AMENORRHOEA

AMENORRHOEA
 Absence of Menstruation
 10 – Failure to menstruate at the onset of puberty (by
16yrs/14yrs (Sexual Charec.) in absence of sec
 20 – Absence of menses 6 months in a woman who has
previously been menstrually regularly
Aetiology:
I. Hypergonadotropic 10 Amenorrhoea
A. Abnormal sex chromosomes
Gonadal dysgenesis : 45 OX (TURNER, SYD);
MOSAKS; Abnormal X.
B. Normal sex chromosomes
 46 XX pure gonadal dysgenesis
 46 XY gonadal dysgenesis (Swyer’s syndrome)
 Gonadotropin – resistant ovary synd.;- savage syn
II. Eugonadotropic 10 Amenorrhoea :
A. Absent / Nonfunctional uterus
 Congenital Mullerian agenesis
 Testicular feminizing syndrome
B. Functional Uterus
 Imperforate Hymen / Transverse vag. septum
 Vaginal atresia
C. Adrenal / Thyroid diseases
III. Hypogonadotropic 10 Amenorrhoea :
A. Hypothalamic Coz’s
 Delayed Menarche
 Hypothalamic hypogonadism (Kallman’s synd.)
 Psychogenic /wt. loss
B. Pituitary Coz’s :
Neoplasms – Prolactinomas; Craniopharyngiomas
Hypo pituitary states: Simmond’s disease
Chiami – frommel syndrome & forbes – Albright
syndrome
C. Severe Systemic disease like T.B
CHECK LIST OF SYMPTOMS AND SIGNS,
AND INVESTIGATIONS IN 10
AMENORRHOEA
Symptoms :
• Exogenous steroid intake
• Family history of delayed puberty / menarche (or)
chr. abn.
• Social – psychological problems
• Excessive wt. loss; dieting; vigorous exercise
• Cyclical lower abdomen pain
• Anosmia; headaches; visual disturbances;
Galactorrhoea
• Head injury; brain irradiation (or) surgery);
Meningitis; Chemotherapy.
• Virilising symp. – Hirsutism; change in voice.
SIGNS:
• Personality
• Height
• Nutritional status
• 20 sex charec.
• Acne; Hirsutism
• Visual fields; expressible galactorrhoea
• Turner’s synd. Features : webbing of neck;
widely spaced nipples; pectus cavum;
congenital heart disease.
• Lower abdominal mass
• Vaginal examination
- External genitalia
- Clitoromegaly
- Imperforate hymen (Tr. Septum)
- Absent / blind – ending vagina
- Uterus & cervix (present / absent on P/R)
General Investigations:
• Chr. Analysis / Karyotype
• Serum LH / FSH / Prolactin / Oestrogens &
Androgens
• X-Rays of wrist & metacarpal bones
• Plain skull X-ray; coned view X-rays / CAT. of
pituitary fossa.
Management of 10 Amenorrhoea :
- To initiate full reproductive potential
- In whom fertility is impossible, Rx to allow
adequate physical development & normal coital
relations.
Correction of short stature :
Imp. Growth determinants are present on short
& long arm of X – chromosomes
Hence in Turner’s syndrome - short stature
 Anabolic steroids may ↑ Ht.
 Pituitary dwarfism due to isolated growth hormone
def. if recognized for the 1st time in patient
presenting with 10 Amenorrhoea.
Rx with G.H. before ‘E’ & ‘P’ Rx is introduced (to
prevent rapid epiphysial fusion)
Correction of sexual infantilism :
Primary breast development can be used by OC pills –
2-3 yrs, commencing Rx around puberty.
Surgery :
- Neurosurgery is indicated in patients with
craniopharyngioma & pituitary tumors.
- In patients with XY Karyotype  Removal
of testicular tissue.
- Construction of an artificial vagina with
isolated vaginal atresia.
- Cryptomenorrhoea with imperforate hymen –
Cruciate incision.
ETIOLOGY OF SECONDARY
AMENORRHOEA
I. CRANIUM:
1. Hypothalamus: - Wt. change
- Anorexia nervosa
- Vigorous exercise
- Stress – anxiety
• Drugs : - Phenothiazines
- Morphine
- Methyl d & a
- Reserpine
- Antihistamines
 Hyperprolactinemia; amenorrhoea – galactorrhoea synd.
 PCOD
 Intracranial supra-sellar tumours – Craniopharyngioma
- Glioma
- Sec. malignancy
2. Pituitary Gland:
• Tumors: Prolactinomas
• Necrosis (Sheeharis syndrome)
• Empty – sella synd.
II. OVARY :
1. Premature ovarian failure
• True premature menopause
• Auto-immune
• Radiotherapy
• Chemotherapy
2. Functioning ovarian tumors – Virilising tumors.
III. UTERUS : Asherman’s synd
Tubercular endometritis
IV. General : - Hyperthyroidism
- Chronic renal failure
- Chronic liver disease
Symptoms : - Use of OC pills
- Pregnancy
- Lactation
- H/o Hysterectomy
- Wt loss, stress, vig exercise, Anorexia
nervosa.
- Visual disturbances, anosmia
galactorrhoea
- Family H/o premature menopause
- Hot flushes
- Drugs
- H/o PPH
- Curellage
- Radiotherapy / Chemotherapy
- Hirsutism
- T.B. / Thyroid / Renal / Liver disease
Signs : - Psychological status
- Wt. Nutritional status
- Visual fields, galactorrhoea, fundoscopy
- Features of Turner’s synd; Hypo /
Hyperthyroidism. Chr. Renal / Liver disease /
Cushing's disease Hypo pituitaries
- Acne / Hirsutism; loss of axillary pubic hair
- Vaginal examination: Clitoromegaly
Atrophy of vulva & vaginal skin
Uterine size
Ovarian tumor
Rx :
1. Severe Anorexia Nervosa combined management
with psychiatrist. Hospitalization for 2-3 months.
2. Temp. derangement of Neuro endocrine system
due to stressful states connection of
Social & domestic problem underlying
cause
SURGERY :
Intracranial surgery: 1. Craniopharyngioma
2. Cushing’s synd due to
pituitary adenoma
3. Macroadema
(Prolactinoma)
Bilateral Ov. wedge Resection – PCOD
Surgical excision – Virilising tumors
Hysteroscopic lysis of intrauterine adhesions
insertion of IUCD
Investigations :
Prog. Challenge test
+ve -ve
Anovulation 1. Low end. Estrogen
2. Non func. end
3. Out flow obstruct
4. Absent uterus.
Oestrogen challenge test
+ve 2. Non func. end.

1. (Low end. oestrogen) 3. Out flow obst.
Cst. FSH 4. Absent uterus
LH
(OV. Failure) (H-P failure)
Karyotype Sr. Prolactin

(N) /
- X-Ray GnRH challenge test

- CAT scan of pituitary fossa
+ -
Hypothalamic defect Pituitary defect

AMENORRHOEA

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AMENORRHOEA

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AMENORRHOEA

Oestrogen challenge test

+ve 2. Non func. end.

Karyotype Sr. Prolactin

- X-Ray GnRH challenge test

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