Shigref Mushtaq

FINAL YEAR

AMENORRHEA

“ABSENCE OF MENSTURATION”

TYPES OF AMENORRHEA

PHYSIOLOGICAL PATHOLOGICAL

PRIMARY SECONDARY

PHYSIOLOGICAL

BEFORE MENARCHE ADOLOSCENCE PREGNANCY LACTATION MENOPAUSE

PATHOLOGICAL

PRIMARY

“ Girls failing to have their menarche by age of 16”

CAUSES OF PRIMARY AMENORRHEA

ABSENT SECONDARY SEX CHARACTER NORMAL SECONDARY SEX CHARACTER HETEROSEXUAL DEVELOPMENT CONSTITUTIONAL DELAY

ABSENT SECONDARY SEX CHARACTER• SHORT STATURE1. Hypothalamic pituitary dysfunction HYDROCEPHALUS CRANIOPHARYNGIOMA PANHYPOPITUITARISM

2. Ovarian Failure TURNER’S SYNDROME MOSAIC TURNER MIXED GONADAL DYSGENESIS

• NORMAL STATURE1.Hypothalamic pituitary dysfunction ISOLATED GnRH DEFICIENCY OLFACTOGENITAL SYNDROME HYPERPROLACTNEMIA

2. Ovarian Failure TRUE GONADAL AGENESIS PREMATURE MENOPAUSE GALACTOSAEMIA

NORMAL SECONDARY SEX CHARACTERS

1. Anatomical Abnormalities

2. Androgen Insensitivity

3. Resistant ovary syndrome

4. Polycystic Ovarian disease

5. Prolactinoma

HETEROSEXUAL DEVELOPMENT

1. Congenital adrenal hyperplasia

2. 5 alpha reductase deficiency

3. Ovarian / adrenal tumours

4. Absent anti Mullerian factor

5. True hermaphrodite

CONSTITUTIONAL DELAY

SECONDARY AMENORRHEA

“THE MENSTURATION STOPS FOR ATLEAST SIX MONTHS AFTER THE WOMAN HAS

MENSTURATED REGURARLY OR AT LEAST ONCE”

10 times more common than primary Amenorrhea Commonest cause is pregnancy

CAUSES OF SECONDARY AMENORRHEA

1. Physiological

2. Social Factors

3. Pregnancy related conditions

4. Gynaecological conditions

5. Drugs

6. Andrgenizing conditions

7. Medical/Surgical conditions

8. Other causes

MANAGEMENT

NORMAL SECONDARY SEX CHARACTERS

SECONDARY AMENORRHOEA

“TREATMENT”

ABSENT SECONDARY SEX CHARACTERS SHORT STATURE

Note: when conception is desired ovulation can induced by human menopausal gonadotrophin injections.

CAUSE TREATMENT DOSE

Hypothalamic pituitary dysfunction

Growth Hormone 0.2 micro gram/kg/day

For secondary sex development

0.01mg ethinyl estradiole bd for 3 weeks, every month for several month

Once they are developed

Combine oral contraceptives as hormonal replacement therapy.

NOTE: In mixed Gonadal genesis Gonads are removed because malignancy

arising from them is 30%

CAUSE TREATMENTOVARIAN FAILURE(turner’s syndrome and mixed gonadal dysgenesis)

SEXUALLY MATURE by LOW DOSE ESTROGENS

OCPs as HRT

NORMAL STRATURECAUSE TREATMENT DOSE

ISOLATED GnRH deficiency

Same as hypogonadrophic hypogonadism association with short strature except for the need of growth hormone

HYPER PLOCATENEMIA

Bromocriptine 2.5mg bd

PITUITARY ADENOMA

Ruled out on CT scan sometimes require surgical treatment

TRUE GONADAL AGENESIS

Treated as turner syndrome & induced with XY genotype would require gonadectomy

NORMAL SECONDARY SEX CHARACTERS

CAUSES TREATMENT

ANATOMICAL ABNORMALITIES SURGICAL RECONSTRUCTION

ANDROGEN INSENSTIVITY VAGINOPLASTY + GONADECTOMY FOLLOWED BY OCP’s

RESISTANT OVARIAN SYNDROME OCP’s FOLLOWED BY OVULATION INDUCTION BY CLOMIPHENE CITRATE

PCO’s WEDGE RESECTION OR LAPROSCOPIC OVARIAN DRILLING FOLLOWED BY OVULATION INDUCTION BY CLOMIPHENE CITRATE

HETEROSEXUAL DEVELOPMENT

CAUSES TREATMENT

CONGENITAL ADRENAL HYPERPLASIA

Steroid therapy and fertility is restored with clomephene citrate

OVARIAN/ADRENAL TUMOUR

Surgical Resection

SECONDARY AMMENORRHAE T/M

CAUSES TREATMENT

ADRENAL/OVARIAN TUMOUR

SURGICAL RESECTION

CONG ADRENAL HYPERPLASIA

STEROIDS + OVULATION INDUCTION

PELVIC TB ANTI TB MEDICATION

PIT ADENOMA BROMOCRIPTINE AND SURGERY

ASHERMAN’S SYNDROME BREAK IU ADHESIONS WITH UTERINE SOUND, FOLLOWED BY IUCD INSERTIONMODEREN TECHNIQUE CAUTERY UNDERDIRECT VISION THROUGH HYSTEROSCOPEOCP’s

OVULATION INDUCTION1.NON HYPERPROLACTINEMIAC AMENORRHEA

2. HYPERPROLACTINEMIAC AMENORRHEA

DRUGS DOSE

CLOMIPHENE CITRATE 50 mg daily on any day and continued for 5 days and dose is increased by 50mg every month till menstruation is achieved

GONADOTROPHINS (LH/FSH) INJECTIONS 75 I.ULH/75 I.UFSH one injection on any day.

BROMOCRIPTINE 1.25mg once a day for 1 week, 1.25 bd for next week followed by 2.5 mg bd