OG 25.1 Secondary amenorrhoea - final yearpptx

Undergraduate class

1. Secondary Amenorrhoea

2. Definition Absence of menstruation for 6 months or more in reproductive age group following normal menstruation

3. Clinical problem More common Less serious effects on reproductive system Avoid confusion with OLIGOMENORRHOEA R/o pregnancy & lactation

4. Etiology - Hypothalamus Weight change: anorexia nervosa, vigorous exercise, stress-anxiety states Drugs: phenothiazines, morphine, methyl dopa, reserpine, anti-histamines Hyperprolactinemia: amenorrhoea-galactorrhoea

5. Intracranial supra-sellar tumors: craniopharyngioma, gliomas, secondary malignancy Head injury/trauma Brain irradiation

6. Pituitary Tumors- prolactinomas, mixed tumors, Necrosis- Sheehan’s Syndrome Empty-sella Syndrome Lymphocytic adeno-hypophysitis Carotid artery aneurysm

7. Ovary Premature ovarian failure Auto-immune Resistant ovary Syndrome Infiltrative metabolic disease - galactosemia Radiotherapy Chemotherapy Turner mosaics Functional ovarian tumors - virilising variety

8. Uterus Asherman’s Syndrome Tuberculous endometritis Hysterectomy

9. General Hypothyroidism/hyperthyroidism Chronic renal failure Chronic liver disease Virilising adrenocortical tumors

10. Check list - Symptoms R/O PREGNANCY & LACTATION H/o contraception Weight change, change in diet, vigorous exercise, stress-anxiety states Visual disturbances, anosmia, galactorrhoea Drugs – phenothiazines H/o PPH, failed lactation

11. Symptoms - Contd H/o curettage H/o RT, CT Hirsutism, change in voice TB, Thyroid, Renal & Liver disease Hot-flushes, dryness of vagina Family h/o premature menopause

12. Signs Psychological status Weight, nutritional status Visual fields, fundoscopy expressible galactorrhoea Hypo/hyperthyroidism, acromegaly, Cushing’s disease Features of Turner’s

13. Signs - Contd Acne/hirsutism Vaginal examination; clitoromegaly atrophy of vulva/ vagina uterine size ovarian tumors

14. Investigations in secondary amenorrhoea R/o pregnancy Estimate TSH, Prolactin X-ray Skull for pituitary tumours If normal, proceed to HPO evaluation

15. Step 1- Progesterone challenge test Causes withdrawal bleeding if endometrium is estrogen primed Bleeding + PCOS Bleeding - Loss of progesterone receptor or diseased endometrium

16. Step 2- Estrogen + Progesterone challenge test Causes bleeding if functional endometrium is present Bleeding + Low endogenous E2 levels Bleeding - non-functional endometrium like tuberculosis, repeated curettage

17. Step 3 - Serum FSH/LH levels High levels Ovarian failure or resistant ovaries Low levels Hypothalamic or Pituitary failure

18. Step 4 – GnRH dynamic test Positive response Hypothalamic failure Negative response Pituitary failure

19. Aim of management Detect & treat any condition which threatens life Re-initiate cyclic events in HPO axis – restore menstruation, improve reproductive potential

20. MANAGEMENT Medical Surgical

21. Medical Management of weight loss & stress-states Thyroid disorders DM/Liver disease/Renal failure Premature menopause-HRT Sheehan’s Syndrome – replace hormones

22. Medical PCOS: OC pills Dexamethasone Insulin sensitisers Anti-androgens Ovulation induction in infertile patient

23. Hyperprolactinemia Dopamine agonists – Bromocriptine 2.5mg/day Cabergoline – 0.25mg twice weekly Discontinue drugs like phenothiazines Treat hypothyroidism

24. Surgical Surgery for Intracranial pathology PCOS : ovarian drilling/puncture Virilising tumors – surgical resection Asherman’s Syndrome: Hysteroscopic adhesiolysis IUCD/Foley’s catheter Post-op dexamethasone Cyclical oral E+P for 3 months

25. TAKE HOME MESSAGE In primary amenorrhoea, more investigations are needed to find the cause with minimal effect In secondary amenorrhoea, with fewer investigations, satisfactory results can be achieved.

26. Thank U