Amenorrhea (and Dysfunctional Uterine Bleeding) Dr. ELHAM GHANBARI JOLFAEI OB&MD Gynecologiest

Amenorrhea: “absence of menses” “Normal cycle is 28 days This occurs in 15% of cycles 98% have cycles between 24-35 days Average duration 4-6 days (2-8 normal) Average blood loss per cycle = 30 ml. > 80 ml. Leads to risk for anemia

PRIMARY AMENORRHEA Patient has never menstruated No period by age 14 with no secondary sexual characteristics No period by age 16 regardless of secondary sexual characteristics

SECONDARY AMENORRHEA Previously established cycles cease

ALWAYS RULE OUT PREGNANCY Then evaluate the four parts of the system

REASONS FOR AMENORRHEA Pregnancy Menopause Thyroid/Prolactin Disorders Anovulation Outflow obstruction CNS/hypothalamic dysfunction Drugs/Stress/Nutrition Chromosomal/Abnormal Sexual Differentiation

ALWAYS RULE OUT PREGNANCY!!!!!!! No matter WHAT!!!

STEP ONE – will diagnose pregnancy, thyroid disorder, hypoprolactinemia and anovulation LABS Beta hcg TSH Prolactin MEDS Progestin challenge {If galactorrhea, obtain MRI of pituitary/sella turcica}

STEP TWO – will diagnose outflow tract obstruction Give estrogen “priming”, followed by progestin Estrogen x 21 days Add progesterone for the last 5 days

STEP 3- will determine if lack of estrogen is due to ovarian failure vs. altered CNS/pituitary axis FSH (LH)

I. UTERUS – VAGINA – OUTFLOW TRACT Asherman’s – secondary amenorrhea Imperforate hymen – primary amenorrhea Vaginal septum – primary amenorrhea Agenesis – primary amenorrhea Testicular feminization – primary amenorrhea

II. OVARY Chromosomes Normal- Chromosomes Abnormal- Menopause Radiation/Chemo Autoimmune Disorder Infection Chromosomes Abnormal- Primary Amenorrhea Premature Menopause

III. ANTERIOR PITUITARY Prolactin Secreting Tumors Sheehan’s Syndrome

IV. CNS / HYPOTHALAMUS Weight loss, anorexia, stress, intense exercise Hypothyroidism – TRH/drugs which affect dopamine Anovulation Hypothalamic Suppression

ALWAYS, ALWAYS, ALWAYS RULE OUT PREGNANCY

CASE STUDY 17 year old female with primary amenorrhea. She is of normal weight and has mature secondary sexual characteristics.

CASE STUDY 15 year old with three months of secondary amenorrhea. She underwent normal pubertal development and had menarche at age 12 with regular cycles for three years. She is on the track team.

CASE STUDY 42 year old G3P3 with 5 months amenorrhea. Normal weight. Has been experiencing hot flashes.

CASE STUDY 28 year old G2P2 with 8 months of amenorrhea. Has been gaining weight lately, feels cold all of the time, and complains of constipation and fatigue.

CASE STUDY 35 year old G0 with amenorrhea for 9 months. Overweight. Slightly hirsute.