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AbnomalMenstruation

MeiQing Xie M.D.Professor & Associate Chairman

Department Of Obstetrics & Gynecology Sun Yat Sen Memorial Hospital

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Amenorrhea

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DefinitionAmenorrhea is the absence of menstruation.

Primary Amenorrhea

Secondary Amenorrhea

1.Absence of menses by age 16 with normal secondary sexual characteristics

2.Absence of menses by age 14 without secondary sexual characteristics development

3.Absence of menses for 6 months or 3 previous cycle in a previously menstruating women

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Basic principles in menstrual function

Compartment : the outflow tract or Ⅰuterine target organ

Compartment : the ovaryⅡ Compartment : the anterior Ⅲ

pituitary Compartment : central nervous Ⅳ

system(hypothalamic ) factors

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Compartment Ⅳ. Central Nervous System Hypothalamus

Compartment Ⅲ. Anterior Pituitary

FSH LH Compartment Ⅱ. Ovary

Estrogen Progesterone Compartment Ⅰ. Uterus

Menses

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Basic principles in menstrual function Compartment :disorders of the Ⅰ

outflow tract or uterine target organ Compartment : disorders of the ovaryⅡ Compartment :disorders of the Ⅲ

anterior pituitary Compartment :disorders of central Ⅳ

nervous system(hythalamic ) factors

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Classification of amenorrhea

uterine amenorrhea ovarian amenorrhea pituitary amenorrhea hypothalamic amenorrhea

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Rule out pregnancy!If she had sexual activity.

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PhysiologicPhysiologic AmenorrheaAmenorrhea

PregnancyLactationMenopause

HormoneHormone : contraception : contraceptionetc.etc.

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Compartment 1Disorders of the Outflow Tract or Uterus

1. Asherman’s syndrome2. Mullerian anomalies3. Androgen Insensitivity ( Testicular Feminization )4. Infection ： TB

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Asherman’s Syndrome

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Asherman’s Syndrome

Cause : – Curettage – Uterine surgery

Diagnosis : – Hysteroscopy– Hysterogram

S/S : – amenorrhea– Miscarriage – Dysmenorrhea

– Hypomenorrhea

TreatmentTreatment– Hysteroscopy Surger Surger

yy– Then IUD insertion Then IUD insertion – or pediatric foley or pediatric foley

catheter filled with catheter filled with 3ml of fluid,and 3ml of fluid,and removed after 7 daysremoved after 7 days

– Large dose of Large dose of estrogenestrogen treatment treatment

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Mullerian Mullerian anomaliesanomalies

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ImperforatImperforatee H Hymensymens

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Mayer- Rokitansky-Kuster-Hauser Syndrome ( utero-vaginal agenesis)

15% of primary amenorrhea

Normal secondary development & external female genitalia

Absent uterus and upper vagina & normal ovaries

Karyotype 46-XX 15-30% renal, skeletal and

middle ear anomalies

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Androgen Insensitivity

Normal breasts but no sexual hair

Normal looking female external genitalia

Absent uterus and upper vagina

Karyotype 46, XY Male range testosterone

level Treatment : gonadectomy

after puberty + HRT

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Mullerian Agenesis Mullerian Agenesis && Testicular emini Testicular eminizationzation

MullerianAgenesis

Testicularfeminization

Karyotype 46,XX 46,XYHeredity Not known X-liked recessiveSexual hair Normal female Absent of sparseTestosterone l Normal female Normal MaleOther anomalies Frequent RareGonadalneoplasia

Normal incidence 5% incidence of CA

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Compartment 1 AmenorrheaAmenorrhea Disorders of the Outflow Tract or Uterus

Karyotype: 46,XX; 46,XY Absent uterus and vagina Normal uterus and vaginal septum ImperforatImperforatee H Hymensymens Normal FSH,LH,E2

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Compartment 2Disorders of the Ovary

1. 1. Chromosomal Chromosomal etiologyetiology

– TurnerTurner’s’s SyndromeSyndrome– MosaicismMosaicism– XY XY gonadal gonadal dysgenesisdysgenesis(Swyer’s S)(Swyer’s S)– Gonadal Gonadal agenesisagenesis

2. 2. Resistance Resistance ovarianovarian syndromesyndrome

3. 3. Premature Premature ovarian ovarian failure failure

(( the the early early depletion depletion of of ovarian follicles)ovarian follicles)

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Compartment 2Disorders of the Ovary

4. Iatrogenic causes:

radiation and chemotherapy

５ . Infections

６ . Autoimmune disorders

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Turner’s Turner’s SyndromeSyndrome

Gonadal dysgenesis associated with Karyotype 45,XO

Mosaicism ： 4545 ，， X/46X/46 ，， XXXX Most common chromosomal abnor

mality in spontaneous abortion

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Typical features of Turner Syndrome

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Turner’s Syndrome

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XY XY gonadal gonadal dysgenesisdysgenesis(Swyer’s S)(Swyer’s S)Gonadal Gonadal agenesisagenesis

Karyotype46,XX ; 46,XY gonadal gonadal dysgenesisdysgenesis normal physical developmentnormal physical development female appearancefemale appearance primary amenorrhea gonadectomygonadectomy with Y chromosome

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Ovarian Resistance Syndrome

Ovarian Resistance Syndrome

– Primordial follicles fail to progress

– Despite elevated gonadotropins

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Premature ovarian failure

– follicular depletion before age 40

– genetics

– infectious

– physical insult :Rad.Chemo.

– Autoimmune disease

– Idiopathic POF

Premature ovarian failure

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Compartment 2Disorders of the Ovary

Karyotype: 45,X; 45,X /46,XY gonadal gonadal dysgenesisdysgenesis Normal uterus FSH↑,LH↑,E2↓

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Compartment 3Disorder of Anterior Pituitary

– Tumor: Prolactin Prolactin Secreting AdenomaSecreting Adenoma

– Empty sella syndrome

– Sheehan syndrome

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Prolactin Prolactin Secreting AdenomaSecreting Adenoma

Most common pituitary tumor 50% identified at autopsy Disruption of the reproductive mech

anism

PRL↑– Amenorrhea - Visual field defect – Galactorrhea - Headache

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Sheehan’s syndrome

Postpartum hemorrhage Acute infarction and necrosis Agalactia in the PP period amenorrhea follows Loss of pubic and axillary hair Deficiencies :

– GH, FSH, LH– ACTH, TSH ( in frequency)

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Compartment 4Compartment 4Dysorder of HypothalamusDysorder of Hypothalamus

– Psychological stress– Anorexia nervosa, weight loss– Increased exercise levels– Drug-induced amenorrhea – Space-occupying lesion of CNS– Kallmann syndrome

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Compartment 3Compartment 4Compartment 4

Normal Karyotype Normal uterus ， Normal ovary FSH↓,LH↓,E2↓

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Amenorrhea Diagnosis

History Physical examination

– Physical examination begins with vital signs, including height and weight, and with sexual maturity ratings

Laboratory evaluation

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Amenorrhea TSH

ProlactinProgestational challenge

TSH↑Withdrawal bleed

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Hypothyroidism Normal prolactinNormal TSH

Anovulation

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Estrogen and progenstin cycle

Withdrawal bleed ＋Withdrawal bleed

－

LOW normal hight

MRI

Hypothalamic amenorrhea

Ovarian failure

FSH,LH assay

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Amenorrhea TSH

ProlactinProgestational challenge

TSH↑ Withdrawal bleed

＋Withdrawal bleed

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HypothyroidismNormal prolactin

Normal TSH

Anovulation

Estrogen and progenstin cycle

Withdrawal bleed－

End organ problem

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Progestational challenge

Progesterone 20mg/d,im for 5 days

withdrawal bleeding +, anovulation

withdrawal bleeding -

estrogen and progestin cycle

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Estrogen and Progestin cycle

CEE 1.25mg/d, for 20 days. Provera 8mg/d, for 10 days in

sequence

withdrawal bleeding +, H-P-O disorder withdrawal bleeding -,utreras disorder

Differential diagnosis of amenorrhea

amenorrheaOvarian function

FSH

LHE P

Disorder of uterine and outflow tract

Normal ovulation + +Disorder of ovary Anovulation, no follicle - -Disorder of pitutary

Anovulation. No follicle - -

Disorder of central

nervous system

Anovulation. No lollicle - -anovulation but follicle development + -

Treatment of amenorrhea

amenorrhea

Ovarian functionFSH

LHE P treatment

Disorder of uterine and outflow tract

Normal ovulation + + surgery

Disorder of ovary

Anovulation, no follicle - - E+P

Disorder of pitutary

Anovulation. No follicle - - E+P

Disorder of

central

nervous

system

Anovulation. No lollicle - - E+Panovulation but follicle development + - P

Treatment of amenorrhea

Ovulation inductionCC+HCGHMG+HCGFSH+HCGBromocriptine- galactorrhea

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Reference

Clincal Gynecologic Endocrinology and Infertility

LEON SPEROFF and MARC A.FRITZ

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ThankThank youyou !!