Amenorrhea

AMENORRHEA 1) Definition-

a) Absence of menstruation.

b) Prevalance of pathologic amenorrhea- 3-4%

2)Clinical Types-

3)Primary Amenorrhea-

a) Definition-

i) Girls who not menstruate by her 16.

b)Etiopathology-

i) Hypogonadotropic hypogonadism-

-Delayed puberty.

-Hypothalamic and pituitary dysfunction.

-Kallmanns syndrome.

ii) Hypergonaddotropic hypogonadism-

-Primary ovarian failure.

-Resistant ovarian syndrome.

-Galactosemia.

-Enzyme deficiency.

iii) Abnormal chromosomal pattern-

-Turner syndrome.

-Gonadal dysgenesis.

-Partial deletion of x chromosome.

iv) Developmental defect of gonadal tract-

-Mullerian agenesis.

-Imperforated hymen.

-Transverse vaginal septum.

-Complete absence of vagina.

v) Dysfunction of thyroid and adrenal cortex-

-Adrenogenital syndrome.

-Cretinism.

vi) Metabolic disorders-

-Juveline diabetes.

vii) Systemic illness-

-Malnutrition.

-Weight loss.

-Tuberculosis.

viii) Unresponsive endometrium.

c) Investigations-

When to start-

-No period of 16 years in presence of normal sexual characters.

-No period by 14 years in absence of growth and development of secondary sexual characters.

d)Management-

i) HPO axis defect-

-Estrogen progesteron therapy.

-Treatment of gonadotropins.

-Craniopharyngioma- Cured by Surgical excision or radiotherapy.

ii) Chromosomal abnormalities-

-Defect-Turner syndrome and gonadal dysgenesis.     Cure- Use of estrogen and progesteron.

-Defect-Androgen insensitivity syndrome.     Cure-Ectopic gonads are removed.

-Hormonal replacement therapy.

-Substitution therapy.

iii) Developmental anamolies-

-Defect-Complete agenesis of vagina.     Cure-Vaginal reconstruction.Thyroid and iv) Adrenal dysfunction.

-Defect-Mild hypothyroidism     Cure-Replacement therapy.

-Defect-Adrenogenital syndrome with enlarge clitoris.      Cure-Clitoroplasty, -Corticosteroid therapy.

v) Metabolic and nutritional-

-Defect-Diabetes and tuberculosis.     Cure Antidiabetes and antituberculosis drugs.

-Correction of anemia, malabsorption, weight loss, stress.

4)Secondary Amenorrhea-

a) Definition-

-Absence of menstruation for 6 months or more.

b) Etiology and causes-

i) Uterine factors-

-Tubercular endometrisis.

-Uterine synchiae.

ii) Ovarian factors-

-PCOS.Premature ovarian failure.

-Resistant ovarian failure.

iii) Hyperestrogenic state-

-Persistant follicle in metropathia.

-Feminizing tumor of ovary.

iv) Hypothalamic amenorrhea-

-Obesity.

-Anorexia nervosa.

-Kallmanns syndrome.

v) Pituitary factors-

-Adenoma.Sheehans syndrome.

vi) Adrenal factors-

-Hyperplasia.

-Cushing syndrome.

vii) Thyroid factors-

-Thyroid dysfunction.

c) Investigations-

Aims at-

-Diagnose or confirm offending factors.

-To guide management protocol either to restore menstruation and fertility.

-General examination-

-Nutritional status.

-BMI.Hirsutism.

-Discharge of milk from breast.

-Abdominal examination.

-Presence of striae.

-A mass in lower abdomen.

-Pelvic examination-

-Enlargement of clitoris.

-Ovarian tumor.

d) Management-

i) Defect- Anxiety and stress.     Cure-Psychotherapy.

ii) Defect- Systemic illness and malnutrition.     Cure-Improve health status.

iii) Defect-Exercise induce amenorrhea.     Cure-Limitation of activity, appropriate diet.

iv) Defect-Hyperprolactenemia, inappropriate galactorrhea.     Cure-Bromocriptine, - Cabergoline, -Transnasal, transphenoidal adenectomy.

v) Defect-Premature ovarian failure.     Cure- Corticostriod therapy,

- Use of estrogen and progesteron,

- Use of GnRH agonist.

vi) Defect-Cushing disease.     Cure-External beam radiation,

-Adrenalectomy,

-Use of Mitotane, aminoglutethimide, metyrapone, ketoconazole.

vii)Defect-Hypothyroid state.     Cure-Use of thyroxine.

viii)Defect-Hyperandrogenic state.     Cure-Glucocorticoids, antiandrogen preperation, oral contraceptives.

ix) Defect-Uterine synchiae.     Cure-Hysteroscopic adhesiolysis, insertion of IUD, oral contraceptives.

x) Defect-Ovarian tumor.     Cure-Surgery.Defect-Anorexia nervosa.     Cure-Behavioral therapy, psychaitric consultation.