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

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Presentation on theme: "EVALUATION AND MANAGEMENT OF AMENORRHEA Mazen Freij, MBBS MRCOG Assistant Professor at JUH EVALUATION AND MANAGEMENT OF AMENORRHEA Mazen Freij, MBBS MRCOG."— Presentation transcript:

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

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

3 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 Neural controlChemical control Dopamine (-) Norepiniphrine (+) Endorphines (-) Hypothalamus Gn-RH Ant. pituitary FSH, LH Ovaries Uterus ProgesteroneEstrogen Menses –± ?

7 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 FSH Serum level Low / normalHigh Hypogonadotropic hypogonadim Gonadal dysgenesis

11 - FSH, LH, Prolactin, TSH - Provera 10 mg PO daily x 5 days + BleedingNo bleeing  Prolactin  TSH Further Work-up (Endocrinologist) - Mild hypothalamic dysfunction - PCO (  LH/FSH) Review FSH result And history (next slide)

12 Amenorrhea Utero-vaginal absence Karyotype 46-XX Rokitansky syndrome) Andogen Insenitivity (TSF syndrome) 46-XY Normal breasts & sexual hair Normal breasts & absent 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  Classic turner’s syndrome (45XO) - Turner variants (45XO/46XX),(46X- abnormal X) - Mixed gonadal dygenesis (45XO/46XY)

15 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 - 80 % 45, X0 - 20% mosaic forms (46XX/45X0) Treatment: HRT

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

17 Ovarian dysgenesis

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

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

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

21  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  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  Endocrine causes.  Genetic causes.  Anatomic causes.

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26  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  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  A. Turner Syndrome  B. CAH  C. Rokitansky Syndrome  D. Imperforsted Hymen  E. PCOS

29  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

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