Primary Amenorrhea

Easy powerpoint presentation for undergraduates

1. Primary amenorrhea DR ANITA RAMESH MD,OBGY

2. DEFINITION Amenorrhea means absence of menstruation TYPES Physiological amenorrhea Pathological amenorrhea Primary amenorrhea Secondary amenorrhea

3. PRIMARY AMENORRHEA Absence of menses by the age of 14 years with no secondary sexual characters 0R Absence of menses by the age of 16 years irrespective of development of secondary sexual characters

4. SECONDARY AMENORRHEA Absence of menses for 6 months or absence of atleast 3 of the previous 3 cycles

5. INCIDENCE OF PATHOLOGICAL AMENORRHEA 3% to 4% About 10% to 20% of those with infertility have amenorrhea

6. EVENTS CAUSING PUBERTY & MAINTAINENCE OF REGULAR MENSES Normal chromosomal pattern Co ordinated HPO axis Anatomical presence & patency of outflow tract Responsive endometrium Active thyroid & adrenal glands

7. PHYSIOLOGICAL AMENORRHEA Before puberty Pregnancy Lactation menopause

8. CRYTOMENORRHEA PATHOPHSIOLOGY

9. Usg image of haematocolpos

10. SYMPTOMS OF CRPTOMENORRHEA Amenorrhea Periodic pain in the lower abdomen Abdominal lump Retention of urine

11. TREATMENT OF CRYPTOMENORRHEA Imperforate hymen:cruciate incision over bulging hymen Cervical stenosis:cervical dilatation Transverse vaginal septum:excision of septum

12. Primary amenorrhea Hypergonadotropic hypogonadism (43%) Developmental defects of genital tract(30%) Hyogonatotropic hypogonadism (27%) Abnormal chromosomal pattern Dysfunction of thyroid or adrenal gland( adrenogenital syndrome,cretinism ) Metabolic disorders(juvenile diabetes) Systemic illnesses( malnutition,TB,weight loss,anaemia ) Unresponsive endometrium:uterine synchiae due to TB

13. Hypergonadotropic hypogonadism Primary ovarian failure Resistant ovarian syndrome Galactosemia Enzyme deficiency:17 alpa hydroxylase deficiency

14. Developmental defects of genital tract Mullerian agenesis or dysgenesis Imperforate hymen Transverse vaginal septum Atresia of upper third of vagina & cervix Complete absence of vagina Absence of uterus(MRKH)

15. HYPOGONADOTROPIC HYPOGONADISM C onstitutional delay:delayed GnRH pulse activation HPO AXIS DYSFUNCTION:stress,weight loss,excessive exercise,chronic disease(TB),anorexia nervosa Kallmans disease(inadequate GnRH pulse secretion CNS TUMOURS:craniophayngioma (reduced Gnrh RELEASE

16. Abnormal chromosomal pattern Turner”s syndrome(45X or various mosaics) Pure gonadal dysgenesis (46XX…phenotypically female with streak gonads) Androgen insensitivity syndrome(testicular feministion syndrome…46XY) Partial deletions of X chromosome

17. Investigations in a pt of primary amenorrhea with n sec sexual characters

18. Investigations in a pt with absent or poorly dev sec sexual characters

19. Management in primarary amenorrhea DEVELOPMENTAL ANOMALIES ABSENT VAGINA:Vaginoplasty before marriage CHROMOSOMAL ABNORMALITIES Turner”s syndrome:short course of E+P for breast development XY Gonadal dysgenesis:gonads to be removed for preventing seminoma or dysgerminoma

20. Androgen insensitivity syndrome:Reared as female only & removal of gonads.HRT with CEE 0.625 mg continued for maintainence of secondary sexual characters HPO Axis defect: Constitutional delay:reassure patient or can be induced using E+P Kallman”s syndrome:periods induced with pulsatile GnRH administration HP tumours like craniopharyngioma needs excision or radiotheraphy

21. Thyroid & adrenal dysfunction: Cretinism:thyroid replacement theraphy A drenogenital syndrome with enlarged clitoris needs clitoroplasty & corticosteriods for prolonged theraphy 17 alpha hydroxylase deficiency:corticosteroid replacement theraphy Prolactinomas:dopamine agonists

22. Metabolic & nutritional Diabetes:antidiabetics TB:Anti TB drugs Correction of weight loss Reduction of stress Unresponsive endometrium due to TB Anti TB drugs,adhesiolysis & high dose E+P

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