AMENORRHEA.pptx Reproductive health medicine

Amenorrhea, causes, differentials, treatment, laboratory findings, imaging.

1. AMENORRHEA

2. Introduction. Menstruation is a sign of female endocrine and reproductive tract maturation. Prerequisites Intact HPO axis, Endometrium that respond to steroid hormones and intact outflow tract. Prolonged or persistent absence of menses may be a sign of neuroendocrine or anatomic abnormality.

3. Amenorrhea Definition Literally defined as the absence of menses. It is a symptom not a disease. Clinical types Physiological Pathological

4. Physiological amenorrhea Prepuberty Pituitary gonadotrophins insufficient for effective steroidogenesis. During pregnancy Large amounts of estrogens and chorionic gonadotrophins suppress the pituitary gonadotrophins. Ovarian follicles do not undergo maturation.

5. During lactation High levels of prolactin inhibits ovarian response to FSH. No follicular growth Hypoestrogenic state thus no menstruation. Menopause Lack of responsive follicles. Estrogen levels fall and pituitary gonadotrophins are elevated.

6. Pathological amenorrhea 1. Concealed Amenorrhea Congenital Imperforate hymen Transverse vaginal septum Acquired Cervical stenosis Secondary vaginal atresia following difficult vaginal delivery

7. 2. True Amenorrhea Primary Amenorrhea Secondary amenorrhea

8. Concealed Amenorrhea There is periodic shedding of the endometrium and bleeding but the menstrual blood fails to come out of the genital tract due to outflow obstruction. Causes Congenital Imperforate hymen- commonest cause of concealed amenorrhea Transverse vaginal septum

9. Acquired Cervical stenosis Secondary vaginal atresia following difficult vaginal delivery

10. Pathology Accumulation of blood in the uterine cavity resulting in haematometra. Haematocolpos – Accumulation of blood in the vaginal cavity. Haematosalpinx - Accumulation of blood in the fallopian tubes

11. Clinical features Cyclic lower abdominal pain Amenorrhea dated back to the event. P/A - Uniform globular mass in the hypogastrium . Pelvic examination reveals the offending lesion. Bulging hymen in imperforate hymen Pelvic u/s- Enlarged uterus ;Haematometra, haematocolpos

12. Treatment Imperforate hymen Cruciate incision of the hymen and drainage of blood. Cervical stenosis Dilatation of the cervix

13. TRUE AMENORRHEA Primary Amenorrhea Secondary Amenorrhea. Primary Amenorrhea Absence of menses by age 13 years in the absence of normal growth or secondary sexual development. Absence of menses by age 15 years in the setting of normal growth and secondary sexual characteristics.

14. Evaluation should begin by age 15 years when 97% of girls should have experienced menarche. Secondary Amenorrhea : Absence of menses for more than 6 consecutive months in a previously menstruating woman.

15. Primary amenorrhea Causes. Developmental defects Imperforate hymen Transverse vaginal septum Congenital absence of uterus Abnormal chromosomal patterns Testicular feminization Vaginal agenesis

16. Systemic illness Tuberculosis Malnutrition Anemia Endocrine disorders Diabetes Thyroid dysfunction ( hypothyroidism)

17. Uterine synechiae. Defects in H.P.O. axis

18. Investigations FBC + ESR TFTS RBS FSH, LH Karyotype Pelvic us HSG- Honey comb appearance in uterine synechiae. Laparoscopy

19. Management Success is limited in management of primary amenorrhea Vaginal agenesis- Vaginal reconstruction Systemic and endocrine disorders- Treat respective illness eg TB, DM, Hypothyroidism Uterine synechiae- Adhesiolysis and iucd insertion

20. Secondary Amenorrhea Common causes of secondary Hypothalamus Stress Contraceptives eg depo provera, jadelle . Pituitary Adenoma( prolactinoma ) Sheehans syndrome

21. Ovary Polycystic ovarian syndrome Premature ovarian failure Uterine TB Endometritis Post radiation Uterine synechiae Post hysterectomy

22. Systemic diseases Malnutrition Hypothyroidism Diabetes.

23. Treatment Anxiety and stress Reassurance and stress management Systemic illness Manage illness PCOD COCS Ovulation induction Laporoscopic ovarian drilling

24. Pituitary adenoma Bromocriptine Surgical removal. Hypothyroid state Thyroxine therapy Uterine synechiae Adhesiolysis and iucd insertion.

25. End