2. Definition OfDefinition Of AmenorrheaAmenorrhea
•Is complete absence ofIs complete absence of
menstruation in themenstruation in the
childbearing period.childbearing period.
4. Background
• Understanding normal menstruation.
• Classification of amenorrhea.
• Amenorrhea is a Symptom not a disease, so
the final diagnosis should be pathological .
5. Pre-requisities for normality of menstruation
• Coordinated Neuro endocrine Axis.Coordinated Neuro endocrine Axis.
• Responsive ,patent Utero vaginal canalResponsive ,patent Utero vaginal canal..
• Good general health .Good general health .
7. Classifications Of AmenorrheaClassifications Of Amenorrhea
• According to the onset:According to the onset:
– Primary amenorrhea.Primary amenorrhea.
– Secondary amenorrhea.Secondary amenorrhea.
• According to the cause:According to the cause:
– Physiological.Physiological.
– PathologicalPathological
• According to Hidden or apparantAccording to Hidden or apparant::
– False amenorrheaFalse amenorrhea ((Crypto menorrheaCrypto menorrhea).).
– True amenorrhea.True amenorrhea.
• These are complementary to each otherThese are complementary to each other
15. Crypto menorrhea
- Intermittent abdominal pain
- Possible difficulty with micturition
- Possible lower abdominal swelling
- Bulging bluish membrane at the
introitus or absent vagina (only
dimple)
32. Craniopharyngioma
• Arises from remnants ofArises from remnants of Rathke'sRathke's pouchpouch
• Compresses the hypothalamusCompresses the hypothalamus
• SuppressSuppress GnRHGnRH secretion .secretion .
• Interrupt portal flow ofInterrupt portal flow of GnRHGnRH in the pituitary stalk.in the pituitary stalk.
• Calcifications may be apparent on radiography ofCalcifications may be apparent on radiography of
thethe sella turcica.sella turcica.
• Frequent manifestations includeFrequent manifestations include visual field defectsvisual field defects
and blurring visionand blurring vision..
33. GalactorrhoeaGalactorrhoea ++ amenorrhea.amenorrhea.
• Chiari-Frommel syndrome
–It occursIt occurs after deliveryafter delivery: due to: due to
persistentpersistent ProlactinProlactin secretion.secretion.
• Delcastello syndrome:
•It is not preceded by delivery.It is not preceded by delivery.
35. Sheehan's syndrome &Simmonds
• Postpartum hge.Postpartum hge.
• Failure of gonadotrphic function +Failure of gonadotrphic function + failure offailure of
lactationlactation..
• More extensive damage lead to :More extensive damage lead to :
• Simmonds :Simmonds : (Destruction of the anterior pituitary gland(Destruction of the anterior pituitary gland
due todue to septic emboliseptic emboli due todue to puerperal sepsispuerperal sepsis.).)
36. Pituitary Adenoma
• Evaluation of theEvaluation of the sella turcicasella turcica withwith (MRI)(MRI) ++ radiographyradiography isis
necessary.necessary.
• Vary in size.Vary in size.
• Micro adenomasMicro adenomas (less than 10 mm).(less than 10 mm).
• Macro adenomasMacro adenomas (more than 10 mm).(more than 10 mm).
• May beMay be associatedassociated with:with:
– Visual changes.Visual changes.
– Galactorrhoea.Galactorrhoea.
– Hypothyroidism.Hypothyroidism.
– AmenorrheaAmenorrhea
37. Work up for : hypothalamic- pituitary
• History
• Exam
• Investigation…
• Then:
• Categorize as primary or secondary
• Categorize cause……..
38. History in primary amenorrhea
• Developmental milestones (age of growth
spurt ,age of thelarche, adrenarche)
• Chronic illness (CRI ,TB, Bl disease).
• Weight changes
• Excessive exercise
• History of anosmia
49. General Principles of management
• Try causative Treatment.
• Do not forget general factors
• Remember stress is common cause in
adolescents
• Pregnancy is the commonest cause of
secondary amenorrhea
50. General Principles of management
. HRT: (estrogen and progesterone)
In hypo-estrogenic amenorrheic women (to prevent
osteoporosis)
. Periodic progestogen:
In euestrogenic amenorrheic women (to avoid endometrial cancer)
. If Y chromosome is present: gonadectomy is indicated
. Many cases require frequent re-evaluation