Amenorrhea

Gedefaw Tigabu
• Who needs evaluation
Full filling the definition
Having stigmata of turner syndrome
Obvious virilization
History of uterine curettage
Delayed puberty
Workup
• First exclude pregnancy and physiological causes
anatomical cause with history and pelvic
examination, secondary sexual characteristics
• Serum β-HCG history of sexual intercourse,
presumptive symptoms
• Eating disorder, elite athlete?
• Is it primary or Secondary?
Etiology of Amenorrhea
Uterus Absent Uterus Present

Breast – Absent 17, 20 desmolase 1. Gonadal failure

deficiency turner 45X
17 a hydroxylase Gonadal dysgenisis
deficiency 46xy
Agonadism 17 a hydroxylase
deficiency with
46XX
2. Hypothalamic
failure
3. Pituitary failure

Breast – Present AIS (T.F.) Hypothalamic,

pituitary, ovarian pt
uterine etiology
Mullerianagenesis
Absent breast + presence of uterus
(Hypogonadism)
Serum FSH

LOW (less than 5 IU/l.)

HIGH (more than 20 IU/l)
Hypothalamo - pituitary
PRIMARY OV. FAILURE
GnRH challenge .

LOW FSH HIGH FSH Gonadal dysgenesis

KARYOTYPE
Gonadal biopsy
PITUITARY HYPOTHALAMIC

History , exam & investigation

2. Presence breast + absence uterus

Sexual hair & Karyotype

46-XY 46-XX

Andogen Mullerian
Insenitivity Agenesis
(TSF syndrome) (MRKH syndrome)

Absent sexual
hair Presence of
sexual hair
3. absence breast + absence uterus

•17, 20 desmolase deficiency

•17 a hydroxylase deficiency
•Agonadism

Very rare
All are 46
XY
4. Presence breast + presence uterus (Like secondary amenorrhea)
PREGESTERONE
BLEEDING NO BLEEDING

CHRONIC ANOVULATION COMBINED OESTROGEN

e.g PCOS & PROGESTERONE

BLEEDING NO BLEEDING

OVARIAN FAILURE UTERINE FACTOR

( Non dysgenetic) ( Ashermann syndrome)

SERUM FSH
• False positive estrogen progesterone challenge test
Hyphothalamic amenorrhea
Early stages of ovarian failure
PCOS and CAH
• 20 percent o women in whom estrogen is present will
fail to bleed following progesterone withdrawal
• to 40 percent of women with hypothalamic
amenorrhea due to stress, weight loss, or exercise
• and in up to 50 percent of women with POF bleeding
derives rom endometrium that grew prior to
amenorrhea onset
Primary
Secondary
Management
Depends on etiology and desire of pregnancy
Pregnancy: ANC
Hypothyroidism: levothyroxine supplement
1.6µg/kg per day
Hyperprolactinemia : Dopamine agonist
bromocriptine
Eating disorders: behavioral therapy
Hypogonads: need estrogen progesterone
replacement except with sensitive tumors
Anatomic defects: surgery may be helpful
Pituitary adenoma :surgery if not tolerable
 PCOS
Metformin
Progesterone, COC
Spironolactone
Clomiphene citrate (Selective estrogen-receptor modulator)
 aromatase inhibitor such as letrozole
 Non classic CAH corticosteroids
 Patient Education
References
• Williams Gynecology 3rd edition
• ACOG and FIGO publications
• Berk and Novaks 15th edition
• Clinical endocrinology and reproductive gynecology
THANK YOU