Amenorrhea

An overview of amenorrhea, including its types, etiology, clinical presentation, diagnosis, and treatment

1. a- men -o- rrhea Rawa Muhsin lack of -- monthly -- flow

2. Classification Primary Secondary

3. Primary Amenorrhea

4. Definition No menses at age 15 yr in the presence of secondary sexual characteristics 13 yr in the absence of secondary sexual characteristics

5. Etiology Hypothalamus Functional Congenital Constitutional Infiltrative disease, trauma, radiation Prader-Willi , Laurence-Moon- Biedl Ovary Gonadal dysgenesis Polycystic ovary syndrome Müllerian structures Imperforate hymen Transverse vaginal septum Vaginal agenesis (MRKH) Receptors and enzymes Androgen insensitivity 5-alpha-reductase deficiency CYP17 deficiency Vanishing testes syndrome Pituitary Hyperprolactinemia Infiltrative diseases, trauma, radiation

6. Etiology

7. Diagnostic approach Step 1: History Secondary sexual characteristics and height Symptoms of virilization Stress, weight, diet, and exercise Galactorrhea Headaches, visual field defects, polyuria , polydipsia Neonatal and childhood health Drugs Family history of delayed puberty

8. Diagnostic approach Step 2: Physical examination Height, weight, BMI Breast development Genital examination Skin examination Features of Turner syndrome

9. Diagnostic approach and the anorexic winners are…

10. Diagnostic approach

11. Diagnostic approach

12. Diagnostic approach

13. Diagnostic approach

14. Diagnostic approach

15. Diagnostic approach

16. Diagnostic approach Step 3: Investigations Uterus absent karyotype serum testosterone Uterus present FSH (then karyotype or MRI) prolactin and TSH serum testosterone and DHEA-S CYP17 deficiency tests

17. Treatment Aims: underlying pathology, fertility, complications Hypothalamic and pituitary causes Functional → weight gain, reduce exercise intensity, resolution of illness or emotional stress, hormone replacement, exogenous gonadotrophins or pulsatile GnRH Congenital → exogenous gonadotrophins or pulsatile GnRH Infiltrative diseases and hyperprolactinemia → specific treatment

18. Treatment Ovarian causes Gonadal dysgenesis → hormone replacement therapy, donor oocytes PCOS → relief of hirsutism , resumption of menses, fertility, endometrial hyperplasia, obesity, metabolic defects

19. Treatment Anatomical causes Corrective surgery Absent müllerian structures → creation of neovagina , surrogacy Psychological counseling Enzyme and receptor defects Surgery to remove testicular substance Psychological counseling

20. Secondary Amenorrhea

21. Definition Absence of menses for more than 3 cycles or 6 months in women who previously had menses

22. Etiology Pregnancy!

23. Etiology Hypothalamus Functional Infiltrative diseases Trauma, radiation Ovary Polycystic ovary syndrome Primary ovarian insufficiency Uterus Asherman syndrome Infections, TB Systemic illness Celiac disease Thyroid disease Pulmonary TB, uremia, Addison Pituitary Hyperprolactinemia Sellar masses Infiltrative diseases Sheehan, radiation

24. Diagnostic approach Step 1: Rule out pregnancy! serum beta- hCG measurement

25. Diagnostic approach Step 2: History Stress, weight, diet, exercise Hot flashes, vaginal dryness, poor sleep, ↓ libido Acne, hirsutism , deepening of voice Galactorrhea Headaches, visual field defects, polyuria , polydipsia Obstetric catastrophe, endometritis , D&C Past medical history Drugs

26. Diagnostic approach Step 3: Physical examination Height, weight, BMI Skin examination Genital examination Parotid glands and teeth

27. Diagnostic approach

28. Diagnostic approach

29. Diagnostic approach Step 4: Investigations FSH (then MRI) Prolactin and TSH (then MRI) Estrogen status Progestin challenge (then HSG or hysteroscopy) Serum testosterone, 17-HP, DHEA-S Transferrin , ACE, blood glucose, Hb A1c

30. Diagnostic approach Diagnostic criteria (Rotterdam) for PCOS are two out of three CAH, Cushing syndrome, and androgen-secreting tumors must be excluded

31. Treatment Hypothalamic Lifestyle changes → adequate caloric intake, ↓ exercise, relief of stress Cognitive behavioral therapy Leptin administration Estrogen therapy

32. Treatment Hyperprolactinemia Dopamine agonists ( cabergoline , bromocriptine , pergolide , quinagolide ) Transsphenoidal surgery ∓ radiation therapy Estrogen + progestin Treat hypothyroidism If due to antipsychotic drug → add dopamine agonist, change to quetiapine , add aripiprazole (e.g. to risperidone ), add estrogen and progestin

33. Treatment Primary ovarian insufficiency Oral contraceptive pill Replacement dose of estrogen and progesterone Asherman syndrome Hysteroscopic lysis Long-term high-dose estrogen, IUD, or Foley catheter

34. Treatment Polycystic ovary syndrome Hirsutism and acne → OCP ∓ antiandrogen , GnRH agonists, mechanical methods Androgenetic alopecia → finasteride , minoxidil , surgery Endometrial protection → OCP, progestin Infertility → weight loss, clomiphene , + adjuvants , FSH injections, ovarian surgery, IVF Treat obesity, insulin resistance, dyslipidemia , OSA, NASH

35. Exercise

36. The End