Amenorrhoea( no menses)

7/28/2019 Amenorrhoea( no menses)

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Amenorrhoea

Is the absence of menstruation.Its a symptom and not a disease.


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Physiological Pathological

Primary

-before puberty

Secondary

-during pregnancy

-during lactation

-following menopause

Concealed(cryptomenorrhoea)

Congenital

Acquired

Real

PrimarySecondary

-imperforate hymen-transverse vaginal

septum

-atresia of upper

third of vagina and

cervix

-stenosis of

cervix

-secondary

vaginal

atresia


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At least 5 basic factors involved in the onset

and continuation of normal menstruation:-

Normal female chromosomal pattern

Co-ordinated hypothalamus-pituitary-

ovarian axis

Responsive endometrium

Active support of thyroid and adrenal

glands

Anatomical patency of outflow tract


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PRIMARY AMENORRHOEA


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The causes are grouped as follows:-

Disorders of hypothalamic-pituitary-

ovarian axis

Developmental defect of genital tract

Abnormal chromosomal pattern

Dysfunction of thyroid and adrenal cortex

Metabolic disorders

Systemic illness

Unresponsive endometrium


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Hypothalamus Anterior

pituitary Ovary Endometrium

Hypothalamic causes:-

-Chronic illness

-Anorexia

-Excessive exercise

-Stress

Pituitary causes:-

-hyperprolactinaemia

-hypothyroidism

-breastfeeding

-kallmans syndrome

Ovarian causes:-

-Polycystic ovarian

syndrome

-premature ovarian

failure

-chemotherapy &radiotherapy

-Depot

medroxyprogesterone

acetate ( DMPA)

-menopause

Uterine

causes:-

-Pregnancy

-cervical

stenosis

GnRH LH

FSH

Oestrogen

Progesterone


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Disorders of hypothalamo-

pituitary ovarian axis

Hypogonadotrophic hypogonadism e.g.

delayed puberty, Kallmans syndrome,

CNS tumours and rarely polycystic ovarian

disease.

Hypergonadotrophic hypogonadism e.g.

premature ovarian failure, individuals with

17 alpha hydroxylase deficiency andgalactosemia.


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Developmental defect of genital

tract

Imperforate hymen

Transverse vaginal hymen

Atresia of upper third of vagina and cervix

Complete absence of vagina

Absence of uterus


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Abnormal chromosomal pattern

Turners syndrome

Androgen insensitivity syndrome


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Clinical featuresFamily history of female relatives with late onset

of menses is suggestive of constitutional delay.Androgen insensitivity is also suggestive offamily history.

Excessive exercise and any change in weightshould be inquired.

Chronic illness or medications should be askedabout.

An imperforate hymen or vaginal septum with ahistory of amenorrhoea and cyclical abdominalpain.


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Examination The important feature is the presence or absence of

secondary sexual characteristics like breast

development, pubic and axillary hair. Absence of thesefeatures suggests Turners, hypothalamic cause orhypothyroidism.

Check weight and height to calculate BMI

Note any features of Turners (webbed neck,shortstature etc)

Prolactinoma..abnormal visual fields

Hypothyroidism

Androgen excess (hirsutism and acne)


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Investigations

Should be initiated in a girl who has no menses

by the age of 16 if no secondary sexual

characteristics are presentAND at 14 if there is

no secondary sex development.

Urine pregnancy test to rule out possible

pregnancy.

Thyroid function and prolactin levels.

Serum gonadotrophin, testosterone and

oestradiol levels. FSH & LH levels.

Karyotyping

Ultrasound scan


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Management

Reassure girls with constitutional delaythat they will menstruate spontaneously.

Thyroxine for hypothyroidism

Bromocriptine or surgery for prolactinoma.Exercise should be limited in exercise-

induced-amenorrhoea and weight gain

should be encouraged if body mass indexis < 19.

Osteoporosis should be prevented by

giving combined oral contraceptive pills.


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Vaginal reconstruction for complete agenesis ofvagina.

In Turners or other gonadal dysgenesis, shortterm use of oestrogen and progesterone isprescribed at least for development of breasts.

In androgen insensitivity syndrome(AIS), theectopic gonads are to be removed after thesecondary characters are well developed.

For hypothalamo-pituitary-ovarian defects aretreated by induction of menstruation orovulation.


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SECONDARY AMENORRHOEAis the absence of menstruation for 6 months or more

after previously regular menses.


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COMMON CAUSES

Hypothalamus

-stress

-Sudden weight

change

-Anti-Ht drugs

Pituitary

- Adenoma

(hyperprolactinoma)

- Sheehans

syndrome

Ovary

-Polycystic

ovarian disease

-Premature

ovarian failure

Uterine

-Intrauterine

adhesions

Systemic

-Malnutrition

-Hypothyroidism

-Diabetes


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History

Preceded by hypomenorrhoea oroligomenorrhoea

Sudden change in environment/ weight loss,emotional stress

Intake of antihypertensives Acne, change in voice, hirsutism.

Inappropriate galactorrhoea

Prolonged lactation

Medical history of TB

Family history of premature menopause


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Examination

Nutritional status

Look for signs of polycystic ovarian syndrome

(hirsutism, obesity and acne), hypothyroidism

and prolactinoma (check visual fields). Marked obesity

In abdominal examination- presence of striae

and masses. In pelvis examination for enlargement of clitoris

and adnexal masses.


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Investigations

oA pregnancy test is usually indicated.

o LH, FSH, testosterone, estradiol to check forpolycystic ovarian syndrome, androgen

secreting tumour and premature ovarianfailure.

o T3 & T4 levels to check for hypothyroidism.

o Serum prolactin levels, CT/MRI for cases ofsuspected prolactinoma.


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ManagementCombined oral contraceptive pill for

polycystic ovaries. If obesity becomes aproblem, weight loss usually restores

menses and fertility.

For premature ovarian failure, hormone

replacement therapy to prevent

osteoporosis. Fertility is only possible byovum donation and in vitro fertilization

( IVF).


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Exercise induced amenorrhoea advice

on change in lifestyle and diet.

Prolactinomas managed by bromocriptine

or cabergoline. Surgery is only indicative if

resistant to medications.

Thyroxine replacement for hypothyroidism.

Contraceptive related amenorrhoea is

restored by expectancy.

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Amenorrhoea( no menses)