assessment of a case of

8/14/2019 Assessment of a Case Of

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Dr.Mohammed AbdallaDr.Mohammed AbdallaObst.Gyn.SpecialistObst.Gyn.Specialist

Egypt, Domiat G. HospitalEgypt, Domiat G. Hospital

ASSESSMENT OF A CASEASSESSMENT OF A CASE

OFOF AMENORRHEAAMENORRHEA


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AMENORRHEAAMENORRHEA

Amenorrhea is the absence or abnormalAmenorrhea is the absence or abnormal

cessation of the menses. A patient iscessation of the menses. A patient is

diagnosed with primary amenorrhea if shediagnosed with primary amenorrhea if she

has not reached menarche by age 15.1has not reached menarche by age 15.1

She meets the criteria for secondaryShe meets the criteria for secondary

amenorrhea if established menses haveamenorrhea if established menses have

ceased for longer than 6 monthsceased for longer than 6 months


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Etiology of AmenorrheaEtiology of Amenorrhea

PrimaryPrim

aryGonadal failure(43%)Gonadal failure(43%)

Congenital absence of uterus and vagina(15%)Congenital absence of uterus and vagina(15%)Constitutional delay(14%)Constitutional delay(14%)

SecondarySeconda

ryChronic anovulation(39%)Chronic anovulation(39%)

Hypothyroidism / hyperprolactinemia(20%)Hypothyroidism / hyperprolactinemia(20%)Weight loss/anorexia(16%)Weight loss/anorexia(16%)


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THE ASSESSMENTTHE ASSESSMENT


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Primary amenorrhea

vagina

no yes

congenital uterovaginalcongenital uterovaginal

agenesisagenesis

imperforate hymenimperforate hymencomplete transversecomplete transverse

vaginal septumvaginal septum

Pubic hair

EstrogenizedEstrogenized

breasts havebreasts havedevelopeddeveloped

the (MPA) challengethe (MPA) challenge

abnormal ovariesabnormal ovariesabnormal hormonal stimulation of normal ovaabnormal hormonal stimulation of normal ova

FSH Level

ChromosomeChromosome

AnalysisAnalysis

no

noyes

complete androgencomplete androgen

insensitivityinsensitivity)syndrome )CAIS)syndrome )CAIS

+ -

high low


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Secondary AmenorrheaSecondary Amenorrhea


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Secondary amenorrhea is the absenceSecondary amenorrhea is the absence

of menstrual periods for 6 months in aof menstrual periods for 6 months in a

woman who had previously beenwoman who had previously been

regular, or for 12 months in a womanregular, or for 12 months in a woman

who had irregular periods.who had irregular periods.


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incidenceincidence

1%1% of women of reproductive age.of women of reproductive age.


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The most common cause of secondaryThe most common cause of secondary

amenorrhea in reproductive ageamenorrhea in reproductive age

women iswomen is pregnancypregnancy and this shouldand this should

always be excluded by physical examalways be excluded by physical exam

and laboratory testing for theand laboratory testing for the

pregnancy hormone - HCG.pregnancy hormone - HCG.


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HistoryHistory

A good history can reveal the etiologicA good history can reveal the etiologicdiagnosis in up to 85% of cases ofdiagnosis in up to 85% of cases of

amenorrhea.amenorrhea.


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GalactorrheaGalactorrhea

hot flashes, breast atrophy andhot flashes, breast atrophy anddecreaseddecreased libidolibido

CertainCertainmedicationsmedications

A large amount of weight loss or gainA large amount of weight loss or gain

Anorexia nervosaAnorexia nervosa

Cushing's disease and hypothyroidismCushing's disease and hypothyroidism

.Sheehan's syndrome.Sheehan's syndrome

Asherman's syndromeAsherman's syndrome

Amenorrhea following cervicalAmenorrhea following cervicalconizationconization

Following discontinuation of oral contraceptionFollowing discontinuation of oral contraception

HistoryHistory


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Physical examinationPhysical examination

Signs of androgen excessSigns of androgen excess

The breast exam may reveal galactorrheaThe breast exam may reveal galactorrhea

Estrogen deficiency may be suggested onEstrogen deficiency may be suggested on

pelvic exam by a smooth vagina thatpelvic exam by a smooth vagina thatlacks the normal rugae (wrinkles) and alacks the normal rugae (wrinkles) and a

dry endocervix with no mucousdry endocervix with no mucous


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what the doctor will dowhat the doctor will do

?next?next


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If the history and physicalIf the history and physical

exam are suggestive of aexam are suggestive of a

certain etiologycertain etiology::

for the sake of efficiency and cost-for the sake of efficiency and cost-effectiveness, the workup caneffectiveness, the workup can

sometimes be more directed.sometimes be more directed. ( in 85%( in 85%

of cases .)of cases .)


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Some patients will not demonstrate anySome patients will not demonstrate any

obvious etiology for their amenorrheaobvious etiology for their amenorrhea

on history and physical exam. Theseon history and physical exam. These

patients can be worked up in a logicalpatients can be worked up in a logical

manner using a stepwise approach.manner using a stepwise approach.


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the first tests to perform after pregnancy isthe first tests to perform after pregnancy is

ruled out are :ruled out are :

a progesterone withdrawal testa progesterone withdrawal test

TSH (thyroid stimulating hormone)TSH (thyroid stimulating hormone)

prolactin level.prolactin level.


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Preg.test

TSH ,PROLACTIN,

Prog.challenge test

withdrawal

bleeding

without withdrawal

bleeding

hypoestrogenic compromised.outflow tract

ve.est,progest.+

challenge testve.est,progest-

challenge test.

FSH>30-40Normal FSH

HSG OR hysteroscopy

asherman

2wk

FSH norm.

repeatRepeat+serum

,est.level

PROFhypothalamic-pituitary failure

anovulation

VE-


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Ovarian failure )prematureOvarian failure )premature

menopausemenopause))

chromosomal

anomalies autoimmune

disease

If the woman is under

30, a karyotype should

be performed to rule

out any mosaicism

involving a Y

.chromosome

it is prudent to screen

for thyroid, parathyroid,

and adrenal dysfunction

If a Y chromosome is

found the gonads

should be surgically.excised

Laboratory evidence of

autoimmune phenomenon is much

more prevalent than clinically

significant disease


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autoimmune related dysfunctionautoimmune related dysfunction

The most common association is with thyroidThe most common association is with thyroid

disease, but the parathyroids and adrenals can alsodisease, but the parathyroids and adrenals can also

be affected.be affected.

Several studies have shown laboratory evidence ofSeveral studies have shown laboratory evidence ofimmune problems in about 15-40% of women withimmune problems in about 15-40% of women with

premature ovarian failure.premature ovarian failure.

In general, ovarian biopsy is not indicated inIn general, ovarian biopsy is not indicated in

patients with premature ovarian failure since nopatients with premature ovarian failure since no

clinically useful information will be obtained.clinically useful information will be obtained.


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Hypothalamic-pituitary failureHypothalamic-pituitary failure

Patients who do not bleed after thePatients who do not bleed after the

progestin challenge but do afterprogestin challenge but do after

estrogen/progestin and have normal orestrogen/progestin and have normal or

low FSH and LH levelslow FSH and LH levels


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Some medications (e.g. phenothiazines) as well asSome medications (e.g. phenothiazines) as well asextremes of weight loss, stress or exercise canextremes of weight loss, stress or exercise cancause this type of secondary amenorrhea.cause this type of secondary amenorrhea.

A pituitary or hypothalamic tumor would be a rareA pituitary or hypothalamic tumor would be a rarefinding in these patients who were all screenedfinding in these patients who were all screenedwith prolactin levels at the beginning of thewith prolactin levels at the beginning of thediagnostic evaluation.diagnostic evaluation.

However, if there is no cause apparent from theHowever, if there is no cause apparent from thehistory, it would be prudent to obtain a baselinehistory, it would be prudent to obtain a baselineCT (or MRI) evaluation of the sellar region to ruleCT (or MRI) evaluation of the sellar region to ruleout a space occupying lesion.out a space occupying lesion.


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Patients with normal prolactin levels and normalPatients with normal prolactin levels and normalimaging studies have hypothalamic amenorrhea ofimaging studies have hypothalamic amenorrhea ofuncertain etiology.uncertain etiology.

If the amenorrhea and lack of withdrawal bleedingIf the amenorrhea and lack of withdrawal bleeding

persists, prolactin levels should be measuredpersists, prolactin levels should be measured

annually since a small microadenoma could beannually since a small microadenoma could be

present that is escaping laboratory andpresent that is escaping laboratory andradiographic detection.radiographic detection.


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In this condition, as well as in the otherIn this condition, as well as in the other

hypothalamic amenorrhea situations, the patientshypothalamic amenorrhea situations, the patients

can be significantly hypo estrogenic (a lowcan be significantly hypo estrogenic (a low

estrogen situation similar to menopause). If theestrogen situation similar to menopause). If thestate is persistent, hormone replacement therapystate is persistent, hormone replacement therapy

should be considered for protection againstshould be considered for protection against

osteoporosis. One approach is to get an estradiolosteoporosis. One approach is to get an estradiol

level andlevel and if it is less than 30 pg/ml,if it is less than 30 pg/ml, counsel thecounsel thepatient that hormonal replacement therapy ispatient that hormonal replacement therapy is

indicatedindicated

assessment of a case of

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