Amenorrhea - Define, Cause, Sign and Symptoms, Type- Pathological and Physiological Amenorrhea and It's Treatment and management, Cushing Syndrome - Define, Causes, Sign And Symptoms in PPT

Amenorrhea - Define, Cause, Sign and Symptoms, Type- Pathological and Physiological Amenorrhea and It's Treatment and management, Cushing Syndrome - Define, Causes, Sign And Symptoms in PPT made By Sonal Patel

2. Definitions:
Amenorrheameanscompleteabsenceof
menstruationinpatientsduringthe
reproductiveyears.Itisnotadisease,but
asymptom.
Pathophysiology:
Amenorrheaoccursifthehypothalamus
andpituitaryfailtoprovideappropriate
gonadotropinstimulationtotheovary,
resultingininadequateproductionof
estradiolorinfailureofovulationand
progesteroneproduction.Amenorrhea
canalsooccuriftheovariesfailto
produceadequateamountsof
estradioldespitenormal and
appropriategonadotropinstimulation
bythehypothalamusandpituitary

3. .

4. Classification of amenorrhea:
A) Physiological amenorrhea:
1-Before puberty:due to suppression of the
hypothalamo-pit.-ovarian axis which is
sensitive to the low level of estrogen
2-Pregnancy:due to pregnancy hormones;
estrogen & progesterone which suppress
gonadotropins.
3-Postpartum:Lactation amenorrhea is due to
prolactin which alters LH & FSH secretion or
inhibits GTH release
4-Postmenopausal:due to intrinsic ovarian
failure (depletion of ovarian follicles)

5. B)Pathologicalamenorrhea:
I-Falseamenorrhea(Cryptomenorrhea):
Actually,menstruationtakesplacebutthereisan
obstructiontomenstrualoutflowproducedby
congenitaloracquiredconditions:
a.Congenitalcauses:
1.Imperforatehymen:therepresentsthemostcommonformof
vaginaloutflowobstruction.
Symptoms:normalyounggirlscomplainingof:-
○Cycliclowerabdominal(menstrual)pain
○Lowerabdominalswelling:
○Retentionofurineordifficultywithmicturition.

6. Examination:
General examination:normal 2ry sex characters
Abdominal examination:pelvi-abdominal swelling
may be felt.
Local examination:bulging membrane at the
introitus which appear as a dark blue or purple
color due to retained blood. Gentle pressure on
the swelling will transmit a thrill to the vaginal
membrane.
2-Vaginal septum & atresia with a functioning
uterus:a transverse vaginal septum or
failure of canalization of the entire vagina.
The uterus develops normally 
hematometra & hematosalpinx when
menstruation is established.

7. Treatment:
 Excision of vaginal septum.
 For vaginal atresia: Laparotomy (open
the uterine cavity) drainage
 Artificial vagina is constructed with a
therich skin graft.
3 -Atresia of the cervix with a
functioning uterus:is rare.
b-Acquired causes of
crytomenorrhoea:
1-Adhesive vaginitis:due to senile
vaginitis or due to radiotherapy or
chemical burns
2-Cervical stenosis:due to excessive
cauterization, amputation of the cervix,
trachelorrhaphy and Fothergil
operation
II -True amenorrhea:may be primary or
secondary
Drainage of hematocolpos

8. Primary amenorrheaI- Constitutional  Delayed puberty
II- Hypothalamic  Frolich's syndrome
 Laurance Moon Bidle syndrome.
III- Pituitary causes  Pituitary infantilism.
- Selective gonadotrophin deficiency
- Panhypopituitrism
IV- Ovarian causes  Congenital defects
- Gonadal dysgenesis
- True hermaphroditism
 I ry ovarian failure
 Prepubertal PCOD
 Insensitive ovarian syndrome.
V- Uterine causes  Congenital absence
 Hypoplasia
 Refractory endometrium
VI- Adrenocortical disorders  Congenital adrenal hyperplasia
 Congenital adrenogenital syndrome
& related disturbances

•Causes:

9. *Definitionofprimaryamenorrhea:failureof
menarchetooccurwhenexpectedinrelation
totheonsetofpubertaldevelopment.
Itisdefinedeitherasabsenceofmensesbyage14
yearswiththeabsenceofgrowthordevelopmentof
secondarysexualcharacteristicsorasabsenceof
mensesbyage16yearsregardlessofgrowthand
devlopmentofsecondarysexualcharacteristics.
*Prevalence:about 0.3%
I) Constitutional:no pathology in the endocrine axis.
Constitutional pubertal delay:is caused by
immature pulsatile release of gonadotrophin-
releasing hormone; maturation eventually occurs
spontaneously.
Common cause (20%)
Under stature and delayed bone age (X-ray Wrist
joint)
Positive family history
Diagnosis by exclusion and follow up
No anatomical abnormality and endocrine
investigations show normal results.
Prognosis is good
No drug therapy is required –Reassurance
Constitutional delay

10. Primary amenorrhea (cont.)
II) Hypothalamic:
1-Frolich's syndrome (Dystrophia adiposo-genitalis):
-Characterized by:
• Adiposity
• Absence of 2ry sex characters
• Atrophy of genital organs (small uterus, acute AVF, pin hole
external os and short vagina)
-Laboratory diagnosis:
• Pituitary gonadotrophins • Estrogen
-Treatment:no specific treatment. Treatment to relieve amenorrhea &
obesity by:
a-Reduction of weight
b-Thyroid hormone
c-Estrogen & progesterone
d-Pituitary gonadotophins FSH & LH
2-Laurance Moon Biedl's syndrome:in addition to findings
in Frolich's syndrome there is: retinitis pigmentosa,
polydactly & mental deficiency
Frolich's syndrome

11. Primary amenorrhea (cont.)
III) Pituitary causes:
Pituitary infantilism:the failure in the pituitary may be:
a-Selective pituitary failure:
-Specific failure to produce GTH
-Characters:
I.No secondary sex characters.
II.Amenorrhea
III.Genital atrophy
IV.Dwarfism
b-Panhypopituitrism:
-Thyroid failure (Hypotension -hypoglycemia)
-Adrenal failure
-17 ketosteroids

12. Primary amenorrhea (cont.)
IV)Ovariancauses:
1-Congenitaldevelopmentaldefects:
a.Gondaldysgenesis:isspectrumofdisorderswith
associatedhypergonadotropicHypogonadism.Chromosomally abnormal Chromosomally normal
- Classic Turner ’s syndrome (45XO) - 46XX (Pure gonadal dysgeneis)
- Turner variants (45XO/46XX) - 46XY (Swyer’s syndrome)
- Mixed gonadal dygenesis (45XO/46XY)
Characters of ovarian dysgenesis:
amenorrhea, stunted growth, genital atrophy and
absence of secondary sex characters
Expel:--Turner’s syndrome
-True Hermaphroditism
-male hermaphroditism

13. Turner’ssyndrome:
Turner'ssyndromeiscausedbyeithera
completeabsenceorapartialabnormality
ofoneofthetwoXchromosomes.
Sexualinfantilismandshortstature.
Associatedabnormalities,webbedneck,
coarctationoftheaorta,high-arched
pallate,cubitusvalgus,broadshield-like
chestwithwidelyspacednipples,low
hairlineontheneck,shortmetacarpal
bonesandrenalanomalies.
HighFSHandLHlevels.
Bilateralstreakedgonads(formedof
stromaonly&nofollicles).
Karyotype:80%45,X0and20%mosaic
forms(46XX/45X0)
Treatment:HRT
Turner’s syndrome

14. b.Truehermaphroditism:
anymixtureofovary,testis,
and ovotestis–either
unilateralorbilateralis
possible,withovariantissue
morefunctional.Themost
commonis46,XX

15. c.Male hermaphroditism (androgen insensitivity):
formerly known as testicular feminization
syndrome
Geneticallymediated(X-linkedtrait)
AffectedindividualshaveKaryotype46,XYandhave
normaltestes(undescended)withnormalproduction
oftestosteroneandnormalconversionto
dihydrotestosterone
Absentcytoplasmictestosteronereceptors
Duetoabsenceofreceptorsintargetorgans,thereis
alackofmaledifferentiationoftheexternaland
internalgenitalia.Therefore,externalgenitaliaremain
femaleandWolffianductdevelopmentfailstotake
place.Also,Müllerianductregressionisinducedby
anti-müllerianhormonewhichisproducedbythe
Sertolicellsofthefetaltestes.Therefore,these
individualshave:

16. Male hermaphroditism
(cont.)
Normalfemaleappearance
Nofemaleormaleinternalgenitalia
Normalfemaleexternalgenitalia
Shortorabsentvaginalpouch
Scantyorabsentpubic/axillaryhair
Normalorenhancedbreasts
Treatment:
Operativeremovalofthetesticlesafter
pubertydueto↑riskofmalignancy
(gonadoblastoma)foundin25%of
patients
Surgicalcorrectionofthevagina
(artificialvagina)
T. F. syndrome

17. 2-1ryOvarianfailure:dueto:
Geneticovariandysgenesis
Non-dysgenesisovarianfailure
Steroidogenicenzymedefects(17-hydroxylase)
Autoimmuneoophoritis
Postinfection(eg.Mumps)
Postoopherectomy
Postradiation
Postchemotherapy
Gonadotropins(FSH/LSH)willbehigh,
similartomenopause.Theovaryisnot
respondingtopituitaryGTHatpuberty

18. 3-Prepubertal polycystic ovarian syndrome
4-Resistant (insensitive ovary syndrome):
1ry amenorrhea with well developed pubic &
axillary hair
Atrophic vaginal & endometrial mucosa
Elevation of FSH & LH with low estrogen
N/E of the ovary resemble prepubertal organ
M/E show numerous primordial follicles not
passed to mature size
Treatment: Ovulation induction by GTH ( high
doses)

19. V) Uterine causes:
1-Mayer-Rokitansky-Kuster-Hauser
Syndrome(MRKH) (utero-vaginal agenesis):
15% of primary amenorrhea. It is due to
congenital absence of mullerian ducts and is
characterized by:
Normal secondary sexual development &
external female genitalia
Normal female range testosterone level
Absent uterus , fallopian tube, upper vagina
and normal ovaries
Karyotype 46-XX
15-30% renal, skeletal and middle ear
anomalies
DD:Testicular Feminization Syndrome
Treatment:dilatation orvaginoplastyin order to
lead to a normal sexual life
2-Severe degrees of hypoplasia
3-Refractory endometrium

20. VI) Disorders of adrenal gland:
Adrenogenital syndrome:Late
onset congenital adrenal
hyperplasia (CAH)
Autosomal recessive trait
Most common form is due to 21-
hydroxylase deficiency in adrenal glands,
androgens can not be converted to
corticosteroids Female
pseudohermaphroditism.
Severe forms show signs of severe
androgen excess Defeminization &
masculinization
High 17 α -OH-progesterone blood level
Treatment: cortisolreplacement and may
be corrective surgery for external genitalia
Late onset CAH

21. Diagnosis of primary amenorrhea:
History:obtaining a thorough history is
essential and comprises:
Childhood growth and development including
height and weight charts and age at thelarche.
Age at menarche of the patient's mother and
sisters
History of chronic illness, trauma, surgery, and
medications
Information regarding exercise, diet and
psychosocial issues.
History of symptoms as cyclic lower abdominal
pain , virilizing changes

22. Diagnosis of primary amenorrhea (cont.)
Physical examination:special attention should be directed toward
evaluating
General:
Body dimensions ( Height & span) and habitus.
Distribution and extent of body hair
Muscle mass or other signs of virilization.
Extent of breast development by Tanner staging
Look for signs of Turner syndrome
Abdominal:look for pregnancy or pelviabdominal mass e.g ovarian mass
or hematocolpos
Local examination:of external and internal genitalia, with emphasis to
look for
Presence or absence of the uterus
Presence or absence of patent vagina or vaginal pouch
Evidence of exposure to androgens (pubic hair distribution and
clitoromegaly).
Imperforate hymen
Pelvic fullness (pregnancy, ovarian mass, and genital anomalies)
P/R: for virgins, hematocolpos

23. U/S examination:If a genital examination is
not feasible, an abdominal ultrasound may be
useful to confirm the presence or absence of
the uterus.
Investigations of primary amenorrhea:
Pregnancy test
Physical examination to determine presence of
uterus
FSH
N.B. Some patients will not demonstrate any obvious etiology for their
amenorrhea on history and physical examination. These patients can
be subjected to work up in a logical manner using a stepwise
approach after pregnancy is excluded.
Diagnosis of primary amenorrhea (cont.)

24. Evaluation of primary amenorrhea
Diagnosis of primary amenorrhea (cont.)

25. * Treatment of primary amenorrhea:
If possible, the aim of therapy is correction of the cause e.g.
Bromocripitine therapy for prolactinoma
Specific therapy for malnutrition, malabsorption, weight loss,
anorexia nervosa, etc
Imperforate hymen: cruciate incision
Transverse vaginal septum: surgical removal
Hypoplasia or absence of cervix in presence of functioning
uterus hysterectomy is required as repair of the cervix has not
been successful
Absent or short vagina: progressive dilatation or Mcindo’s
split thickness graft
Patients with karyotype XY or mosaic gonads should be
removed
Clomiphene citrate is ineffective in patients with hypogonadism
due to hypoestrogenism but HMG or pulsatile Gn RH can be
effective
Patients with physiologic delay reassurance
Patients with all forms of gonadal failure and hypogonadotropic
hypogonadism cyclic estrogen and progestin therapy

26. Secondary amenorrhea
Definition:the cessation of menstruation for at least 6 months
or for at least 3 of the previous 3 cycle intervals.
Prevalence:about 3% I- Constitutional  Acute infections
 Chronic debilitating diseases
 Nutritional disorders
 Psychological disturbances
 Endocrinal (thyroid & pancreas)
II- Hypothalamic  Frolich's syndrome
 Diseases mid brain
 Idiopathic hypothalamic insufficiency
 Chiari frommel syndrome
 Iatrogenic (drugs & steroids)
III- Pituitary causes  Adenomas: . Acidophil .Basophil
. Chromophobe Simmond’s D.
 Hypofunction panhypopit. Sheehan’s
( Insufficiency) Levi-lorian syndrome.

IV- Ovarian causes (A) Partial failure: as
 Chronic anovulation
 Stein leventhal syndrome ( PCOD)
 Estrogenic ovarian tumours
 Hyperthecosis ovarii
 Masculinizing ovarian tumours.
Premature menop.
(B) Complete ovarian failure Casteration
T B
V- Uterine causes  Hysterectomy.
 Over curettage.
TB
 Endometrial. destruction. Radiation
Infection
 Asherman's syndrome.
 Uterine atrophy.
VI- Adrenocortical disorders  Addison's disease.
 Tumours of adrenal cortex.
 Cushing's syndrome.
 Virilism due to excess androgen.

27. 1.Constitutional amenorrhea:
1.Acute infections:influenza & fevers
2.Chronic debilitating diseases:asanemia, liver cirrhosis, T.B.
3.Nutritional disturbances:malnutrition & extreme obesity.
4.Psychological:
a.Major & minor psychosis
b.Emotional shock following trauma
c.Pseudocyesis characterizedby:
1.An obsession of pregnancy
2.Weight gain.
3.Normal secondary sex characters & pelvic organs
4.lactation
5.Disturbed FSH/LH ratio.
6.HCG -ve
d.Anorexia nervosa

28. d-Anorexia nervosa: disease
of adolescence & is
characterized by
1ry or 2ry amenorrhea is often first
sign
A body mass index (BMI) <17 kg/m²
Hypothalamic suppression
Abnormal body image, emaciation,
intense fear of weight gain, often
strenuous exercise
Sense of wellbeing despite weight
loss
Mean age of onset 13-14 yrs (range
10-21 yrs)
Bulemics less commonly have
amenorrhea due to fluctuations in
body weight.
Anorexia nervosa

29. 5) Endocrinal:
a-Pancreas (D.M):causes menstrual
disturbances
b-Thyroid:
Anorexia nervosa
1-Cretinism & Childhood myxedema 
amenorrhea..
2-Adult myxedema
3-Hyperthyroidism
Treatment of thyroid disorders:
-For myxedema L-thyroxin
-For hyperthyroidism anti-thyroid drugs

30. II) Hypothalamic amenorrhea:
1-Frolich’s syndrome
2-Diseases of mid brain
3-Idiopathic hypothalamic insufficiency
4-Chiari-Frommel syndrome:representsa prolonged physiological lactational
amenorrhea due to inhibition of PRL inhibiting factor of hypothalamus and is characterized
by: . Atrophy of vaginal & uterine mucosa
. Sustained breast developments
. Low pituitary gonadotropins
N.Bif unassociated with pregnancy, the presence of pituitary tumour should be
considered e.g. Ahumada Del Castello syndrome.
DD of postpartum amenorrhea:
Physiological condition (lactation or pregnancy)
Sheehan's syndrome & anterior pituitary necrosis
History of postpartum D&C causing infection and endometrial scarring
(Asherman's syndrome)
Chiari-Fromel syndrome -Cesarian Hysterctomy
Amenorrhea-galactorrhea

31. -Phenothiazine derivatives
-Oral contraceptive pills
They hypothalamic releasing
hormone (prolonged effect in some
cases can occur)
5-latrogenic (Drugs & steroids):

32. A)Pituitarytumors:produce
-PressureaffectsBitemporalhemianopia
-Endocrinedisturbances
C/P:Historyofheadache&visualdisturbances
Diagnosis:X-raysellaturcica,C.Tscan&MRI,
visualfielddefects.
1)Acidophiladenoma:sourceofgrowthhormone
.Characters:
a-Excessivegrowthofhands&feet
b-↑incoarsenessofallfeatures
c-↑sizeofnose&lowerJawprognathism
d-Polyuria,polydepsia&muscleweakness.
.Laboratory:
-Serumgrowthhormone
-Absenceofurinarygonadotrophins
-Impairedglucosetolerance.
Acromegaly
Secondary amenorrhea
III) Pituitary causes of amenorrhea:

33. Pituitary T. (cont.)
2)Basophiladenoma(Cushing'ssyndrome):
Characters:seediagram
3)Chromophobeadenoma:
-Amenorrheaduetodestructionofpituitary
tissue
-Prolactin producing adenoma are associated
with Forbes Albright syndrome
characterized by persistent lactation in
absence of a previous pregnancy
-Atrophyofuterine&vaginalmucosa
-Smallsizedovaries
-Galactorrhea
Diagnosis:PRLassay
Anylevel>120ng%indicatesinvestigation
forpituitarytumor
Cushing's syndrome

34. B) Pituitary insufficiency (Scarring):
-Simmond's disease:panhypopituitrism
-Sheehan syndrome:
Etiology:
1-Postpartum hemorrhage
2-Shock
3-Puerperal sepsis
4-Fracture base, meningitis
5-Use of ergot (pituitary thrombosis)
Criteria of Sheehan 's syndrome:
After immediate recovery of pituitary thrombosis
or postpartum collapse, amenorrhea and failure
of lactation occur

35. Sheehan syndrome (cont.):
Signs:
A)Early:
1-Atrophyofuterus&vagina2-Slightweightgain
B)Late:
1-Lossofaxillary&pubichair2-B.Pressure
3-Lossofweight&wasting 4-Susceptibilitytoinfection
5-Apathy 6-Prematuresenility
7-Adrenalfailure 8-Insulinintolerance
N.BAmeliorationofdiseaseismostlyduetocompensatory
hypertrophyoflowerremainingpituitarycells.Pregnancycan
occur.
Laboratorydiagnosis:panhypopituitrism
-orabsentGTH -17Ketosteroids
-T3&T4 -Flatglucosetolerancetest.
-Anemia

36. IV) Ovarian causes:
1-Premature menopause:
-Caused by disappearance of
oocytes from the ovary
-Etiology: germ cells damage due
to radiation, methotrexate, T.B,
surgical removal and
auto-immune diseases
2-PCOD (Stein Leventhal
Syndrome):see ovulation
disorders
Asherman's syndrome

37. Secondary amenorrhea (cont.)
V) Uterine causes:destruction of the endometriumdue to T.B or
Asherman'ssyndrome
Diagnosis:
-Endometrial curettage for T.B
-HSG & Hysteroscopy for Asherman'ssyndrome
VI-Disorders of adrenal gland:
1-Adrenogenitalsyndrome: see before
2-Cushing's syndrome:due to excess secretion of corticosteroids by
adrenals
3-Adrenal tumours:
Characters:
1-Marked hypertension due to corticosteroids
2-Early amenorrhea
3-17 ketosteroidsNot suppressed by dexamethasone
4-DHEA-S is specific to adrenal androgens
5-Defeminizationand masculinization

38. N.B.Causes of amenorrhea & galactorrhea:
-Lactation
-Chiari Frommel syndrome -Ahumada
-Del Castello
-Pituitary tumours -Drugs
Causes of hirsutism & amenorrhea:
-PCOD -Ovarian tumours
-Adrenal tumours -Drugs

39. Diagnosisofacaseofamenorrhea:
1-Historytaking:
–Personalhistory:agetoexcludemenopause
–Riskofpregnancy:Pregnancysymptoms
–Associatedsymptoms,e.g.galactorrhoea,hirsutism,hotflushes,dryvagina,
symptomsofthyroiddisease
–Recentchangeinbodyweight
–Recentemotionalupsets
–Levelofexercise
–Previousmenstrualandobstetrichistory
–Previoussurgery,e.g.endometrialcurettage,oophorectomy
–Previousabdominal,pelvic,orhistorycranialradiotherapy
–Pasthistory:ofdrugs,operationsasD&C
–Family,e.g.ofearlymenopause
–Drughistory,e.g.progestogens,combinedoralcontraceptive,chemotherapy
–SymptomsofIntracranialtension

40. Diagnosis of a case of amenorrhea: (cont.)
2-Examination:
General:for
Heightandweight:calculatebodymassindexif
appropriate.
Signsofexcessandrogens,e.g.hirsutism,acne
Signsofvirilization,e.g.deepvoice,clitoromegalyin
additiontohirsutism,andacne
Signsofthyroiddisease.
Acanthosisnigricans:thishyperpigmentedthickeningof
theskinfoldsoftheaxillaandneckisasignof
profoundinsulinresistance.Itisassociatedwith
polycysticovarysyndrome(PCOS)andobesity.
Breastexaminationforgalactorrhoea.
Fundoscopyandassessmentofvisualfieldsifthereis
suspicionofpituitarytumour.

41. Diagnosis of a case of amenorrhea
Abdominalexamination:
Pelvi-abdominalmasses:excludepregnancyinevery
caseof2ryamenorrhea.
Pubichair
StriaeasinCushing'ssyndrome.
Localpelvicexamination:
Vulva:developmentisanindexofovarianfunction
Vagina:thin&poorlydevelopedinhypogonadism
Cervix:stenosis
Uterus:masses-size

42. 3-Investigations:
A-Clinicalinvestigations:
i-Examinationunderanesthesia ii-Uterinesounding
iii-Vaginalsmear iv-Cervicalmucus
v -Endometrial biopsy vi-Hormonal withdrawal test
(progesterone)
Seeworkupof2ryamenorrhea
B-Laboratoryinvestigations:
-Pergnancytest:ineverycaseofsecondaryamenorrhea
-T3&T4 -Glucose.T.T -Hormonalassays:
1)Gonadotrophins(FSH&LH):
*Highin:primaryovarianfailureandprematuremenopause
•Lowin:pituitaryfailure
2)Estrogen:
*Highin:pregnancyandfunctioningovariancyst
*Lowin:primaryovarianfailure,menopause,virilizingovariantumoursand
Cushing'ssyndrome
3)17ketosteroids,17OHprogesterone&DHEAS:highinadrenogenital
syndromeadrenalhyperplasiaandadrenaltumours
C-Radiological:-X-raychest(T.B) -X-rayskull -HSG
-C.T&MRI -Ultrasonography(TA&TVS)
D-Endoscopic:hysteroscopy,laparoscopy&ovarianbiopsy

43. Work up of secondary amenorrhea

44. Treatment of secondary amenorrhea:treat the cause
1-Asherman’s syndrome:
Hysteroscopic resection with scissors or electrocautery
Pediatric Foley catheter placed in uterine cavity for 7-10
days
Systemic B. spectrum antibiotic and 2 month course of
high dose estrogen with monthly progesterone
withdrawal to prevent reformation of adhesions.
2-Ovarian failure:
-Estrogen replacement
-Gonadectomy when y cell line is present

45. Treatment of secondary amenorrhea:
3-Hypothalamo-pituitary lesions and dysfunctions:
CNStumours:surgicalremoval,radiationtherapyorcombinationofboth
forCNStumoursotherthanprolactinomas
Thyroiddisorders:thyroidhormone,radioactiveiodineorantithyroiddrugs
Hyperprolactinemia:
-Discontinuemedicationsleadingtohyperprolactinemia.
-Bromocriptine -Rarely,surgeryforlargepit.tumours
Panhypopititirism:variousreplacementregimens
-Estrogenreplacementtherapyforlackofgonadotropins
-CorticosteroidreplacementforlackofACTH
-ThyroidhormoneforlackofTSH
-Syntheticvasopressin

46. 3-Hypothalamo-pituitary lesions and
dysfunctions (cont.):
Hormonallyactiveovariantumorssurgicalremoval
Obesity,malnutrition,chronicdisease,Cushing'ssyndrome,
acromegaly:shouldbetreated
Pseudocyesisandstressinducedamenorrhea
psychotherapy
Exercise-inducedamenorrheamoderationofactivity
andweightgainwhereappropriate
Anorexianervosamultipleapproach,severecases
requirehospitalization
ChronicanovulationorPCOsyndrome:differaccordingto
whetherpregnancyisdesiredornot
Congenitaladrenalhyperplasia:Dexamethazone0.5mgat
bedtime.