1. Amenorrhea DI WEN M.D., Ph.D., DI WEN M.D., Ph.D., Professor & Chairman Professor & Chairman Department Of Obstetrics & Gynecology Department Of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine Renji Hospital Affiliated to SJTU School of Medicine

2. Amenorrhea Amenorrhea Amenorrhea is the absence of menstruation.Amenorrhea is the absence of menstruation. PrimaryPrimary –Absence of menses by age 16 with normal secondary sexual characteristics. –Absence of menses by age 14 without secondary sexual development. SecondarySecondary –Absence of menses for 6 months in a previously menstruating female.

3. Events of Puberty Events of Puberty Thelarche (breast development)Thelarche (breast development) –Requires estrogen Pubarche/adrenarche (pubic hair development)Pubarche/adrenarche (pubic hair development) –Requires androgens

4. Events of Puberty Events of Puberty MenarcheMenarcheRequires: –GnRH from the hypothalamus –FSH and LH from the pituitary –Estrogen and progesterone from the ovaries –Normal outflow tract

5. P1 P5 P4 P3 P2 Tanner’s

6. Classification of amenorrhea Classification of amenorrhea hypothalamic amenorrheahypothalamic amenorrhea pituitary amenorrheapituitary amenorrhea ovarian amenorrheaovarian amenorrhea uterine amenorrheauterine amenorrhea

7. Etiology Etiology hypothalamic amenorrheahypothalamic amenorrhea –Psychological stress –5a-Reductase deficiency –Anorexia nervosa, weight loss – Increased exercise levels –Kallmann syndrome – drug-induced amenorrhea –Space-occupying lesion of CNS

8. Etiology Etiology pituitary amenorrheapituitary amenorrhea – tumor – Empty sella syndrome – Sheehan syndrome

9. Etiology Etiology ovarian amenorrheaovarian amenorrhea –Gonadal dysgenesis –Turner syndrome: low hair line, web neck, shield chest, and widely spaced nipples –Swyer syndrome –resistant ovary syndrome –Premature ovarian failure

10. Tunner staging Tunner staging

11. Acanthosis nigrans Acanthosis nigrans

12. Striae Striae

13. Typical features of Turner Syndrome Typical features of Turner Syndrome

14. Etiology Etiology uterine amenorrheauterine amenorrhea – Absence of uterus – Asherman syndrome anatomic abnormalities of the reproductive tractanatomic abnormalities of the reproductive tract –Imperforate Hymen

15. Imperforate Hymen Imperforate Hymen

16. Mayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis) Mayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis) 15% of primary amenorrhea15% of primary amenorrhea Normal secondary development & external female genitaliaNormal secondary development & external female genitalia Normal female range testosterone levelNormal female range testosterone level Absent uterus and upper vagina & normal ovariesAbsent uterus and upper vagina & normal ovaries Karyotype 46-XXKaryotype 46-XX 15~30% renal, skeletal and middle ear anomalies15~30% renal, skeletal and middle ear anomalies

17. Androgen Insensitivity Androgen Insensitivity Normal breasts but no sexual hairNormal breasts but no sexual hair Normal looking female external genitaliaNormal looking female external genitalia Absent uterus and upper vaginaAbsent uterus and upper vagina Karyotype 46, XYKaryotype 46, XY Male range testosterone levelMale range testosterone level Treatment : gonadectomy after puberty + HRTTreatment : gonadectomy after puberty + HRT

18. Diagnosis Diagnosis HistoryHistory Physical examinationPhysical examination –Physical examination begins with vital signs, including height and weight, and with sexual maturity ratings Laboratory evaluationLaboratory evaluation

19. VE- preg test TSH,PROLACTIN’, Prog.challenge test withdrawal bleeding without withdrawal bleeding hypoestrogenic compromised outflow tract. +ve.est,progest. challenge test -ve.est,progest.challenge test FSH>30-40 Normal FSH HSG OR hysteroscopy asherman 2wk FSH norm. repeat Repeat+serum,est.level PROF hypothalamic- pituitary failure anovulation

20. Treatment Treatment treatment varies depending upon the causes of the amenorrhea. Treatment options include:treatment varies depending upon the causes of the amenorrhea. Treatment options include: –Dietary changes, including an increase in fat and calories in order to stimulate estrogen production. –Counseling for eating disorders. –Using stress reduction techniques to help regulate the period. –Hormonal supplements, like the birth control pill or patch, or hormone replacement therapy. birth control pillpatchhormone replacement therapybirth control pillpatchhormone replacement therapy –Surgery to remove cysts, fibroids or tumors

21. DI WEN M.D., Ph.D. DI WEN M.D., Ph.D. Professor & Chairman Professor & Chairman Department of Obstetrics & Gynecology Department of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine Renji Hospital Affiliated to SJTU School of Medicine Thanks for Your Attention Thanks for Your Attention