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.