PRETES

1. a. Sebutkan pengertian amenorhea primer

b. Sebutkan pengertian amenorhea sekunder
2. Sebutkan 3 amenorhea fisiologis
3. Organ apa saja yang termasuk dalam kompartemen 4
4. Sebutkan 4 hormon yang berkaitan dengan siklus haid
5. Sebutkan 2 penyakit yang termasuk dalam
kompartemen 1
6. Karakteristik haid normal
- durasi…
- Jumlah darah…
- Interval…
7. Sebutkan 2 karakteristik kallmann syndrome
8. Sebutkan karyotipe dari syndrome turner
9. Apa penyebab penderita hyperprolactinemia mengalami
amenorhea
10. Sebutkan 3 pemeriksaan penunjang yang dapat
dilakukan untuk mendiagnosis amenorhea
AMENORHEA
FARIZAN HASYIM HARI PRATHAMA
DEFINITIONS
• Primary Amenorrhea
Absence of menses by age 15 years
Absence of breast development or menses by age 13
years
• Secondary Amenorrhea
If established menses have ceased for longer than 6
months without any physiological reasons.
NORMAL MENSTRUAL CYCLE
Karakteristik haid normal :
- Durasi 4 – 7 hari
- Jumlah darah 30 – 80 ml
- Interval 24 - 35
CLASSIFICATION
• Physiological :
Pre puberty
Pregnancy related
Menopause
• Pathological
Primary
secondary
ETIOLOGI
CHRONIC DISEASE
• Malnutrition and cirrhosis associated with alcoholism
• AIDS, HIV disease, or other types of immune-deficiency states may induce
• systemic infection, lipodystrophy, or other chronic health complications
• Occult malignancy with progressive weight loss and a catabolic state may lead to
loss of menstrual regularity
• Sickle cell disease and thalassemia
• Type 1 and type 2 diabetes may both be associated with disordered menses
• Epilepsy, as well as antiepileptic medications, are associated with reproductive
dysfunction in women.
• Polycystic ovarian syndrome (PCOS)
• Hypothalamic amenorrhea
• Hyperprolactinemia
• Chronic kidney disease requiring hemodialysis
• Associated with loss of menstrual cyclicity
• Vitamin D deficiency
• High risk of bone mineral density loss.
PRIMARY AMENORRHEA
IMPERFORATE HYMEN
• Imperforate hymen represents one form of failure of
complete canalization of the vagina.
• Most frequent obstructive anomaly of the femalegenital
tract. Incidence: 1/1000-10,000
• Presentation: primary amenorrhea associated withcyclical
abdomen pain – abdominal swelling andurinary retention.
• Signs: Bluish bulging membrane at the introitus
TURNER SYNDROME
ANDROGEN INSENSITIVITY (AIS)
A syndrome found in patient with XY chromosome but
resistant to androgens (androgen insensitivity). Has male
karyotype (46XY) with female appearance. Male levels of
testosterone
Presentation:
• Female appearance with normal breast development and
external genitalia, but no pubic/axillary hair
• Primary amenorrhea, absent uterus
• Gonad - testes
MULLERIAN AGENESIS
• Usually clinically diagnosed if pubic hair present
• Normal breast development
• Pelvic ultrasound shows absent uterus and normal
ovaries and/or serum testosterone in normal female range
• Vaginal dilator or vaginoplasty when sexual activity is
desired
KALLMANN’S SYNDROME
• Incidence is 1/50,000 females More common in males -
1/4000-1/10,000
• Congenital disorder (CHH) characterized by:
1) Hypogonadotropic hypogonadism
2) Eunuchoidal features
3) Anosmia or hyposmia
4) Primary amenorrhea
• Failure of the hypothalamus to release GnRH at the
appropriate time as a result of the GnRH releasing
neurones not migrating into the correct location during
embryonic development.
SECONDARY
AMENORRHEA
POLYCYSTIC OVARIAN SYNDROME
• PCOS accounts for 90% of cases of oligoamenorrhea
• Also known as Stein-Leventhal syndrome
• The etiology is probably related to insulin resistance, with
a failure of normal follicular development and ovulation
• The classical picture – AMENORRHEA, OBESE,
SUBINFERTILITY and HIRSUITISM
• CRITERIA FOR PCOS :
1. OLIGO- OR ANOVULATION
2. CLINICAL AND/OR BIOCHEMICAL SIGNS OF
HYPERANDROGENISM
3. POLYCYSTIC OVARIES
Exclusion of other etiologies (CAH, androgen secreting
tumors, cushing syndrome
HYPOTHALAMIC CAUSE
• Hypothalamic dysfunction is a common cause (30%-35%)
• It is more often seen as a result of stress, intense
exercise, weight loss and eating disorders
• NEED minimum of 18% body fat to bleed
• Infiltrative disease (Craniopharyngioma, sarcoidosis,
histiocytosis)
PITUITARY CAUSES
• Pituitary failure  It is usually the acquired type as the
result of trauma, treatment of pituitary tumor or infarction
after massive blood loss ( Sheehan’s syndrome )
• Pituitary tumor  Hyperprolactinemia which cause
secondary amenorrhea.
TSH-INDUCED
HYPERPROLACTINEMIA
• Primary hypothyroidism
• Modest (10%) increase in prolactin
• May have appearance of tumor on MRI
• Mechanism: Increased TRH stimulating lactotropes
HYPERPROLACTINEMIA
• Hyperprolactinaemia accounts for 20% of cases of
amenorrhea.
• Prolactin inhibits GnRH release from the hypothalamus
• Drugs that may cause hyperprolactinaemia:
1). Phenothiazines
2). Methyldopa
3). Cimetidine
4). Butyrophenones
5). Antihistamines
ENDOCRINE CAUSE
• Thyroid disorder and Cushing’s disease interfere with
the normal functioning of the hypothalamic  pituitary 
ovarian axis  present with amenorrhea.
• High level of thyroxine inhibit FSH release.
• Androgen  secreting tumors of the ovaries  cause
secondary amenorrhea.
CUSHING SYNDROME
ASHERMAN’S SYNDROME
• Risks
Dilation and curettage
- Highest risk if peripartum curettage
Surgery
- Myomectomy
Infection
- Tuberculosis in undeveloped countries
ANOREKSIA
DIAGNOSIS
PUBERTAL/MENSTRUAL HISTORY
• Pregnancy?
• Age of thelarche, pubarche and menarche
• Patterns of bleeding
EVALUATION: HISTORY
• Possibility of pregnancy
• Medical history
• Medications
• Prior surgeries
• Dietary history
• Adolescent /pubertal history
• Headaches
• Blurry vision
• Sx of Diabetes Insipidus
• Breast discharge
• Constipation
• Diarrhea
• Hot flashes
• Vaginal dryness
• Insomnia
• Sexual dysfunction
• Excess hair growth
• Acne
• Change in weight
PHYSICAL EXAM/ANATOMIC
EVALUATION
• Breast present or absent
• Uterus present or absent
• Secondary sexual characteristics
• Body habitus
• Hirsutism
• Acanthosis Nigricans
• Enlarged thyroid
• Galactorrhea
• Vaginal atrophy vs estrogenized vagina, cervical mucus
INVESTIGATING PRIMARY
AMENORRHEA
• BLOOD TESTS
• ULTRASOUND
• CT scan of pituitary
• KAROTYPING
• LAPAROSCOPY
INVESTIGATING SECONDARY
AMENORRHEA
• Once pregnancy has been excluded

• TSH (thyroid stimulating hormone)

• Progesterone challenge test
• FSH, LH, Estradiol
• Prolactin level
DIAGNOSIS
TREATMENT
• PITUITARY TUMOR 
Cabergoline/Bromocriptine/Surgery
• ANDROGEN producing tumor of ovary  Surgery
• ANDROGEN INSENSITIVITY  removed gonads + HRT
• TURNER’S syndrome  HRT/possibly egg donation
• IMPERFORATE HYMEN  surgical incision
• THYROID disease  appropriate medical treatment
• POI  HRT/egg donation
• EATING DISORDERS  referred to psychiatrist
• EXCESSIVE EXERCISE  counseling/stress
management/HRT
• PCOS  appropriate treatment- fertility rx/ovarian
drilling/BCPS/Monthly P4 withdrawal/weight
reduction/lifestyle
• ASHERMAN’s syndrome  breaking down adhesion +
insert IUD/uterine stent + estrogen