amenorrhea (and dysfunctional uterine bleeding) dr. elham ghanbari jolfaei ob&md gynecologiest
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Amenorrhea Amenorrhea (and Dysfunctional (and Dysfunctional Uterine Bleeding)Uterine Bleeding)
Dr. ELHAM GHANBARI JOLFAEIOB&MD
Gynecologiest
Amenorrhea: Amenorrhea: “absence of menses“absence of menses””
“Normal cycle is 28 days◦This occurs in 15% of cycles
98% have cycles between 24-35 days
Average duration 4-6 days (2-8 normal)
Average blood loss per cycle = 30 ml.
◦ >80 ml. Leads to risk for anemia
PRIMARY AMENORRHEAPRIMARY AMENORRHEA
Patient has never menstruated
◦No period by age 14 with no secondary sexual characteristics
◦No period by age 16 regardless of secondary sexual characteristics
SECONDARY SECONDARY AMENORRHEAAMENORRHEA
Previously established cycles cease
ALWAYS RULE OUT ALWAYS RULE OUT PREGNANCYPREGNANCY
Then evaluate the four parts of the system
REASONS FOR REASONS FOR AMENORRHEAAMENORRHEA
PregnancyMenopauseThyroid/Prolactin DisordersAnovulationOutflow obstructionCNS/hypothalamic dysfunctionDrugs/Stress/NutritionChromosomal/Abnormal Sexual
Differentiation
ALWAYS RULE OUT ALWAYS RULE OUT PREGNANCYPREGNANCY!!!!!!!!!!!!!!No matter WHAT!!!
STEP ONE – STEP ONE – will diagnose pregnancy, thyroid will diagnose pregnancy, thyroid disorder, hypoprolactinemia and disorder, hypoprolactinemia and
anovulationanovulationLABS
◦Beta hcg◦TSH◦ProlactinMEDS
◦Progestin challenge{If galactorrhea, obtain MRI of
pituitary/sella turcica}
STEP TWO – will diagnose STEP TWO – will diagnose outflow tract obstructionoutflow tract obstruction
Give estrogen “priming”, followed by progestin
◦Estrogen x 21 days◦Add progesterone for the last 5 days
STEP 3- will determine if STEP 3- will determine if lack of estrogen is due to lack of estrogen is due to ovarian failure vs. altered ovarian failure vs. altered CNS/pituitary axisCNS/pituitary axis
FSH(LH)
I. I. UTERUS – VAGINA – UTERUS – VAGINA – OUTFLOW TRACTOUTFLOW TRACT
Asherman’s – secondary amenorrhea
Imperforate hymen – primary amenorrhea
Vaginal septum – primary amenorrhea
Agenesis – primary amenorrheaTesticular feminization – primary
amenorrhea
II. OVARYII. OVARY Chromosomes Normal-◦Menopause◦Radiation/Chemo◦Autoimmune Disorder◦InfectionChromosomes Abnormal-
◦Primary Amenorrhea◦Premature Menopause
III. ANTERIOR PITUITARYIII. ANTERIOR PITUITARY
Prolactin Secreting TumorsSheehan’s Syndrome
IV. CNS / HYPOTHALAMUSIV. CNS / HYPOTHALAMUSWeight loss, anorexia, stress,
intense exerciseHypothyroidism – TRH/drugs
which affect dopamineAnovulationHypothalamic Suppression
ALWAYS, ALWAYS, ALWAYS, ALWAYS, ALWAYSALWAYS
RULE OUT PREGNANCY
CASE STUDYCASE STUDY
17 year old female with primary amenorrhea. She is of normal
weight and has mature secondary sexual characteristics.
CASE STUDYCASE STUDY
15 year old with three months of secondary amenorrhea. She
underwent normal pubertal development and had menarche at
age 12 with regular cycles for three years. She is on the track
team.
CASE STUDYCASE STUDY
42 year old G3P3 with 5 months amenorrhea. Normal weight. Has
been experiencing hot flashes.
CASE STUDYCASE STUDY
28 year old G2P2 with 8 months of amenorrhea. Has been gaining
weight lately, feels cold all of the time, and complains of
constipation and fatigue.
CASE STUDYCASE STUDY
35 year old G0 with amenorrhea for 9 months. Overweight.
Slightly hirsute.