Amenorrhoea

AMENORRHOEA

1. 1 BY DR.AKINBI OLUBAYODE.O AMENORRHOEA

2. INTRODUCTION 2 Proper function of the Hypothalamic-Pituitary ovarian system is required for normal menstruation.( GnRH -LH/FSH-EST./PROG). Regular and predictable menstrual cycles occur if the ovarian hormones estradiol and progesterone are secreted in an orderly fashion in response to stimulation by the hypothalamus and pituitary. The occurrence of menstruation also requires healthy and intact outflow tract AMENORRHOEA occurs if the above are not met

3. DEFINATION 3 Amenorrhoea, derived from the Greek words men (month) and rein (to flow), denotes the absence or suppression of menstruation. Amenorrhoea is a symptom, not a disease, and it has a variety of causes. Traditionally, amenorrhoea is classified as primary or secondary. PRIMARY AMENORRHOEA is defined as the absence of menstruation by the age of 14 years in the absence of 2 sexual characteristics, or the absence of menstruation by 16 years. The median age of menarche is 10-15 years and weight 51.1kg.

4. DEFINATION CTD 4 SECONDARY AMENORRHOEA is defined as secondary when no menses have occurred for 6 months in a woman who previously had normal menstrual function, or for 12 months if her cycles were irregular. OTHER TERMS: 1. OLIGOMENORRHOEA (INT.>35DAYS 2. HYPOMENORRHOEA (SCANTY VOLUME& SHORT DURATION OF FLOW 3. POLYMENORRHOEA (INT.<21DAYS) 4. HYPERMENORRHOEA (PROLONGD FOR >10DYS)

5. PATHOPHYSIOLOGY 5 The menstrual cycle is an orderly progression of coordinated hormonal events in the female body that stimulates growth of a follicle to release an egg and prepare a site for implantation if fertilization should occur. Menstruation occurs when an egg released by the ovary remains unfertilized. The menstrual cycle can be divided into 3 physiologic phases: follicular, ovulatory, and luteal. Each phase has a distinct hormonal secretory milieu. Consideration of the target organs of these reproductive hormones (hypothalamus, pituitary, ovary, uterus) is helpful for identifying the disease process responsible for a patient’s amenorrhea.

6. 6 Fig. 1.0

7. ETIOLOGY 7 PHYSIOLOGICAL AMENORRHOEA: Puberty (in young girls), Pregnancy(in women of reproductive age groups), Post menopause (in elderly women) HYPOTHALAMIC DISORDER Eating disorder ( a minimum of 17% body fat is required for the onset of menarche and 22% body fat for maintenance or resumption of normal menstrual function Exercise induced amenorrhea ( 6% to 18% of women who are recreational runners) Medication Stress Chronic illness Kallmanns syndrome

8. 8 3. PITUITARY DISORDER Hyperprolactinaemia (10–40 % of women with hyperprolactinaemia present to their physician with amenorrhea). Prolactinoma Isolated gonadotrophin deficiency Craniopharyngioma (They are epithelial tumors arising from the craniopharyngeal duct in the sellar or parasellar region).

9. 9 THYROID DISORDER Hypothyroidism Hyperthyroidism ADRENAL DISORDER Congenital adrenal hyperplasia Cushing syndrome VAGINAL ANOMALY Imperforate hymen Transverse vaginal septum Vaginal agenesis

10. 10 UTERINE ANOMALY Androgen insensitivity Mullerian agenesis (The syndrome, often referred to as Mayer – Rokitansky – Kuster –Hauser syndrome, is the second most common cause of primary amenorrhea). Uterine adhesion ( Asherman syndrome is the presence of intrauterine synechiae or scarring preventing normal growth of endometrium, typically from a previous infection, endometrium curettage or endometritis ). Cervical agenesis

11. 11 OVARIAN DISORDER Gonadal dysgenesis (Turner's syndrome 45XO) Ovarian insufficiency or premature ovarian failure (Onset of menopause before 40 years). Chemotherapy or radiation injury Ovarian insensitivity syndrome (Savage's syndrome) Polycystic ovarian syndrome

12. 12 Polycystic ovarian syndrome PCOS is a syndrome of ovarian dysfunction along with the cardinal features of hyperandrogenism and polycystic ovary morphology Its clinical manifestation include menstrual irregularities,signs of androgen excess and obesity They are oligo -ovulatory or anovulatory and have oligomenorrhea or amenorrhea. In typical cases, the ovaries are enlarged, with white, thickened capsules beneath which are multiple cystic follicles in various developmental stages. High incidence of related Hyperprolactinemia . Serum LH levels are chronically elevated:LH;FSH INCREASES TO 2:OR 3:1 The constant, tonic LH stimulation of the ovaries results in abnormal follicular stimulation—hence the polycystic appearance

13. CLINICAL EVALUATION OF THE AMENORRHOEIC PATIENT 13 HISTORY TAKING PHYSICAL EXAMINATION INVESTIGATIONS TREATMENT

14. HISTORY 14 Pregnancy is the most common cause of amenorrhea. Ask about sexual activity Use of contraceptive methods Difficulty with dates; menstrual calendar X 3 months. Absence of breast development or pubertal growth 14 years is abnormal.& requires investigation. Breast development, pubertal growth spurt, and adrenarche are delayed or absent in persons with hypothalamic pituitary failure.

15. 15 Normal growth and pubertal development plus primary amenorrhea may suggests: Imperforate Hymen(cyclical abd.pain+heamatocolpos ) Rokitansky Syndrome( lap.shows rudimentary uterus) Test.Feminisation syndrome(blind end vaginal, absent uterus, XY KARYOTYPE History of evacuation, post abortal infection, post partum endometritis , major myomectomy, endometrial procedures may suggest Asherman

16. OVARIAN DISORDER 16 Symptoms of vaginal dryness, hot flashes, night sweats, or disordered sleep may be a sign of ovarian insufficiency or premature ovarian failure. History of chemotherapy or radiation Hormonal contraceptives use in recent times Recent surgery . e.g TATH+BSO Sometimes no clear cut symptom or sign

17. HYPOTHALAMIC DISORDER 17 Intracranial tumor ; galactorrhea , headaches, or ↓↓peripheral vision Impaired sense of smell +primary amenorrhea& failure of normal pubertal development = Kallmann syndrome Dieting with excessive restriction of energy intake, especially fat restriction, may lead to loss of menstrual regularity and associated bone loss.

18. 18 Strenuous exercise related to a wide variety of athletic activities can be associated with the development of amenorrhea. Abuse of drugs such as cocaine and opioids have central effects that may disrupt the menstrual cycle. Anorexia nervosa;intense fear of fatness and a body image that is heavier than observed .

19. EXAMINATION 19 GENERAL EXAMINATION. SECONDARY SEXUAL CHARACTERISTICS. EXAMINATION OF THE EYE-VISUAL FIELD. ABDOMINAL EXAMINATION. PELVIC EXAMINATION

20. INVESTIGATION 20 Pregnancy test. Ultrasound, CT, MRI. Hormonal assay- LH, FSH, prolactin and androgens Thyroid function tests. Karyotype. Autoimmune screen

21. TREATMENT 21 Depends on the cause of amenorrhoea. The most common cause of primary amenorrhoea is constitutional delay. MEDICAL. SURGICAL

22. 22 MEDICAL THERAPY: Dopamine agonists e.g Bromocriptine for treatment of Hyper.PRL (build the dose up to 2.5mg tds ) Hormone replacement therapy; In cases of Estrogen deficiency( estrogen + 10-14 days of medroxyprogesterone ) Ovulation Induction in those desiring pregnancy: clomiphene, FSH/LH combination, GnRH analogue. Treatment of Hyperandrogenism (5α- reductase inhibitors e.g spironolactone, cyproterone acetate, Finasteride ) cocp+depo provera : rx of hirsuitism

23. 23 SURGICAL THERAPIES: GONADECTOMY; XY DYSGENESIS TUMOR EXCISION FOR LARGE ADENOMAS RECONSTRUCTIVE SX:VAGINOPLASTY, PROGRESSIVE VAGINAL. DILATATION ADHESIOLYSIS(HYSTEROSCOPY, MANUAL SHARP DISSECTION)+FOLEYS CATHETER OR LIPPES LOOP OVARIAN DIATHERMY:4-POINT DIATHERMY AT 40W FOR 4SEC. IVF : FOR TURNERS&OTHER GONADAL DYSGENETIC CASES ELECTROLYSIS RX.FOR HIRSUITISM WEIGHT REDUCTION ORAL CONTRACEPTIVES,OVULATION INDUCTION FOR PCOS

24. 24 THANK YOU