3 Introduction Menarche: Duration: Median age: 12.7 yrs African-american earlier than Caucasian2-2.5yrs after breast developmentAnovulatory cycles: 1st 1-2yrs of onset (55-82%)For 5 yrs (10-20%)Duration:Between 21 and 35 days (mode: 28)Lasting: 3-7daysBlood lost: 30-40ml
6 Definitions Amenorrhea: Primary: absence of menarche by age 16 in the presence of normal pubertal development (Tanner 4-5)Or: lack of menses by age 14 in absence of pubertal developmentSecondary: absence of 3 consecutive menstrual cycles or 6 months of amenorrheaMenorrhagia: normal intervals with excessive flowCycles more than 8days, > 80mlMetrorrhagia: irregular intervals with excessive flowOligomenorrhea: menstruation ocurring more than every 35 days to 6 months
9 Amenorrhea Classification: With pubertal delay With normal pubertal developmentGenital abnormalitiesHyperandrogenic anovulation
10 Amenorrhea 1. With pubertal delay Hypergonadotropic hypogonadismOVARIAN FAILURETurnerXY gonadal dysgenesisAutoinmmune oophoritisExposure to chemo or RT(alkylating)17 alpha hydroxylase deficiencyElevated FSHBA
11 Amenorrhea 1. With pubertal delay B. Hypogonatropic hypogonadism PITUITARY:AdenomaProlactinomaCraniopharyngiomaHemochromatosisHypothyroidismBreast stimulationSxPhenothiazines, opiates(-PRL inhibitor factor)HYPOTHALAMIC:Suppresion:StressMalnourishmentWt loss < 15% of ideal body wtStrenous exerciseBody fat < 22%If prior to menarche, each yr of training delays onset by 5 monthsPrader-WilliKallmanMigration olfatory and GnRH neurons)Low or normal FSH
12 Amenorrhea 2. with normal pubertal development PregnancyChronic diseasesExc IBD, DM, hypothyroidism, anorexiaUse of hormonal contraceptiveProgestational effectUterine synechiae (Asherman sd)Sheehan sd.
16 Primary amenorrhea Presence of breasts Surgery Hormone replacement TSH PRLMRI braintestosteroneSurgeryEnzymatic defectHormone replacement
17 Secondary amenorrhea DHEAS: > 700ng/ml Testosterone >90ug/ml Abd-pelvic MRI17OH progesteroneAshermanHirsutism: spirinolactone 50mg po TID
18 Evaluation: Secondary amenorrhea Progesterone challenge test:Oral medroxyprogesterone acetate for 5-10 mg QD for 5-10 days), or IM 200mg x1.POSITIVE TEST: withdrawal bleeding 2-7 days after+uterus+estrogen stimulation: ovaries okEstrogen-progesterone challenge test:Oral conjugated estrogen (1.25 mg) or 2 mg estradiol qd for days 1 through 21 with oral medroxyprogesterone acetate (10 mg) on days 17 through 21.Insufficient estrogen stimulation
20 Dysfunctional Uterine Bleeding Prolonged # of days of bleeding or excessive bleedingMost common: anovulationthe lack of progesterone secretion increases risk of endometrial hyperplasiaHigh estrogen levelsBleeding is prolonged, irregular and sometimes profuseAdolescentsObese
24 Dysmenorrhea (painful menses) Primary:Decrease of progesterone levels al end of luteal phase: lysosomal membranes are unstable::::release enzymes formation:ProstaglandinsKeep increasing during luteal and menstrual phasesUterine hypercontractibilityTissue ischemiaNerve hypersensitivity(just before or 1st days of menses)Secondary:Associated with pelvic pathology:EndometriosisMiomasPIDSTDGenital tract obstruction(Later age, Menorrhagia, Dyspareunia, Pain with defecation, worsening with every cycle or mid-cycle, symptoms that persist after menses have finished)
25 Dysmenorrhea: Treatment Inhibiting prostaglandin synthesis:Ibuprofen: mg po q4-6hrsNaproxen 500mg load then 250mg po q6-8hrsStarted on 1st day of bleedingPrevent ovulation and decrease endometrial growthOral contraceptives30-35mcg combined estrogen-progestin x4-6monthsLaparoscopy
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