1. EVALUATION AND MANAGEMENT OF AMENORRHEA Assistant Professor at JUH
Mazen Freij, MBBS MRCOG
Assistant Professor at JUH

2. Objectives Know the definition of Amenorrhea and Oligomenorrhea
Understand the endocrine, genetic and anatomical basis for these disorders

3. Definitions Primary amenorrhea
No menses by age 14, absence of 2º sexual characteristics.
No menses by age 16 , presence of 2º sexual characteristics.

4. Secondary amenorrhea
No menses for 3 months  if previous menses were regular.
No menses for 6 months  if previous menses were irregular

5. Oligomenorrhea
Interval of more than 35 days between periods

6. ± – ? Menses Neural control Chemical control Dopamine (-)
Norepiniphrine
(+)
Endorphines
(-)
Hypothalamus
Gn-RH ? –
Ant. pituitary
FSH, LH
Ovaries
Estrogen
Progesterone
Uterus
Menses

7. AN APPROACH FOR DIAGNOSIS
AMENORRHOEA
AN APPROACH FOR DIAGNOSIS
HISTORY
PHYSICAL EXAMINATION
BLOOD TESTS
ULTRASOUND EXAMINATION
Exclude Pregnancy
Exclude Cryptomenorrhea

8. Cryptomenorrhea Outflow obstruction to menstrual blood
- Imperforate hymen
- Transverse Vaginal septum with functioning uterus
- Isolated Vaginal agenesis with functioning uterus
- Isolated Cervical agenesis with functioning uterus

9. Imperforated hymen

10. Amenorrhea and no breast development.
FSH Serum level
Low / normal
High
Hypogonadotropic
hypogonadim
Gonadal
dysgenesis

11. Amenorrhea and normal breast development.
- FSH, LH, Prolactin, TSH
Provera 10 mg PO daily
x 5 days
Prolactin  TSH
+ Bleeding
No bleeing
- Mild hypothalamic
dysfunction
- PCO (LH/FSH)
Further
Work-up
(Endocrinologist)
Review FSH result
And history (next slide)

12. Amenorrhea Utero-vaginal absence Andogen Insenitivity (TSF syndrome)
Karyotype
46-XY
46-XX
Andogen Insenitivity (TSF syndrome)
Rokitansky syndrome)
Normal breasts
& absent sexual
hair
Normal breasts
& sexual hair

13. Amenorrhea PRIMARY AMENORRHEA . Ovarian failure . Hypogonadotrophic
Hypogonadism.
. PCOS
. Congenital lesions
(other than dysgenesis)
. Hypopituitarism Hyperprolactinaemia
. Weight related
SECONDARY AMENORRHEA
. Polycystic ovary syndrome
. Premature ovarian failure
. Weight related amenorrhoea
. Hyperprolactinaemia
. Exercise related amenorrhoea
. Hypopituitarism

14. Gonadal dysgeneis Classic turner’s syndrome (45XO)
- Turner variants (45XO/46XX),(46X-abnormal X)
- Mixed gonadal dygenesis (45XO/46XY)

15. Turner’s syndrome • Sexual infantilism and short stature.
• Associated abnormalities, webbed neck,coarctation of the aorta,high-arched pallate, cubitus valgus, broad shield-like chest with wildely spaced nipples, low hairline on the neck, short metacarpal bones and renal anomalies.
• High FSH and LH levels.
• Bilateral streaked gonads.
• Karyotype % 45, X0
- 20% mosaic forms (46XX/45X0)
• Treatment: HRT

16. Turner’s syndrome
(Classic 45-XO)
Mosaic (46-XX / 45-XO)

17. Ovarian dysgenesis

18. Hypogonadotrophic Hypogonadism
Normal hight
Normal external and internal genital organs (infantile)
Low FSH and LH
30-40% anosmia (kallmann’s syndrome)
Treat with HRT

19. Constitutional pubertal delay
• delayed bone age
( X-ray Wrist joint)
• Positive family history
• Diagnosis by exclusion and follow up

20. Weight-related amenorrhoea Anorexia Nervosa
1o or 2o Amenorrhea is often first sign
A body mass index (BMI) <17 kg/m² menstrual irregularity and amenorrhea
Hypothalamic suppression
Low estradiol  risk of osteoporosis
Treatment :  body wt. (Psychiatrist referral)

21. Utero-vaginal Agenisis Mayer-Rokitansky-Kuster-Hauser syndrome
Second most common cause of Primary amenorrhea.
Normal breasts and Sexual Hair Normal looking external female genitalia
Karyotype 46-XX
15-30% renal abnormalities.
Treatment : Vaginal creation (Dilatation VS Vaginoplasty)

22. Androgen insensitivity Testicular feminization syndrome
Normal breasts but no sexual hair
Normal looking female external genitalia
Absent uterus and upper vagina
Karyotype 46, XY
Male range testosterone level
Treatment : gonadectomy after puberty + HRT

23. Amenorrhea
Endocrine causes.
Genetic causes.
Anatomic causes.

25. TEST

26. A. History of leukemia during infancy B. Short stature
A 17-year-old girl presents to the clinic for the evaluation of primary amenorrhea. Which would be an important aspect of her clinical history?
A. History of leukemia during infancy
B. Short stature
C. History of delayed puberty in the family
D. All of the above
E. None of the above

27. B. Estradiol of 100 pg/ml (normal 40–410)
After receiving Chemotherapy, which of the following labs results would make you consider the diagnosis of ovarian failure?
FSH of 60 IU/L (normal 0.33–10.54)
B. Estradiol of 100 pg/ml (normal 40–410)
C. LH of < 0.2 IU/L (normal 0.69–7.15)
D. All of the above
E. None of the above

28. The commonest cause for primary amenorrhea is
A. Turner Syndrome
B. CAH
C. Rokitansky Syndrome
D. Imperforsted Hymen
E. PCOS

29. C. Androgen insensitivity. D. Rokitansky syndrome
One of the following can be the cause for primary amenorrhea with normal secondary sexual development.
A. Imperforated hymen.
B. Turner Syndrome
C. Androgen insensitivity.
D. Rokitansky syndrome
E. Hypogonadotropic hypogonadism

30. What is the definition of Primary Amenorrhea?

31. 19 year old presented with primary amenorrhea, normal breast development but no pubic hair, absent uterus. The most likely diagnosis is:
A. Rokitansky syndrome
B. Turner Syndrome
C. Androgen insensitivity
D.Hypogonadotropic Hupogonadism

32. Thank You