Amenorrhea Flashcards
Def
- types
- absence of menstruation
- types
• phsyiological : - before puberty : no fsh /lh
- after menopause : depletion of oocytes
- during preg : continuous prg/estro
- during lactation: prl interfer with lh surge ~> anovulation , prl also inhibits gnRH
• pathological
* outflow tract
* ut
+ secondary sexual charach
- ovaries
- pit
- hypothalamus
- secondary sexual charach ( in primary amen only as all secondary amen have secondary sexual charach)
- endocrine problems
Talk about outflow tract
(3)
- There are secondary sexual
- primary amen ( as all congenital )
- cryptoamenorrhra
Incidence of outflow tract
1- imperforted hymen
2- transverse vaginal septum
3- cervical atresia
Talk about imperforted hymen
(5)
- patho : no orifice ~> blood accumulation
* hematocolpos
* hematometra
* hematosalpinx
*endometriosis
- cp : (4)
- secondary sexual
- 1st amenorrhea
- abdominal swelling due to blood accumulation
Misdiagnosed as preg - synchronising pain with menstral cycle ( elly ezed elten balla )
- signs :
Insp , palpation of lower abdomin ~> suprapubic bulge law hematocolpos shda helha
Insp of vulva , vagina ~> no orifice , bluish colour if hematocolpos is large
- inv : pelvic us : hematocolpos etc
- ttt : cruciate insicion , drainge of dark accumulated blood
Talk about transverse
(5)
- pathogensis : transverse septum between upper vag ~> mullerian duct and lowr vag ~> urogenital sinus ~> accumulation of blood
* hematocolpos
* hematometra
* hematosalpinx
*endometriosis
- cp : * secondary sexual
- 1st amenorrhea
- abdominal swelling due to blood accumulation
Misdiagnosed as preg - synchronising pain with menstral cycle ( elly ezed elten balla )
- signs :
Insp , palpation of lower abdomin ~> suprapubic bulge law hematocolpos shda helha
Insp of vulva , vagina ~> normal hymenal orifice with deeper septum
- inv : pelvic us : hematocolpos etc
- ttt : total exsicion of septum ( vaginal with a report )
Talk about cervical atresia
(5)
- patho : failure of canalization of cervix ~> accumulation of blood
- hematometra
- hematosalpinx
*endometriosis :BUT ITS EARLER ( closer to ut) - cp : * secondary sexual
- 1st amenorrhea
- abdominal swelling due to blood accumulation
Misdiagnosed as preg - synchronising pain with menstral cycle ( elly ezed elten balla )
- signs :
Insp , palpation of lower abdomin ~> suprapubic bulge
Insp of vulva , vagina ~> normal hymenal orifice ( exclude imperfort)
- inv : pelvic us : cervical atresia , hematometra etc
- ttt :
- canalisation is attempted with poor prognosis
- resection &anastomisis ~> infection , fast abortion
- hysterectomy is done
Talk about mullerian agenesis
( MRKH )
(5)
-Pathogenesis :Mullerian agenesis~>absence of tubes, uterus, cervix, upper vagina
-cp : *secondary sexual characters
*primary amenorrhea,
*infertility, no uterus
* dyspareunia, short, blind-ended vagina
-Signs : pv : Short blind-ended vagina, no cervix, no uterus
-Inv:
Karyotyping 46XX ( مانا حايفة ماهي معندهاش حاجة(
Pelvic us : No tubes, no uterus, etc
-Ttt: Uterine transplantation to treat infertility Vaginoplasty or McIndoe procedure to treat dyspareunia
Talk about complete androgen insensitivity
( testicular feminzation )
(5)
- patho : 46xy with andro insensitivity ~> external female genitalia, small dimple vagina ~> beacuse of Y chromosome ~> inhibition of mullerian system develop ( along with mullerian inhib factors ) and testicular differntiation
- cp :
*Secondary sexual due Fat cells ( androgen~> E1) ,Hairless due to androgen insensitivity.
* 1st anennorrhea
*Infertility, no uterus.
*Dyspareunia. Small dimple vagina.
-signs : External female genitalia. Small dimple vagina. Gonadal tissue into external female genitalia or inguinal canal.
- Inv:
*Karyotyping. 46XY
*Pelvic U.S. Absence of uterus etc
-ttt : (3)
*Gonadectomy. 20% risk of gonadoplastoma. *New vagina or vaginoplasty or Mcindoe to treat dyspareunia.
*Estrogen to preserve the external female appearance , prevent Osteoporosis.
Talk about asherman syndrome
(4)
-patho : endometritis (post-abortive, IUD, Tb ,vigorous currettage in D and C)
- cp : secondary amenorrhea following endometritis
-INV: histoscope
-TTT: lysis of adhesions with cyclic progesterone, estrogen, for three successive cycles to restore endometrial regeneration.
Incidenoce of primary amen
- turner
- mullerian
- androgen insensitivity
Ovarian ?
- turner
- pco
- pof or poi
Talk about turner
(3)
- patho: Ovaries are connective tissue streaks
-CP:
*No secondary sexual.
*Primary amenorrhea.
*Turner syndrome.
•Short stature, Low posterior hairline
• 3W
Webbing of the neck
Widely separated nipples.
Wide carrying angle
Coarctation of aorta
-ttt :
Cyclic PRG and estrogen ~> menaces, prevent osteoporosis, secondary sexual
No preg ~> no oocytes
**Mosaic-Turner syndrome may have menses and got pregnant, but they undergo menopause very early or POF.
Talk Bout pof or poi
(5)
-DEF: Premature failure of the ovaries to ovulate due to early exhaustion of premordial follicles
- age : before 45
-Etiology :
•Idiopathic associated with autoimmune ovarian destruction
•Karyotyping :Loss of small portion of X chromosome
•Infection: mumps
•Chemotherapy, radiation
-CP :Secondary amenorrhea with high FSH and LH
-TTT : HRT To avoid complications of premature menopause (Osteoporosis)
Talk about resistent ovary syndrome
-Secondary amenorrhea with high FSH and LH. -Defect of ovarian receptors to LH and FSH. -Temporary
-AMH levels to differentiate between POF or poi
Pit ?
- insufficiency
- empty sella
- prolactinoma
Talk about pit Insufficiency
(2)
- diminished levels of FSH and LH due to :-•Sheehan syndrome, necrosis of anterior lobe of pituitary gland, following severe postpartum hemorrhage (failure to lactate)
•Simmond disease, exhaustion of pituitary gland
•radiation
•pituitary infarction
-ttt:
•complete replacement of hormones from anterior lobe, TSH, ACTH, etc.
•Cyclic PRG \estrogen prevents osteoporosis secondary sexual characters , menses
• Induction of ovulation by FSH and HCG
Talk about empty sella syndrome
(4)
-def : sella torcica but the pituitary gland is not entirely filling it
-patho: defect in diaphragma sella, causing the CSF to drop on pituitary stalk, causing pressure atrophy.
-CP, secondary amenorrhea with galactorrhea
-inv :CT or MRI.
Talk about prolactinoma
- bu gnrh inhibition , lh surge ~> anovulayion , 2ry amenorrhea
- prolactinoma is the commenst cause for hyper prolactimia
- is most common pit cause for 2ry ameno
Hypothalamus ?
- kalmann syndrome
- psychiatric
- rapid weight loss , excessive exercise
- drug induced
Talk about kalmann syndrome
(3)
- patho :Deficiency of GnRH and anosmia due to failure of olfactory placode to pass into nose
-CP: no secondary sexual
primary amenorrhea
-TTT:
*cyclic PRG and estro for secondary sexual ,menses ,prevent osteoporosis
*induction of ovulation by FSH-HCG.
Talk about psychiatric
-Stressful life events
-False pregnancy or pseudocyesis: It happens in extremely emotional woman desirous of pregnancy(Stress) with galacturia due to high prolactin
-Anorexia nervosa Bulimia in 50% of cases
Talk about rapid weight loss , excessive exercise
-Minimum of 20% of body fat responsible for initiation of menarche , maintenance of it. Loss of 20% can cause 2ry amen amenorrhea.
-Excessive exercise due to increased endorphins inhibiting GnRH~> 2ry amen
Talk about drug induced amen
1-GnRH agonists: Continuous usage ~> down regulation receptor effect ~>Low GnRH, low FSH and LH ~> 2ry amenorrhea
2-OCPs:
*Continuous usage ~>2ry amenorrhea
*Resolving except in 1% called postpill amenorrhea due to excessive continuous and combination OCP intake,Self-limiting within 2-6 months.
3-Androgenic drugs as denazole taken in endometriosis Because of atrophic endometrial changes
4-Antipsychotics and tricyclic antidepressants: + prl
Talk about endocrine problems
1-Cushing’s syndrome due to androgenic activity
2- Primary hypothyroidism :TRH increases prl
3-Hyperthyroidism : Release of stress hormone, (cortisol ),Fast metabolism of estro and prg ~> Imbalance
Clinicl asses in case of amen
1- History Taking to Differentiate Between 1st Amenorrhea and 2ry Amenorrhea
2- Exclude Physiological Causes
3- Local Examination in Cases of Crypto-Amenorrhea
4-General Examination to Look for Secondary Sexual Characters
5-If Present, then Pelvic US,
6-Not Present, Hormonal Assay
7-Genetic Studies
Listen to voice 17
List Seconadary amen
(10)
1- ashermann
2-pof
3- pco
4- prolactinoma
5- insufficiency
6- empty sella
7-,psychiatric
8- rapid weight ….
9- drug induced
10- endocrine
ALL SECONDARY AMEN HAVE SECONDARY SEXUAL
Types of estrogen
1- Estradiol (E2 ) : ovaries, the most potent.
2- Estrone (E1) : fat cells, weaker than E2
3- Estriol (E3) : placenta , the weakest
