Definition:
Absence of cyclic shedding of menstruation = No menstruation.
There is no disease called amenorrhea, it is only a symptom.
Classification:
Primary : Menarche not happens by the age of:
♦♦♦ 16 with secondary sexual characters.
♦♦♦ 14 without secondary sexual characters.
Secondary: Delay of menstruation for 3 normal cycles (Regular cycles), or
6 months (Irregular cycles).
Aetiology:
1- Physiological : Menstruation normally not occurs in such women.
2- Pathological : a- False (cryptomenorrhea).
b- True.
Physiological :
1- Before puberty. Low output of pituitary GnRH can’t stimulate ovaries.
2- After menopauses; No other follicles within ovaries, all follicles are used up.
3- Short period after menarche and before menopause:
Ovaries produce low level of estrogen can’t stimulate LH peak.
4- Pregnancy (commonest cause of secondary amenorrhea):
High levels of pregnancy hormones prevent pituitary gonadotropin.
5- Lactation: Prolactin has antigonadotrophic effect.
Pathological :
(A) False amenorrhea (cryptomenorrhea):
Menstrual blood is retained within genital tract due to obstruction as:
1. Imperforate hymen; no hymeneal orifice for outlet (commonest cause).
2. Complete transverse vaginal septum or absent vagina (agenesis).
3. Atretic cervical canal (atresia); congenital or acquired (excessive cauterization).
Imperforate hymen:
Pathogenesis & Pathology:
♦ Absorption of some fluids makes the blood dark and viscid.
♦ Menstrual blood is retained and filling the vagina “Hematocolpos”.
♦ The filled uterus with menstrual blood “Hematometra”, and the tubes “Hematosalpnix”.
♦ Peritoneal adhesions may occur in advanced cases.
Symptoms:
♦ The girl not menstruates up till now (primary amenorrhea).
♦ Monthly lower abdominal pain.
♦ Lower abdominal enlargement.
♦ Painful micturition, then retention (Distended vagina stretch and compress urethra).
Signs:
General examination: signs of puberty (breast and pubic hair).
Abdominal examination: – Pelvi abdominal mass
– Hematocolpos (soft, tense and cystic).
Pelvic examination: hymen bulging bluish, no aperture.
PR: cystic swelling is felt in front of the rectum.
US: distended uterus and vagina with altered fluid.
Treatment:
♦ General Anesthesia, complete Asepsis and Antibiotics.
♦ Cruciate incision of hymen with trimming of edges.
♦ The retained blood is allowed to escape slowly.
(B) True Amenorrhea:
(I) Hypothalamic amenorrhea:
(II) Pituitary amenorrhea:
(III) Ovarian amenorrhea:
(IV) Uterine amenorrhea:
1- Congenital: – Severe hypoplasia or agenesis.
2- Asherman syndrome:
♦ Synonyms; Intrauterine adhesions, intrauterine synechiae.
– Etiology:
– Destruction of basal layer of endometrium caused by over curettage leads
to subsequent development of intrauterine adhesions, e.g. post-abortive or post-partum curettage.
– Chronic endometritis affecting basal layer e.g. TB endometritis.
– Diagnosis:
* Clinical picture: – Amenorrhea or hypomenorrhea (post operative).
– Infertility or recurrent abortion (relative infertility).
– Uterine sound fails to pass through uterine cavity.
– No bleeding in estrogen-progesterone withdrawal.
* Investigations: – Hysterography; injecting radio opaque dye into
uterine cavity → Difficult injection of dye.
→ irregular filling defects.
– Hysteroscopy.
– Treatment:
-Hysteroscopic adhesolysis.
– Intrauterine foreign body insertion e.g. IUD for 1-2 months or balloon for 7 days.
– Drug; – Corticosteroid; inhibit fibroblastic activity.
– Antibiotic therapy; manage the inserted foreign body.
– Cyclic estrogen progesterone; promote endometrial proliferation.
3- Refractory endometrium:
– Endometrial cells have no steroid receptors so not respond to estrogen or
progesterone.
4- Destruction of endometrium:
– Sever endometritis that may destruct basal layer e.g. T.B. endometritis.
(V) Chromosomal (genetic) causes:
(VI) General causes:
1- Acute conditions affecting the body followed by short period of amenorrhea.
2- Chronic diseases with deterioration as severe anemia, TB, chronic nephritis.
3- Diabetic patient, especially uncontrolled cases.
4- Nutritional factors: starvation or marked obesity.
5- Thyroid disorders:
– Hypothyroidism; critinism or myxedema → amenorrhea and galactorrhea
– Hyperthyroidism firstly cause menorrhagia followed by amenorrhea with
picture of thyrotoxicosis.
6- Suprarenal disorders:
−−− Hypocorticism (Addison’s disease) → general disability and amenorrhea.
−−− Hypercorticism → cortical hyperplasia or adenoma.
→ Cushing’s syndrome with excess Cortisol and androgen
leading to obesity, hirsutism and amenorrhea.
Causes of primary amenorrhea.
Causes of Secondary amenorrhea.
Investigations of a case of amenorrhea:
* History:
* Personal history:
– Age: Before puberty (physiological), middle age (pregnancy, lactation), old (menopause).
– Marital state: Pregnancy is the most common cause of secondary amenorrhea.
* Menstrual history; previous menstrual pattern (in case of 2ry amenorrhea).
* Obstetric history:
– Previous complicated labor and puerpurium.
– Postpartum hemorrhage → think about Sheehan’s syndrome.
– Puerperal or post-abortive sepsis → suspect Asherman syndrome.
* Past history:
– Disease; Any recent medical or psychological disturbance.
– Drugs; contraceptive pills may cause post pill amenorrhea.
– Operation; * Curettage may be complicated with Asherman syndrome or hysterectomy.
* Irradiation may destruct ovaries.
* Present history:
– Type of amenorrhea (1ry or 2ry),
– Duration of 2ry amenorrhea.
– Associated symptoms; * 1ry amenorrhea + cyclic lower abdominal pain → cryptornenarrhea.
* 2ry amenorrhea with;
♦ Morning sickness, appetite change → Pregnancy.
♦ Hot flushes Menopause.
* Associated symptoms.
– Obesity and weight loss (Anorexia nervosa).
– ↑ ICT, Vomiting, visual disturbance or headache.
– Hirsutism (PCO or virilizing tumours).
– Galactorrhea (hyperpholactinemia).
– Symptoms-suggestive of Cushing syndrome.
* Examination:
* General examination:
1. General; Body weight, Height and span.
2. Eye; Fundus examination can suspect ↑ ICT in hypothalamic and pituitary disorders.
3. Nose; Kallmann’s syndrome presented with anosmia).
4. Neck; Goiter referring to thyroid disorders.
5. Breast; – development (Tanner staging also note pubic hair).
– Changes of pregnancy or galactorrhea
6. Hair; Hirsutism indicator of hyperandrogenic states.
7. Manifestations of syndromes; – Cushing OR Criteria of Turner syndrome.
* Abdominal and locol examination:
– Exclude pregnancy.
– Exclude cryptomenorrhea.
– Development of the genital organs.
– Any abnormality.
* Special investigations:
(A) Investigations of uterine factor:
(B) Investigations of ovarian factor:
1. Ultrasonography: visualize cyst (PCO) or mass (ovarian tumors).
2. Hormonal assay: FSH > 40 mlU/ml (ovarian failure, search for the cause).
3. Laparoscopy: confirm PCO, biopsies diagnose streak gonads & ovarian tumors.
4. Chromosomal studies:
– Missing chromosome 45XO: Turner syndrome.
– Mosaics → 46XX/45XO female turner mosaic.
→ 45XO/46XY: Male turner mosaic.
(C) Investigations of pituitary:
1. Progesterone withdrawal bleeding: negative.
2. Estrogen-progesterone withdrawal bleeding: positive.
3. FSH <40 mlU/ml
4. Hormonal assays:
– ↓ Pituitary hormone (ant loop) → Sheehan’s syndrome.
– ↓ GnH, GH: Levi-Lorain syndrome.
– ↑ GH: Acidophil adenoma.
– ↑ ACTH: Basophil adenoma.
– ↑ PRL level → chromophobe adenoma.
– Thyroid functions T3, T4, TSH.
5. Pituitary imaging: X-ray, CT and MRI.
6. Fundus examination: Adenoma compressing the optic chiasma.
(D) Investigations of hypothalamus:
1. Progesterone withdrawal: negative.
2. Estrogen-progesterone withdrawal: positive.
3. FSH <40 mlU/ml.
4. Prolactin level and thyroid functions.
5. Pituitary imaging: Normal.
Oligomenorrhea & Hypomenorrhea
* Oligomenorrhea:
♦ Few number of periods (infrequent menstruation) due to abnormally prolonged interval between
cycles; > 35 days (Normally 21-35 days).
* Hypomenorrhea:
♦ Decreased amount of menstrual blood and/ or duration of bleeding per cycle.
* Oligohypomenorrhea:
♦ Combination of both conditions,
♦ Most commonly coexist.
Etiology;
♦ Constitutional;
– Dating since puberty.
– Patient is ovulatory, fertile, and
– Need no treatment.
♦ Physiological;
– Oligohypomenorrhea frequently precedes the menopause.
♦ Pathological;
– Causes, investigation and treatment as amenorrhea.
Amenorrhea Videos:
Amenorrhea.
The Association of Professors of Gynecology and Obstetrics (APGO) Medical Student Educational Objectives define a central body of women’s health knowledge, skills and attitudes that are fundamental to the practice of a general physician, and are intended to provide clerkship directors, faculty and students with a resource for curriculum development, teaching and learning.
Amenorrhea power point presentations:
Secondary amenorrhea is defined as absence of mensesfor more than three cycles or six months in womenwho previously had menses.Pregnancy is the most common cause of secondaryamenorrhea.
CLINICAL GUIDELINES FOR EVALUATION AND MANAGEMENT OF AMENORRHEA. Dr.B.ALJOHANI
Amenorrhea, Oligomenorrhea and Hypomenorrhea