Dr Khaldoun Khamaiseh MRCP FRCOG

Consultant Obstetrician & Gynecologist and Reproductive endocrinologist

Menarche occur between 11-14 years of age

Regular menstruation indicates that the hypothalamo–pituitary–ovarian axis is intact

Cycles between 23 and 35 days indicates ovulation.

The luteal phase is fixed(14 days) and the follicular phase is variable

Diagnosed when there is amenorrhoea in girls up to age of 14 years of age who have no secondary sexual characteristics.

Or, when there is amenorrhoea in girls up to age of 16 yrs with normal secondary sexual characteristics.

Defined as absent periods for at least six months in a woman who has previously had regular periods

hirsutism

menopausal symptoms

headache or visual disturbance – suggestive of CNS tumor such as craniopharyngioma

anosmia – one of the causes is Kallmans syndrome

chronic systemic illness, chemotherapy, radiotherapy

Chromosomal : Turner, fragile X syndrome

Hypothalamic: Kallman’s syndrome

Pituitary: Hypogonadotrohic hypogonadism

(Levi Lorraine syndrome)

Congenital uterine hypoplasia/Aplasia

(Meyer Rokitansky Kuster Hauser Syndrome)

Anorexia nervosa

Testicular feminization syndrome: XY male karyotype, normal breast development, short vagina, absent uterus, gonads should be removed agfter puberty to prevent dysgerminoma

Late onset congenital Adrenal hyperplasia: Severe hirsutism and amenorrhoea

Ovarian in origin 40% (PCOS, ovarian failure)

Hypothalamic 35% (Hyperprolactinaemia, Sheehan’s, pituitary necrosis due severe PPH)

Uterine in origin. 5% (Asherman’s syndrome)

Iatrogenic

Severe systemic illness: Renal failure, Endocrine

Secondary amenorrhoea can follow destruction and scarring of the endometrium and/or cervical canal resulting from postpartum curettage.

Typically, multiple synechiae may be seen on hysteroscopy.

Asherman's syndrome has been reported following generalised pelvic infection.

Treatment Hysteroscopic lysis of adhesions . Up to 80% of

patients can conceive following treatment but pregnancy is frequently complicated by premature labour, abnormal placentation (accrete/praevia) and postpartum haemorrhage.

Antipsychotics

Chemotherapy

Radiotherapy

Illicit drug use e.g. cocaine and opiates

Primary or secondary,

Age of the woman.

take a history, examine then requesting the appropriate investigations

Rule out physiological cause: Pregnancy , Lactation and menopause.

Irregular menstrual cycles – associated with polycystic ovary syndrome

malaise, fatigue, anorexia, weight loss – may be due to chronic illness

headaches – may be suggestive of CNS tumor

galactorrhoea – may be due to prolactinoma

H/O postpartum hemorrhage – may be associated with Sheehans syndrome

H/O dilataion and curretage – may be associated with Ashermans syndrome

Drugs: Contraception, antidepressants and antipsychotics, Chemotherapy

General Weight, height, body mass index (BMI) Blood pressure, thyroid,

Dysmorphic signs

Tanner staging: Breast, axillary and pubic hair stages

The woman's height and weight should be recorded.

Raised BMI is associated with polycystic ovarian syndrome

Reduced BMI with stress, anorexia nervosa.

Male pattern baldness and features of virilisation may be due to androgen secreting tumors of the ovary.

Assess for galactorrhoea by doing a breast examination.

Look out for features of hypothroidism.

Abdomen/pelvis Mass arising from pelvis

Perineum Inspection

Under anaesthesia, vaginoscopy, hysteroscope or cystoscope,

Pregnancy test

FSH & LH.

PCOS

TURNER SYNDROME

ovarian failure

Pituitary failure, anorexia

Prolactin levels

Testosterone levels , DHEA & Androstenodione

Estrogen and progesterone challenge tests.

Ultrasound and MRI

hysteroscopy and laparoscopy

Karyotyping in premature ovarian failure,

HRT. Estrogen and progesterone

Dopamine agonists: cabergoline,bromocriptine,

Surgery: Reconstructive, adhesiolysis

Thank you

A- first pregnancy in a woman's life.

B- Last period in the woman's life

C- First period in woman's life

D- Painful periods

E- Heavy periods

A- protein

B- Steroid

C- Lipid

D- Glycoprotein

E- Glycolipid

A- Ovarian failure

B- Addisons disease

C- Hyperthyroidism

D- Hyperprolactinaemia

E- Diabetes

A- High estrogen

B- Low FSH and LH

C- High progesterone

D- High FSH and LH

E- Non of the above

A- Continuous combined HRT

B- Estrogen only HRT - oral tablets

C- Estrogen only HRT - patches

D- Sequential combined HRT

E- Tibolone

a. chronic renal failure.

b. Galactorrhea.

c. Cimitidine therapy.

d. Methyldopa therapy.

e. Adrenogenital syndrome.

7- Recognised causes of raised FSH

a. Polycystic ovarian syndrome

b. Anorexia nervosa

c. Premature ovarian failure

d. Kallman's syndrome

e. All of the above

8- Concerning the menstrual cycle:

a- New endometrial growth starts during menstruation

b- Ovulation coincides with LH peak

c- Menstruation occurs following estrogen withdrawal

d- Is not ovualtory if the cycle is short

e- Is always prolonged if high prolactin level is present

9- Premature ovarian failure

a. The incidence is 5%

b. It may be associated with

hypothyroidism

c. Ovarian biopsy is essential to confirm

the diagnosis

d. Spontaneous pregnancy never occurs

e. Primary amenorrhoea occurs in 90% of

cases

10- All the following are features of Turner's syndrome, except

a. Cystic hygroma

b. Lymphoedema

c. Coarctation of the aorta

d. Cubitus varus

e. kyphoscoliosis

11- One of the following causes only primary amenorrhoea

A- Polycystic ovarian syndrome

B- Hyperprolactinaemia

C- Mullerian agenesis

D- Chemotherapy

D-Turner syndrome

12- Testicular fenminization syndrome(Androgen insensitivity) is a cause of primary amenorrhoea, the karyotype is

A- XO

B- XX

C- XY

D- XXX

E- XXY

A- Reduces the incidence of respiratory distress

syndrome

B- Reduces the incidence of intraventricular

hemorrhage

C- Used between 26 -34 weeks gestation

D- Betamethasone and dexamethasone may be given

E- Contraindicated in uncontrolled DM because it causes

severe hyperglycemia

a. The donar twin develops oligohydramnios and intrauterine growth restriction b. The recipient twin is at more risk of intrauterine fetal death c. Fetal hydrops develops in the donor twin d. Fetoscopic laser ablation is an established treatment e. Should be managed by fetal medicine specialist