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

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

3. 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

4. SECONDARY AMENORRHEA
Previously established cycles cease

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

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

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

10. 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}

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

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

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

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

18. III. ANTERIOR PITUITARY
Prolactin Secreting Tumors
Sheehan’s Syndrome

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

20. ALWAYS, ALWAYS, ALWAYS
RULE OUT PREGNANCY

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

22. 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.

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

24. 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.

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