal phenomenon of female menstruation. The absence of menstruation during the female during the reproductive ages of approximately 12 to 49 years is known as amenorrhea. There are primary and secondary causes of amenorrhea. The most common cause of amenorrhea is pregnancy, and it is the first thing that needs to be ruled out when investigating such a patient. In general, if a female does not have menses for 6 months, she has amenorrhea.

5. DEFINITION Amenorrhea is the absence of a menstrual period in a female who has reached reproductive age. Physiological states of amenorrhoea are seen, most commonly, during pregnancy and lactation (breastfeeding). Outside the reproductive years, there is absence of menses during childhood and after menopause.

6. DEFINITION There are 2 main types of Amenorrhea. Primary amenorrhea is defined as an absence of secondary sexual characteristics by age 13 with no menarche or normal secondary sexual characteristics but no menarche by 15 years of age. It may be caused by developmental problems, such as the congenital absence of the uterus, failure of the ovary to receive or maintain egg cells, or delay in pubertal development.

7. DEFINITION Secondary amenorrhoea , ceasing of menstrual cycles after menarche, is defined as the absence of menses for three months in a woman with previously normal menstruation, or six months for women with a history of oligomenorrhoea. It is often caused by hormonal disturbances from the hypothalamus and the pituitary gland, premature menopause, intrauterine scar formation, or eating disorders

8. EPIDEMIOLOGY Amenorrhea is not life-threatening, but the loss of the menstrual cycle has been associated with a high risk of hip and wrist fractures. In the US, amenorrhea affects about 1% of women. Recent studies indicate that childhood obesity may contribute to the early onset of menarche. Many causes are defined according to the type of amenorrhea

9. BACKGROUND Physiologically, menstruation is controlled by the release of gonadotropin-releasing hormone (GnRH) from the hypothalamus. GnRH acts on the pituitary to stimulate the release of follicle stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH then act on the ovaries to stimulate the production of estrogen and progesterone which, respectively, control the proliferative and secretary phases of the menstrual cycle.

10. Physiopathology The absence of menses in a female of reproductive age is related to the disturbance of normal hormonal, physiological mechanism, or female anatomic abnormalities. The normal physiological mechanism works by balancing hormones and providing feedback between the hypothalamus, pituitary, ovaries, and uterus. Although amenorrhea has multiple potential causes, ultimately, it is the result of hormonal imbalance or an anatomical abnormality.

11. Physiopathology During normal female menstruation cycle, gonadotropin-releasing hormone (GnRH) is released from the hypothalamus, and it works on the pituitary to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH) and these 2 hormones from the pituitary act on ovaries and ovaries finally make estrogen and progesterone to work on the uterus to carry out the follicular and secretory phase of the menstrual cycle. Any defect at any level of this normal physiology of females can cause amenorrhea. On the other hand, deviation from the normal anatomy of the reproductive organs of a female can also cause amenorrhea.

12. CAUSES Primary amenorrhea Turner syndrome Turner syndrome, monosomy 45XO, is a genetic disorder characterized by a missing, or partially missing, X chromosome. Turner syndrome is associated with a wide spectrum of features that vary with each case. However, one common feature of this syndrome is ovarian insufficiency due to gonadal dysgenesis. Most people with Turner syndrome experience ovarian insufficiency within the first few years of life, prior to menarche. Therefore, most patients with Turner syndrome will have primary amenorrhea.

13. CAUSES MRKH MRKH (Mayer–Rokitansky–Küster–Hauser) syndrome is the second-most common cause of primary amenorrhoea . The syndrome is characterized by Müllerian agenesis. In MRKH Syndrome, the Müllerian ducts develop abnormally and result in the absence of a uterus and cervix. Even though patient's with MRKH have functioning ovaries, and therefore have secondary sexual characteristics, they experience primary amenorrhea since there is no functioning uterus.

14. CAUSES Intersex conditions Individuals with a female phenotype can present with primary amenorrhea due to complete androgen insensitivity syndrome (CAIS), 5-alpha-reductase 2 deficiency, pure gonadal dysgenesis, 17β-hydroxysteroid dehydrogenase deficiency, and mixed gonadal dysgenesis.

15. CAUSES Constitutional delay of puberty it is a diagnosis of exclusion that is made when the workup for primary amenorrhea does not reveal another cause. Constitutional delay of puberty is not due to a pathologic cause. It is considered a variant of the timeline of puberty. Although more common in boys, girls with delayed puberty present with onset of secondary sexual characteristics after the age of 14, as well as menarche after the age of 16. This may be due to genetics, as some cases of constitutional delay of puberty are familial.

16. CAUSES Secondary amenorrhea Breastfeeding Physiologic amenorrhea is present before menarche, during pregnancy and breastfeeding, and after menopause. Breastfeeding or lactational amenorrhea is also a common cause of secondary amenorrhoea . Lactational amenorrhea is due to the presence of elevated prolactin and low levels of LH, which suppress ovarian hormone secretion. Breastfeeding typically prolongs postpartum lactational amenorrhoea , and the duration of amenorrhoea varies depending on how often a woman breastfeeds. Due to this reason, breastfeeding has been advocated as a method of family planning, especially in developing countries where access to other methods of contraception may be limited.

17. CAUSES Diseases of the thyroid Disturbances in thyroid hormone regulation has been a known cause of menstrual irregularities, including secondary amenorrhea. Patients with hypothyroidism frequently present with changes in their menstrual cycle. It is hypothesized that this is due to increased TRH, which goes on to stimulate the release of both TSH and prolactin. Increased prolactin inhibits the release of LH and FSH which are needed for ovulation to occur.

18. CAUSES Patients with hyperthyroidism may also present with oligomenorrhea or amenorrhea. Sex hormone binding globulin is increased in hyperthyroid states. This, in turn, increases the total levels of testosterone and estradiol. Increased levels of LH and FSH have also been reported in patients with hyperthyroidism.

19. CAUSES Hypothalamic and pituitary causes Changes in the hypothalamic-pituitary axis is a common cause of secondary amenorrhea. GnRH is released from the hypothalamus and stimulates the anterior pituitary to release FSH and LH, which in turn stimulate the ovaries to release estrogen and progesterone. Any pathology in the hypothalamus or pituitary can alter the way this feedback mechanism works and can cause secondary amenorrhea.

20. CAUSES Pituitary adenomas are a common cause of amenorrhea . Prolactin secreting pituitary adenomas cause amenorrhea due to the hyper-secretion of prolactin which inhibits FSH and LH release. Other space occupying pituitary lesions can also cause amenorrhea due to the inhibition of dopamine, an inhibitor of prolactin , due to compression of the pituitary gland.

21. CAUSES Polycystic ovary syndrome Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 4–8% of women worldwide. It is characterized by multiple cysts on the ovary, amenorrhea or oligomenorrhea, and increased androgens. Although the exact cause remains unknown, it is hypothesized that increased levels of circulating androgens is what results in secondary amenorrhea. PCOS may also be a cause of primary amenorrhea if androgen access is present prior to menarche. Although multiple cysts on the ovary are characteristic of the syndrome, this has not been noted to be a cause of the disease.

22. CAUSES Low body weight Women who perform extraneous exercise on a regular basis or lose a significant amount of weight are at risk of developing hypothalamic amenorrhoea . Functional hypothalamic amenorrhoea (FHA) can be caused by stress, weight loss, or excessive exercise. Many women who diet or who exercise at a high level do not take in enough calories to maintain their normal menstrual cycles.

23. CAUSES The threshold of developing amenorrhoea appears to be dependent on low energy availability rather than absolute weight because a critical minimum amount of stored, easily mobilized energy is necessary to maintain regular menstrual cycles. Amenorrhoea is often associated with anorexia nervosa and other eating disorders. Relative energy deficiency in sport, also known as the female athlete triad, is when a woman experiences amenorrhoea , disordered eating, and osteoporosis.

24. CAUSES Energy imbalance and weight loss can disrupt menstrual cycles through several hormonal mechanisms. Weight loss can cause elevations in the hormone ghrelin which inhibits the hypothalamic-pituitary- ovarial axis. Elevated concentrations of ghrelin alter the amplitude of GnRH pulses, which causes diminished pituitary release of LH and follicle-stimulating hormone (FSH). Low levels of the hormone leptin are also seen in females with low body weight.[ Like ghrelin, leptin signals energy balance and fat stores to the reproductive axis. Decreased levels of leptin are closely related to low levels of body fat, and correlate with a slowing of GnRH pulsing.

25. CAUSES Drug-induced Certain medications, particularly contraceptive medications, can induce amenorrhoea in a healthy woman. The lack of menstruation usually begins shortly after beginning the medication and can take up to a year to resume after stopping its use. Hormonal contraceptives that contain only progestogen, like the oral contraceptive Micronor , and especially higher-dose formulations, such as the injectable Depo-Provera, commonly induce this side effect. Extended cycle use of combined hormonal contraceptives also allow suppression of menstruation.

26. CAUSES Patients who stop using combined oral contraceptive pills (COCP) may experience secondary amenorrhoea as a withdrawal symptom. The link is not well understood, as studies have found no difference in hormone levels between women who develop amenorrhoea as a withdrawal symptom following the cessation of COCP use and women who experience secondary amenorrhoea because of other reasons. New contraceptive pills which do not have the normal seven days of placebo pills in each cycle, have been shown to increase rates of amenorrhoea in women. Studies show that women are most likely to experience amenorrhoea after one year of treatment with continuous OCP use.

27. CAUSES The use of opiates (such as heroin) on a regular basis has also been known to cause amenorrhoea in longer term users. Anti-psychotic drugs , which are commonly used to treat schizophrenia, have been known to cause amenorrhoea as well. Research suggests that anti-psychotic medications affect levels of prolactin, insulin, FSH, LH, and testosterone. Recent research suggests that adding a dosage of Metformin to an anti-psychotic drug regimen can restore menstruation. Metformin has been shown to decrease resistance to the hormone insulin, as well as levels of prolactin, testosterone, and luteinizing hormone (LH).

28. CAUSES Primary ovarian insufficiency Primary ovarian insufficiency (POI) affects 1% of females and is defined as the loss of ovarian function before the age of 40. Although the cause of POI can vary, it has been linked to chromosomal abnormalities, chemotherapy, and autoimmune conditions. Hormone levels in POI are similar to menopause and are categorized by low estradiol and high levels of gonadotropins. Since the pathogenesis of POI involves the depletion of ovarian reserve, restoration of menstrual cycles typically does not occur in this form of secondary amenorrhea.

29. CAUSES Cushing syndrome Ovarian tumors Dont forget that the commonest cause of secondary amenorrhea is pregnancy

30. Risk factors Stress, excessive intense exercise, being overweight or underweight, nutritional imbalances, eating disorders, chronic illness, family history of early menopause or amenorrhea, or genetic health conditions that affect the female reproductive system.

31. CLINICAL DIAGNOSIS The main symptom is the lack of periods. Other symptoms depend on the cause. patient may experience: Hot flashes. Nipples leaking milk. Vaginal dryness. Headaches. Vision changes. Acne. Excess hair growth on your face and body.

32. PARACLINICAL DIAGNOSIS healthcare provider may do some tests, including: Pregnancy test. Blood tests to check hormone levels and detect thyroid or adrenal gland disorders. Prolactin level to rule out prolactinoma Testosterone and DHEAS to rule out hyperandrogenism FSH and LH for hypothalamic amenorrhea, BMI (to look for malnutrition, anorexia nervosa, and excessive strenuous exercise) MRI,CT scan if suspecting a problem with the pituitary gland.

33. PARACLINICAL DIAGNOSIS Ultrasound, if suspecting an issue with ovaries or uterus. Karyotyping is sometimes an important test for Turner and androgen insensitivity syndromes. Genetic testing, if patient have primary ovarian insufficiency and are younger than 40. Progesterone challenge test: This test is performed to differentiate between the anovulation, anatomic, and estradiol deficiency as causes of amenorrhea.

34. MANAGEMENT Natural causes of amenorrhea, such as pregnancy or breastfeeding, require no treatment. However, if amenorrhea is due to other issues, lifestyle adjustments can be helpful. Start by adopting a healthy diet and regular exercise like weightlifting or muscle-strengthening activities and managing stress. Some individuals may require hormone therapy with substances like estrogen, calcium, or vitamin D. In structural abnormalities, surgery may be performed for uterine adhesion, pituitary tumor, vaginal septum, or imperforate hymen.

35. COMPLICATIONS Amenorrhea isn’t life-threatening. However, some causes can lead to long-term complications, so amenorrhea should always be evaluated by a healthcare provider. Having amenorrhea may make patient more likely to develop: Osteoporosis or cardiovascular disease (due to a lack of estrogen). Difficulties getting pregnant or infertility. Pelvic pain (if structural issues are the cause).

36. PREVENTION Consume a balanced diet that includes all five food groups. Engage in regular physical exercise. Ensure adequate and quality sleep and relaxation. Manage stress effectively. Schedule regular check-ups with a gynecologist for pelvic examinations and Pap smears. Keep a record of your menstrual cycles to track the onset and duration of your periods and identify any missed periods.

37. CONCLUSION Amenorrhea is a commonest situation amongst young women . The causes of amenorrhea are diverse an interprofessional approach is required. Patients must be followed up for several years to ensure that the menstrual cycle has returned.

38. THANKS