Aboubakr Elnashar

1. Amenorrhoea
Prof.
Aboubakr
Elnashar
Benha
university
hospital,
Egypt
elnashar53@hotmail.com
Aboubakr
Elnashar
CONTENTS
1.
INTRODUCTION
2.
CLASSIFICATIONS
3.
CAUSES
4.
DIAGNOSIS
5.
TREATMENT
5
Aboubakr
Elnashar

2. Sequence
Of
Menstruation
CNS
IV.
Hypothalamus

GnRh

III.
Ant.
Pituitary
FSH
+
LH

II.
Ovary

E
+
P

I.
Uterus
&
outflow
tract
V.
Others
Aboubakr
Elnashar
2.
CLASSIFICATIONS
•
According
to
the
onset:
•
Primary
amenorrhea.
•
Secondary
amenorrhea.
•
According
to
the
cause:
•
Physiological.
•
Pathological
•
According
to
Hidden
or
apparent:
•
False
amenorrhea
(Crypto
menorrhea).
•
True
amenorrhea.
•
According
to
level
of
LH/FSH
•
Hypogonadptophic
•
Eugonadotrophic
•
Hypergonadotophic
•
These
are
complementary
to
each
other
Aboubakr
Elnashar

3. ▪
Primary:
▪
Lack
of
menstruation
by
age
▪
16
in
the
presence
of
2ndry
"
sexual
characteristics
or
▪
14
in
their
absence.
▪2ndary:
▪
Absence
of
menstruation
for
a
time
equivalent
to
a
total
of
3
previous
cycles
or
6
months.
±:
diagnostic
error
&
should
be
avoided.
Aboubakr
Elnashar
Primary
Amenorrhoea
Aboubakr
Elnashar

4. 2ndry
Amenorrhoea
Aboubakr
Elnashar
▪
The
commonest
causes
Primary
Amenorrhoea
▪
Turner’s
syndrome
▪
Abscent
vagina
▪
Gn
deficiency
▪
Constitutional
delay
Secondary
Amenorrhoea
▪
Pregnancy
▪
PCOS
▪
Hyperprolactinemia
▪
POI
Aboubakr
Elnashar

5. 3.
CAUSES
I.
Physiological
causes
•Pregnancy:
must
always
be
excluded.
•Lactation.
•Menopause.
II.
Iatrogenic
causes
•Progestagenic
contraceptives:
Depo-Provera",
Mirena
IUS*,
Nexplanon*,
POP.
•Therapeutic
progestagens
•Continuous
COCP
use
•GnRH
analogues
Aboubakr
Elnashar
Physiologic
causes
Aboubakr
Elnashar

6. Compartment
II:
Disorders
of
the
Ovary
Compartment
I:
Disorders
of
the
Outflow
Tract
Compartment
IV:
Hypothalamic
Disorders
Compartment
III:
Disorders
of
the
Anterior
Pituitary
Eugonadism
Hypogonadotropic
hypogonadism
Hypogonadotropic
hypogonadism
Hypergonadotropic
hypogonadism
Normogonadotropic
Hypogonadism(PCOD)
Aboubakr
Elnashar
▪
Pathological
causes
I.
Anatomic:
Genital
tract
outflow
obstruction:
▪Congenital
1.
Imperforate
hymen
2.
Transverse
vaginal
septum
3.
Cervical
stenosis
4.
Agenesis
of
uterus
&
mulerian
duct
structures:
sporadic
or
associated
with
AIS.
▪Acquired
1.
Asherman's
syndrome
(intrauterine
adhesions).
2.
TB
3.
Surgery
II.
Hormonal/Endocrinologic
1.
Hpogonadotropic
2.
Normogonadotropic
3.
Hypergonadotropic
Aboubakr
Elnashar

7. Speroff
et
al,
2020
Aboubakr
Elnashar
❑Imperforate
hymen
▪
Complaint
1.
Cyclic
abd.
pain
▪
for
almost
a
year
with
lack
of
menses
▪
colicky
in
nature
2.
Vomiting
3.
Urine
retention
4.
Severe
back
pain
5.
Swelling
of
the
lower
abdomen
Aboubakr
Elnashar

8. ▪
Local
ex.
▪
Bluish
bulging
imperforate
hymen
▪
At
the
proper
examining
position
▪
U/S
examination
▪
Cystic
pelvic
mass
extending
to
the
abdomen.
▪
Tender
during
examination
▪
Trans
perineal
U/S
with
trans
rectal
U/S
confirm
the
thickness
of
the
Hymen
and
the
diagnosis.
Aboubakr
Elnashar
❑
Androgen
Insensitivity
Syndrome
▪Axillary&pubic
hair
do
not
develop
or
spare
▪{resistance
to
testosterone}.
▪46
XY
❑
Asherman
Syndrome
Aboubakr
Elnashar

9. II.
Hormonal
Aboubakr
Elnashar
I.
Aboubakr
Elnashar

10. Aboubakr
Elnashar
MRI:
pituitary
macroadenoma
(classic
"snowman"
appearance
of
the
bi-lobed
pituitary
MRI:
pituitary
microadenoma
(arrows).Coronal
image.
Aboubakr
Elnashar

11. II.
Aboubakr
Elnashar
•
NI
(1990)
▪
Chronic
anovulation.
▪
Cl
and/or
biochemical
hyperandrogenism.
Rotterdam
(2003)
2
out
of
3
▪
Ch
anovulation.
▪
Cl
and/or
biochemical
hyperandrogenism.
▪
PCO
on
US
AES
(2006)
AE-PCOS(2009)
▪
Cl
and/or
biochemical
hyperandrogenism.
▪
Ovarian
dysfunction
(anovulation
and/or
PCO)
▪
Exclusion
of
related
ovulatory
or
other
androgen
excess
disorders
(e.g.,
thyroid
dysfunction,
hyperprolactinemia,
androgen-secreting
neoplasms,
or
non
classic
adrenal
hyperplasia)
8%
18%
12%
Prevalence
of
PCOS
Aboubakr
Elnashar

12. Aboubakr
Elnashar
❑
Late
onset
congenital
adrenal
hyperplasia
HLA
Manifestations
Incidence
Subtype
BW
14
Amenorrhea,
Hirsutism
+++
Late-onset
BW
51
Virilization
++
Simple
virilizing
BW
47
Virilization,
Salt
loss
+
Salt-loosing
Aboubakr
Elnashar

13. Centripetal
obesity
79-97
Facial
plethora
50-94
Glucose
intolerance
39-90
Weakness,
proximal
myopathy
29-90
Hypertension
74-87
Psychological
changes
31-86
Easy
bruisability
23-84
Hirsutism
64-81
Oligomenorrhea
or
amenorrhea
55-80
Acne,
oily
skin
26-80
Abdominal
striae
51-71
Ankle
edema
28-60
Backache,
vertebral
collapse,
fracture
rare
Clinical
manifestations
%
❑
Cushing
syndrome
Aboubakr
Elnashar
❑
Crushing’s
Syndrome
Aboubakr
Elnashar

14. III.
Aboubakr
Elnashar
❑
Turner
syndrome
Turner’s
stigmata
▪
Sexual
infantilism
▪
Short
stature
▪
Webbed
neck
▪
Spaced
nipples
▪
Cubitus
valgus
▪
Shield
chest
▪
Pigmented
nevi
▪
Coarctation
of
aorta
▪
Renal
anomaly
▪
Streak
gonads
Turner’s
Karyotype
XO
XO/XX
XXp-
XXr
Aboubakr
Elnashar

15. Aboubakr
Elnashar
Turner's
S.
Aboubakr
Elnashar

16. Mosaic
(46-XX
/
45-XO)
(Classic
45-XO)
Turner’s
syndrome
Aboubakr
Elnashar
4.
DIAGNOSIS
I.
History
▪Present
1.
Sexual
activity,
risk
of
pregnancy
2.
Type
of
contraceptive
used.
3.
Galactorrhoea
4.
Androgenic
symptoms:
weight
gain,
acne,
hirsutism
5.
Menopausal
symptoms:
night
sweats,
hot
flushes
6.
Issues
with
eating
or
excessive
exercise.
▪Past
1.
Drug
use:
dopamine
antagonists
2.
Genital
tract
surgery:
intrauterine
instrumentation
Aboubakr
Elnashar

17. II.
Examination
▪General:
1.
BMI
<17/>30
2.
Hirsutism
3.
Stigmata
of
endocrinopathies:
thyroid
Turner's
syndrome.
4.
Evidence
of
virilization:
deep
voice,
male
pattern,
balding,
cliteromegaly
5.
2°
sexual
characteristics
(Tanner
staging).
Aboubakr
Elnashar
▪
Abdominal:
▪
Masses
due
to
tumours
▪
Genital
tract
obstruction.
▪
Pelvic
1.
Imperforate
hymen
2.
Blind
ending
vaginal
septum
3.
Absence
of
cervix
and
uterus.
Aboubakr
Elnashar

18. ▪
Progestin
challenge
test:
▪
(MPA
5mgX5d
or
P
in
oil
100
mg
/3d
X
3)
▪
+ve:
Anovulation
▪
-ve:
E
+
P:
▪
-ve:
outflow
or
uterine
failure
→
HSG,
hysteroscopy,
IVP
&
laparoscopy.
▪
+ve:
Ovarian
failure
or
pituitary-hypothalamic
dysfunction.
Aboubakr
Elnashar
Progesterone
challenge
test
Bleeding
No
bleeding
Chronic
anovulation
e.g
PCOS
Combined
oestrogen
&
progesterone
Bleeding
No
bleeding
Ovarian
failure
Serum
FSH
Primary
Secondary
Uterine
factor
Aboubakr
Elnashar

19. ▪
limitations.
1.
Women
with
high
androgen
levels,
(such
as
occurs
with
PCOS
and
CAH,)
may
have
an
atrophic
endometrium
and
may
fail
to
bleed.
Specifically,
up
to
20%
of
women
in
whom
estrogen
is
present
will
fail
to
bleed
following
progesterone
withdrawal
(Rarick,
1990)
2.
Estrogen
levels
may
fluctuate
both
in
hypothalamic
amenorrhea
and
in
the
early
stages
of
ovarian
failure:
patients
with
these
disorders
may
have
at
least
some
bleeding
after
progesterone
withdrawal.
Namely,
menses
may
be
observed
after
progesterone
administration
in
up
to
40%
of
women
with
hypothalamic
amenorrhea
due
to
stress,
weight
loss,
or
exercise
and
in
up
to
50%
of
women
with
POI
(Nakamura,
1996).
This
bleeding
derives
from
endometrium
that
grew
prior
to
amenorrhea
onset.
▪
Use
of
this
test
is
best
restricted
to
those
situations
in
which
accurate
serum
hormone
measurements
are
unavailable.
Aboubakr
Elnashar
II.
Investigations:
▪
modified
by
patient
history
and
physical
examination.
▪Lab:
▪Pregnancy
test.
All
reproductive-aged
women
with
amenorrhea
and
a
uterus
are
assumed
pregnant
until
proven
otherwise
▪Prolactin
should
always
be
tested
▪TSH
▪FSH/LH:
▪
inc
in
POF
▪
dec
in
hypothalamic
causes
▪
not
useful
in
PCOS
▪
Testosterone&
(SHBG):
most
useful
for
PCOS.
Aboubakr
Elnashar

20. ▪Pelvic
ultrasound:
•congenital
abnormalities
•Asherman's
syndrome
•Haematometra
•PCOS
morphology
•Physiological
activity
or
endometrial
atrophy
in
POF.
▪Karyotype
if
uterus
absent
or
suspicion
of
Tumer's
syndrome
▪Specific
tests
for
endocrinopathies
where
there
is
clinical
suspicion.
Aboubakr
Elnashar
William
gynecology,
2019)
Aboubakr
Elnashar

21. Aboubakr
Elnashar
IHH
=
idiopathic
hypogonadotropic
hypogonadism
Aboubakr
Elnashar

22. Aboubakr
Elnashar
Aboubakr
Elnashar

23. 5.
MANAGEMENT
▪Must
be
guided
by
the
diagnosis
and
fertility
wishes.
▪Obese
or
under
wt:
attain
normal
BMI.
▪Hyperprolactinaemia:
Cabergoline
or
surgery
▪PCOS:
Cyclical
withdrawal
bleeds
(COCP
)
▪POI:
HRT
▪Genital
tract
obstruction:
▪
cervical
dilation
▪
hysteroscopic
resection
▪
incision
of
hymen.
▪Endocrinopathies
&
tumours:
TT
▪Major
congenital
abnormalities,
AIS:
multidisciplinary
teams
Aboubakr
Elnashar
Imperforate
hymen
Hymenotomy
or
curiciate
incision
Aboubakr
Elnashar

24. Thanks
Aboubakr
Elnashar
Oligomenorrhoea
Aboubakr
Elnashar
Aboubakr
Elnashar

25. DEFINE
▪Cycles
are
longer
than
32
days
▪anovulation
or
intermittent
ovulation.
❑Transient
oligomenorrhoea
common
stress'
or
emotionally
related
causes
usually
self-limiting.
Aboubakr
Elnashar
CAUSES
▪Similar
to
many
of
the
causes
of
2
º
amenorrhoea:
1.
PCOS
is
the
commonest
cause
2.
Borderline
low
BMI.
3.
Obesity
without
PCOS.
4.
Ovarian
resistance:
anovulation
e.g.
incipient
POF.
is
rare,
but
important,
5.
Milder
degrees
of
hyperprolactinaemia
6.
Mild
thyroid
disease.
Aboubakr
Elnashar

26. MANAGEMENT
What
does
the
patient
want?
Regular
periods
or
fertility?
1.
Provide
reassurance.
2.
Treat
any
underlying
causes
3.
It
is
not
uncommon
for
no
cause
to
be
found,
but
serious
pathology
must
be
excluded.
4.
Attain
normal
BMI
(weight
loss
or
gain
as
appropriate).
Aboubakr
Elnashar
▪Provide
regular
cycles:
1.
COCP
or
cyclical
progestagens
2.
PCOS
a
minimum
of
3
periods/yr
{avoid
the
risk
of
endometrial
hyperplasia
due
to
unopposed
oestrogen}.
▪Full
fertility
screening
should
be
performed
if
ovulation
induction
is
required
Aboubakr
Elnashar