Amenorrhoea Professor Zouhair O Amarin MD MSc (Med. Sci) MSc (Med. Edu) FRCOG FFPH (RCP, UK) Department of Obstetrics and Gynaecology Jordan University of Science and Technology

Definition

Primary No secondary sexual characteristics (Growth spurt, Breast development, Pubic hair growth, Menstruation, Axillary hair growth), by the age of 14, or no menstruation by the age of 16

Secondary No menstruation for more than 6 months in a normal female of reproductive age that is not due to pregnancy

Aetiology

Reproductive outflow tract abnormalities

Vaginal disorders Imperforate hymen Transverse vaginal septum Absent vagina and functional uterus Müllerian agenesis: complete or partial absence of the uterus and variable malformations of the vagina (Mayer- Rokitansky-Küster-Hauser Syndrome). Common Vaginal disorders Imperforate hymen Transverse vaginal septum Absent vagina and functional uterus Müllerian agenesis: complete or partial absence of the uterus and variable malformations of the vagina (Mayer- Rokitansky-Küster-Hauser Syndrome). Common

Baron Von Rokitansky ( ), Bohemian physician, pathologist, humanist, philosopher and liberal politician Bohemianphysician pathologistphilosopherpoliticianBohemianphysician pathologistphilosopherpolitician

Uterine disorders Cervical stenosis Asherman Syndrome TB of the uterus Uterine disorders Cervical stenosis Asherman Syndrome TB of the uterus

Ovarian disorders Premature ovarian failure (genetic, autoimmune, infective, radio/chemo) Resistant ovary syndrome PCOS Ovarian disorders Premature ovarian failure (genetic, autoimmune, infective, radio/chemo) Resistant ovary syndrome PCOS

Hypothalamic/pituitary causes Constitutional delay Kallmann Syndrome Wt loss Exercise Craniopharyngioma, Glioma, germinoma, dermoid cyst Head injuries Sarcoidosis TB Congenital infection Chronic infection Psychological stress Idiopathic Hyperprolactinaemia Empty sella syndrome Hypopituitarism Hypothalamic/pituitary causes Constitutional delay Kallmann Syndrome Wt loss Exercise Craniopharyngioma, Glioma, germinoma, dermoid cyst Head injuries Sarcoidosis TB Congenital infection Chronic infection Psychological stress Idiopathic Hyperprolactinaemia Empty sella syndrome Hypopituitarism

Kallmann syndrome is a decreased production of sex hormones caused by a deficiency of GnRH. It is also called hypothalamic hypogonadism, with anosmia, and hypogonadotropic hypogonadism. The primary cause lies within the pituitary and hypothalamus rather than a physical defect of the testes or ovaries The syndrome was described in 1944 by Franz Josef Kallmann, a German-American geneticist. hypothalamichypogonadism anosmiahypogonadotropic hypogonadismFranz Josef KallmannGermanAmericangeneticisthypothalamichypogonadism anosmiahypogonadotropic hypogonadismFranz Josef KallmannGermanAmericangeneticist

Other causes

Drug induced hyperprolactinaemia Tranquilizers Tricyclic antidepressants Narcotics COCs Drug induced hyperprolactinaemia Tranquilizers Tricyclic antidepressants Narcotics COCs

Chromosomal Genetic Enzymatic Other

Basis of human development 46 XY will develop as a male 46 XX will develop as a female The presence or absence of the Y chromosome will determine if the gonad becomes a testis or an ovary The Y chromosome contains a gene sequence on its short arm (Yp). This gene is known as the Sex Determining Region on the Y (SRY gene), and encodes for Testis Determining Factor (TDF) Basis of human development 46 XY will develop as a male 46 XX will develop as a female The presence or absence of the Y chromosome will determine if the gonad becomes a testis or an ovary The Y chromosome contains a gene sequence on its short arm (Yp). This gene is known as the Sex Determining Region on the Y (SRY gene), and encodes for Testis Determining Factor (TDF)

TDF induces differentiation through the cell surface antigen (H-Y antigen) which is found in all individuals containing the Y chromosome The gene locus for the H-Y antigen is close to TDF The H-Y antigen gene locus is also located on autosomal chromosomes and other autosomal genes are involved in testicular development This comes from studies on XX males (containing the normally-male SRY gene)

SRY Testes Testosterone MIH Ext. Gen WD

Chromosomal causes Turner Syndrome 45X and 45X/46XX (mosaics) Swyer Syndrome 46XY (complete gonadal dysgenesis) 45X/46XY (Mixed gonadal agenesis/dysgenesis) Gonadal agenesis: complete failure of development of the gonad (These girls may be with 46 XX or 46 XY) 47XXX, 48XXXX, 49XXXXX Chromosomal causes Turner Syndrome 45X and 45X/46XX (mosaics) Swyer Syndrome 46XY (complete gonadal dysgenesis) 45X/46XY (Mixed gonadal agenesis/dysgenesis) Gonadal agenesis: complete failure of development of the gonad (These girls may be with 46 XX or 46 XY) 47XXX, 48XXXX, 49XXXXX

Gonadal dysgenesis The gonad is abnormally formed Turner syndrome is commonest (45 X or 45 X/46XX) Short stature as the gene for height is on the short arm of the X chromosome Gonadal dysgenesis The gonad is abnormally formed Turner syndrome is commonest (45 X or 45 X/46XX) Short stature as the gene for height is on the short arm of the X chromosome

Lymphoedema in a newborn with Turner syndrome

45-X

Gonadal dysgenesis The gonad is abnormally formed In XY women, the gonads are dysgenetic due to enzymatic failure, with no testosterone but normal Mullerian inhibitor So there is Mullerian atrophy, but Wollfian structure and external masculinization failure The external phenotype is female with a short vagina Gonadal dysgenesis The gonad is abnormally formed In XY women, the gonads are dysgenetic due to enzymatic failure, with no testosterone but normal Mullerian inhibitor So there is Mullerian atrophy, but Wollfian structure and external masculinization failure The external phenotype is female with a short vagina

SRY Testes Testosterone MIH Ext. Gen WD

In 46 XX pure gonadal dysgenesis (autosomal recessive with involvement of genes other than those on the X chromosomes). Their genotype does not affect their phenotype, all being female In 46 XY (Swyer Syndrome) or 45 X/46 XY with absence of TDF or its receptor, there is failure of testicular development, with no androgen or MIF, therefore Wolffian structures regress and Mullerian structures persist, with normal female phenotype, normal or excessive height (delayed epiphyseal closure due to low androgens or oestrogens). Menses will occur with oestrogens

Androgen insensitivity Testicular feminization syndrome X-linked trait X-linked trait Absent cytosol receptors Absent cytosol receptors Normal breasts but no sexual hair Normal breasts but no sexual hair Normal looking female external genitalia Normal looking female external genitalia Absent uterus and upper vagina Absent uterus and upper vagina Karyotype 46 XY Karyotype 46 XY Male range testosterone level Male range testosterone level Treatment: gonadectomy after puberty + HRT Treatment: gonadectomy after puberty + HRT ? Vaginal creation (dilatation VS Vaginoplasty ) ? Vaginal creation (dilatation VS Vaginoplasty )

Androgen insensitivity syndrome

Swyer V. AIS Swyer: no breast, but has uterus and pubic hair

Heterosexual development Congenital adrenal hyperplasia Arrenoblastoma 5 alpha reductase deficiency (XY female) True hermaphrodite Absent Mullerian Inhibitor Heterosexual development Congenital adrenal hyperplasia Arrenoblastoma 5 alpha reductase deficiency (XY female) True hermaphrodite Absent Mullerian Inhibitor

Autosomal recessive trait Autosomal recessive trait Most common form is due to 21- hydroxylase deficiency Most common form is due to 21- hydroxylase deficiency Mild forms closely resemble PCO Mild forms closely resemble PCO Severe forms show signs of severe androgen excess Severe forms show signs of severe androgen excess High 17-OH-progesterone levels High 17-OH-progesterone levels Rx:cortisol replacement and ? corrective surgery Rx:cortisol replacement and ? corrective surgery Late onset CAH

5 Alpha Reductase Deficiency XY gene type Failure of testosterone to change into DHT Girls have no uterus or cervix Girls have vagina which is sometimes smaller then usual Some treatment may be needed to enlarge vagina Gonads are usually in the abdomen Removal of gonads and HRT needed for girls Carrying a pregnancy not possible

Systemic causes Chronic debilitating illness Wt loss Endocrine (thyroid, Cushing etc … ) Systemic causes Chronic debilitating illness Wt loss Endocrine (thyroid, Cushing etc … )

Cushing syndrome Clinical suspicion : Hirsutism, truncal obesity, purple striae,  BP Clinical suspicion : Hirsutism, truncal obesity, purple striae,  BP If suspicion is high: If suspicion is high: Dexamethasone suppression test (1 mg PO 11 pm ) and obtain serum cortisol level at 8 am: Dexamethasone suppression test (1 mg PO 11 pm ) and obtain serum cortisol level at 8 am: < 5 µg/dl excludes Cushing’s < 5 µg/dl excludes Cushing’s 24 hours total urine free cortisol level to confirm diagnosis 24 hours total urine free cortisol level to confirm diagnosis 2 forms: adrenal tumour or ACTH hypersecretion (pituitary or ectopic site) 2 forms: adrenal tumour or ACTH hypersecretion (pituitary or ectopic site)

History Developmental history Age of menarche Cyclical symptoms Chronic illness Wt loss Exercise Anosmia Medical and surgical history Menopausal symptoms Current medications Family history of premature menopause Virilizing signs Gallactorrhoea Psychological history Stressful events History Developmental history Age of menarche Cyclical symptoms Chronic illness Wt loss Exercise Anosmia Medical and surgical history Menopausal symptoms Current medications Family history of premature menopause Virilizing signs Gallactorrhoea Psychological history Stressful events

Weight-related amenorrhoea Anorexia Nervosa

Exercise-associated amenorrhoea

Clinical examination

Height Secondary sexual characteristics Visual fields and papilloedema Pelvic examination

Investigations

Step 1

Pregnancy test Prolactin TFT LH/FSH Testosterone (<5 nmol/l) Progesterone withdrawal test

Step 2

If PCT is negative: 21 days of oestradiol 2mg/d for 21 days followed by progesterone as in PCT

No bleeding; ? Outflow abnormality Bleeding: HPO problem

Step 3

Bleeding: Repeat LH and FSH 6 weeks after tests If elevated: POF If LH and FSH not elevated: hypothalamic

This should determine compartment Depending on results karyotyping may be appropriate

PCOS

PCOS is a syndrome of ovarian dysfunction along with hyperandrogenism and polycystic ovary morphology

Prevalence 5-10 % On ultrasound 25% Prevalence 5-10 % On ultrasound 25%

Aetiology is unclear Increased ovarian androgen production Disordered ovarian cytochrome p450 activity Increased LH production Insulin resistence Family clusters: gene or a cluster of genes Aetiology is unclear Increased ovarian androgen production Disordered ovarian cytochrome p450 activity Increased LH production Insulin resistence Family clusters: gene or a cluster of genes

Clinical features Oligo/amenorrhoea Hirsutism Subfertility Recurrent miscarriage Acanthosis nigricans Clinical features Oligo/amenorrhoea Hirsutism Subfertility Recurrent miscarriage Acanthosis nigricans

Laboratory tests Elevated T levels Decreased SHBG Elevated LH levels Elevated LH/FSH ratio Increased fasting insulin levels Eight or more subcapsular cysts <10 mm and increased stroma Laboratory tests Elevated T levels Decreased SHBG Elevated LH levels Elevated LH/FSH ratio Increased fasting insulin levels Eight or more subcapsular cysts <10 mm and increased stroma

Treatment Treatment

Oligo/amenorrhoea: progesterone COC Metformin

Hirsutism Eflornithine cream Cyproterone acetate Metformin GnRH analogues with low-dose HRT Laser or electrolysis Hirsutism Eflornithine cream Cyproterone acetate Metformin GnRH analogues with low-dose HRT Laser or electrolysis

Subfertility

Obesity

Long term sequleae DM and CVD

Thank you