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Secondaryamenorrhoealectures 230316163724 360b79b3
Secondaryamenorrhoealectures 230316163724 360b79b3
Secondaryamenorrhoealectures 230316163724 360b79b3
AMENORRHEA
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Dr Parul Sinha
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AMENORRHEA
PHYSIOLOGIAL PATHOLOGIAL
AMENORRHEA AMENORRHEA
CONTROL OF MENSTRUAL CYCLE
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HYPOTHALAMUS
PITUITARY
ENDOCRINE
OVARIAN
OUTFLOW TRACT
AXIS
CLASSIFICATION OF AMENORRHEA
AMENORRHEA
PHYSIOLOGICAL PATHOLOGICAL
Pre-puberty Primary
Pregnancy related
Menopause Secondary
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AMENORRHEA
PATHOLOGICAL AMENORRHEA
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Secondary amenorrhea is the absence of menstrual
periods for 6 months in a woman who had
previously been regular.
Secondary Amenorrhea
- Physiological -
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The most common cause of secondary
amenorrhea in reproductive age women is
pregnancy and this should always be
excluded by physical exam and laboratory
testing for the pregnancy hormone - HCG.
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Secondary Amenorrhea
- ETIOLOGY -
ENDOCRINE HYPOTHALAMUS-PITUITARY
Pituitary tumour
Hypothyroidism Sheehan’s
Cushing’s syndrome
Adrenal tumour Hypothalamic
Ovarian tumour dysfunction
(androgen)
Uterine disease – 5%
Other – 1%
Secondary Amenorrhea/Oligomenorrhea:
z Etiology
Pregnancy
Thyroid disease
Hyperprolactinemia
Prolactinoma
Breastfeeding, Breast stimulation
Medication (i.e. Antipsychotics, Antidepressants)
Hypergonadotropic hypogonadism
Postmenopausal ovarian failure
Premature ovarian failure
Hypogonadotropic hypogonadism
Functional hypothalamic amenorrhea (i.e. Anorexia or Bulimia nervosa)
CNS tumor (i.e. Craniopharyngioma)
Sheehan’s syndrome
Chronic illness
Normogonadotropic
Outflow tract obstruction (i.e. Asherman’s syndrome, Cervical stenosis)
Hyperandrogenic anovulation (i.e. PCOS, Cushing’s disease, CAH)
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Secondary Amenorrhea
- ETIOLOGY -
HYPOTHALAMIC CAUSES
Commonest example:
1). Hysterectomy
2). Endometrial ablation
3). Asherman’s syndrome (damage to
the endometrium with adhesion formation)
4). Stenosis of the cervix following
cone biopsy
1-Uterine defect
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Asherman`s syndrome
This is intrauterine synechiae
- ETIOLOGY -
PREMATURE OVARIAN FAILURE
Premature ovarian failure occurs in
about 1% before
the age of 40.
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HISTORY
EXAMINATION
INVESTIGATIONS
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ASSESSMENT
History
- HISTORY -
ASK ABOUT
Menstrual cycle age of menarche and previous menstrual
history
Previous pregnancies - severe PPH (Sheehan’s syndrome)
Weight change A large amount of weight loss (anorexia
nervosa)
Hot flashes , decreased libido premature menopause
Certain medications
Contraception
Associate symptoms - Cushing's disease , hypothyroidism
- EXAMINATION -
CHECK FOR
BODY MASS INDEX (BMI) weight loss-related amenorrhea
- INVESTIGATIONS -
- INVESTIGATIONS -
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The most common cause of secondary
amenorrhea in reproductive age women is
pregnancy and this should always be
excluded by physical exam and laboratory
testing for the pregnancy hormone - HCG.
z INVESTIGATING
SECONDARY AMENORRHEA
Once pregnancy has been excluded
FSH, LH
Prolactin level
Secondary Amenorrhea/Oligomenorrhea:
z Evaluation
Progestin challenge test
Medroxyprogesterone acetate 10 mg daily for 10 days
IF withdrawal bleed occurs – Not outflow tract obstruction
IF no withdrawal bleed occurs – Estrogen/Progestin
challenge test
Hysterosalpingogram or Hysteroscopy to
evaluate endometrial cavity
INVESTIGATING SECONDAY AMENORRHEA
NEGATIVE PREGNANCY TEST
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WITHDRAWAL NO WITHDRAWAL
BLEEDING BLEEDING
HYPOESTROGENIC COMPROMISED
ANOVULATION OUTFLOW TRACT
Positive E-P
FSH normal + high LH PCOS challenge test Negative E-P
High prolactin pituitary tumour challenge test
Very high FSH
Normal or Low Normal FSH
FSH
Ovarian
Asherman’s syndrome
Hypothalamic-pituitary Failure
failure (HSG or hysteroscopy)
Secondary Amenorrhea/Oligomenorrhea:
z Evaluation
Evaluation of hyperandrogenism
Symptoms: hirsutism, acne, alopecia,
masculinization, and virilization
Differential diagnosis:
Adrenal disorders: Atypical congenital adrenal
hyperplasia (CAH), Cushing’s syndrome,
Adrenal neoplasm
Hormone Level Indication
Ovarian disorders: PCOS, Ovarian neoplasms
Testosterone < 200 ng/dL PCOS
Lab: Testosterone, DHEA-S,
> 200 ng/dL Evaluate 17α- or ovarian tumor
for adrenal
DHEA-S hydroxyprogesterone
< 700 ng/dL PCOS
> 700 ng/dL Evaluate for adrenal or ovarian tumor
17α-hydroxyprogesterone > 4 ng/mL Consider ACTH stimulation test to diagnose CAH
SECONADARY AMENORRHEA
Ovarian failure
(premature menopause)
chromosomal
autoimmune
anomalies
disease
Hypothalamic-pituitary
failure
Underlying causes
NEED CONTRACEPTION
Confirmed ovarian failure will not required contraception
Diagnosis Management
Ovarian insufficiency Hormone replacement therapy (HRT)
Premature ovarian failure
Postmenopausal ovarian failure
*Congenital anatomic lesions Surgical correction
*Presence of Y chromosome (i.e. AIS) Gonadectomy
*Gonadal dysgenesis (i.e. Turner syndrome) Estrogen + progestin, growth hormone
IVF (IF pregnancy desired)
Hyperprolactinemia Dopamine agonist (Bromocriptine, Cabergoline)
Functional hypothalamic amenorrhea Increase caloric intake > energy expenditure
Hypothalamic or pituitary dysfunction OCP’s, pulsatile GnRH or exogenous gonadotropins
(non-reversible)
CNS tumor Surgical resection
Craniopharyngioma Microadenoma (< 10mm) – Dopamine agonist
Prolactinoma Macroadenoma (>10mm) – Trans-sphenoidal resection