O slideshow foi denunciado.
Utilizamos seu perfil e dados de atividades no LinkedIn para personalizar e exibir anúncios mais relevantes. Altere suas preferências de anúncios quando desejar.
Amenorrhoea
Prof.
Aboubakr
Elnashar
Benha
university
hospital,
Egypt
elnashar53@hotmail.com
Aboubakr
Elnashar
CONTENTS
1.
...
Sequence
Of
Menstruation
CNS
IV.
Hypothalamus

GnRh

III.
Ant.
Pituitary
FSH
+
LH

II.
Ovary

E
+
P

I.
Uterus
&
outf...
▪
Primary:
▪
Lack
of
menstruation
by
age
▪
16
in
the
presence
of
2ndry
"
sexual
characteristics
or
▪
14
in
their
absence.
...
2ndry
Amenorrhoea
Aboubakr
Elnashar
▪
The
commonest
causes
Primary
Amenorrhoea
▪
Turner’s
syndrome
▪
Abscent
vagina
▪
Gn
d...
3.
CAUSES
I.
Physiological
causes
•Pregnancy:
must
always
be
excluded.
•Lactation.
•Menopause.
II.
Iatrogenic
causes
•Prog...
Compartment
II:
Disorders
of
the
Ovary
Compartment
I:
Disorders
of
the
Outflow
Tract
Compartment
IV:
Hypothalamic
Disorder...
Speroff
et
al,
2020
Aboubakr
Elnashar
❑Imperforate
hymen
▪
Complaint
1.
Cyclic
abd.
pain
▪
for
almost
a
year
with
lack
of
...
▪
Local
ex.
▪
Bluish
bulging
imperforate
hymen
▪
At
the
proper
examining
position
▪
U/S
examination
▪
Cystic
pelvic
mass
e...
II.
Hormonal
Aboubakr
Elnashar
I.
Aboubakr
Elnashar
Aboubakr
Elnashar
MRI:
pituitary
macroadenoma
(classic
"snowman"
appearance
of
the
bi-lobed
pituitary
MRI:
pituitary
micro...
II.
Aboubakr
Elnashar
•
NI
(1990)
▪
Chronic
anovulation.
▪
Cl
and/or
biochemical
hyperandrogenism.
Rotterdam
(2003)
2
out
...
Aboubakr
Elnashar
❑
Late
onset
congenital
adrenal
hyperplasia
HLA
Manifestations
Incidence
Subtype
BW
14
Amenorrhea,
Hirsu...
Centripetal
obesity
79-97
Facial
plethora
50-94
Glucose
intolerance
39-90
Weakness,
proximal
myopathy
29-90
Hypertension
7...
III.
Aboubakr
Elnashar
❑
Turner
syndrome
Turner’s
stigmata
▪
Sexual
infantilism
▪
Short
stature
▪
Webbed
neck
▪
Spaced
nip...
Aboubakr
Elnashar
Turner's
S.
Aboubakr
Elnashar
Mosaic
(46-XX
/
45-XO)
(Classic
45-XO)
Turner’s
syndrome
Aboubakr
Elnashar
4.
DIAGNOSIS
I.
History
▪Present
1.
Sexual
acti...
II.
Examination
▪General:
1.
BMI
<17/>30
2.
Hirsutism
3.
Stigmata
of
endocrinopathies:
thyroid
Turner's
syndrome.
4.
Evide...
▪
Progestin
challenge
test:
▪
(MPA
5mgX5d
or
P
in
oil
100
mg
/3d
X
3)
▪
+ve:
Anovulation
▪
-ve:
E
+
P:
▪
-ve:
outflow
or
u...
▪
limitations.
1.
Women
with
high
androgen
levels,
(such
as
occurs
with
PCOS
and
CAH,)
may
have
an
atrophic
endometrium
an...
▪Pelvic
ultrasound:
•congenital
abnormalities
•Asherman's
syndrome
•Haematometra
•PCOS
morphology
•Physiological
activity
...
Aboubakr
Elnashar
IHH
=
idiopathic
hypogonadotropic
hypogonadism
Aboubakr
Elnashar
Aboubakr
Elnashar
Aboubakr
Elnashar
5.
MANAGEMENT
▪Must
be
guided
by
the
diagnosis
and
fertility
wishes.
▪Obese
or
under
wt:
attain
normal
BMI.
▪Hyperprolacti...
Thanks
Aboubakr
Elnashar
Oligomenorrhoea
Aboubakr
Elnashar
Aboubakr
Elnashar
DEFINE
▪Cycles
are
longer
than
32
days
▪anovulation
or
intermittent
ovulation.
❑Transient
oligomenorrhoea
common
stress'
o...
MANAGEMENT
What
does
the
patient
want?
Regular
periods
or
fertility?
1.
Provide
reassurance.
2.
Treat
any
underlying
cause...
Próximos SlideShares
Carregando em…5
×

10

Compartilhar

Baixar para ler offline

Amenorhea

Baixar para ler offline

Aboubakr Elnashar

Livros relacionados

Gratuito durante 30 dias do Scribd

Ver tudo

Audiolivros relacionados

Gratuito durante 30 dias do Scribd

Ver tudo

Amenorhea

  1. 1. Amenorrhoea Prof. Aboubakr Elnashar Benha university hospital, Egypt elnashar53@hotmail.com Aboubakr Elnashar CONTENTS 1. INTRODUCTION 2. CLASSIFICATIONS 3. CAUSES 4. DIAGNOSIS 5. TREATMENT 5 Aboubakr Elnashar
  2. 2. Sequence Of Menstruation CNS IV. Hypothalamus  GnRh  III. Ant. Pituitary FSH + LH  II. Ovary  E + P  I. Uterus & outflow tract V. Others Aboubakr Elnashar 2. CLASSIFICATIONS • According to the onset: • Primary amenorrhea. • Secondary amenorrhea. • According to the cause: • Physiological. • Pathological • According to Hidden or apparent: • False amenorrhea (Crypto menorrhea). • True amenorrhea. • According to level of LH/FSH • Hypogonadptophic • Eugonadotrophic • Hypergonadotophic • These are complementary to each other Aboubakr Elnashar
  3. 3. ▪ Primary: ▪ Lack of menstruation by age ▪ 16 in the presence of 2ndry " sexual characteristics or ▪ 14 in their absence. ▪2ndary: ▪ Absence of menstruation for a time equivalent to a total of 3 previous cycles or 6 months. ±: diagnostic error & should be avoided. Aboubakr Elnashar Primary Amenorrhoea Aboubakr Elnashar
  4. 4. 2ndry Amenorrhoea Aboubakr Elnashar ▪ The commonest causes Primary Amenorrhoea ▪ Turner’s syndrome ▪ Abscent vagina ▪ Gn deficiency ▪ Constitutional delay Secondary Amenorrhoea ▪ Pregnancy ▪ PCOS ▪ Hyperprolactinemia ▪ POI Aboubakr Elnashar
  5. 5. 3. CAUSES I. Physiological causes •Pregnancy: must always be excluded. •Lactation. •Menopause. II. Iatrogenic causes •Progestagenic contraceptives: Depo-Provera", Mirena IUS*, Nexplanon*, POP. •Therapeutic progestagens •Continuous COCP use •GnRH analogues Aboubakr Elnashar Physiologic causes Aboubakr Elnashar
  6. 6. Compartment II: Disorders of the Ovary Compartment I: Disorders of the Outflow Tract Compartment IV: Hypothalamic Disorders Compartment III: Disorders of the Anterior Pituitary Eugonadism Hypogonadotropic hypogonadism Hypogonadotropic hypogonadism Hypergonadotropic hypogonadism Normogonadotropic Hypogonadism(PCOD) Aboubakr Elnashar ▪ Pathological causes I. Anatomic: Genital tract outflow obstruction: ▪Congenital 1. Imperforate hymen 2. Transverse vaginal septum 3. Cervical stenosis 4. Agenesis of uterus & mulerian duct structures: sporadic or associated with AIS. ▪Acquired 1. Asherman's syndrome (intrauterine adhesions). 2. TB 3. Surgery II. Hormonal/Endocrinologic 1. Hpogonadotropic 2. Normogonadotropic 3. Hypergonadotropic Aboubakr Elnashar
  7. 7. Speroff et al, 2020 Aboubakr Elnashar ❑Imperforate hymen ▪ Complaint 1. Cyclic abd. pain ▪ for almost a year with lack of menses ▪ colicky in nature 2. Vomiting 3. Urine retention 4. Severe back pain 5. Swelling of the lower abdomen Aboubakr Elnashar
  8. 8. ▪ Local ex. ▪ Bluish bulging imperforate hymen ▪ At the proper examining position ▪ U/S examination ▪ Cystic pelvic mass extending to the abdomen. ▪ Tender during examination ▪ Trans perineal U/S with trans rectal U/S confirm the thickness of the Hymen and the diagnosis. Aboubakr Elnashar ❑ Androgen Insensitivity Syndrome ▪Axillary&pubic hair do not develop or spare ▪{resistance to testosterone}. ▪46 XY ❑ Asherman Syndrome Aboubakr Elnashar
  9. 9. II. Hormonal Aboubakr Elnashar I. Aboubakr Elnashar
  10. 10. Aboubakr Elnashar MRI: pituitary macroadenoma (classic "snowman" appearance of the bi-lobed pituitary MRI: pituitary microadenoma (arrows).Coronal image. Aboubakr Elnashar
  11. 11. II. Aboubakr Elnashar • NI (1990) ▪ Chronic anovulation. ▪ Cl and/or biochemical hyperandrogenism. Rotterdam (2003) 2 out of 3 ▪ Ch anovulation. ▪ Cl and/or biochemical hyperandrogenism. ▪ PCO on US AES (2006) AE-PCOS(2009) ▪ Cl and/or biochemical hyperandrogenism. ▪ Ovarian dysfunction (anovulation and/or PCO) ▪ Exclusion of related ovulatory or other androgen excess disorders (e.g., thyroid dysfunction, hyperprolactinemia, androgen-secreting neoplasms, or non classic adrenal hyperplasia) 8% 18% 12% Prevalence of PCOS Aboubakr Elnashar
  12. 12. Aboubakr Elnashar ❑ Late onset congenital adrenal hyperplasia HLA Manifestations Incidence Subtype BW 14 Amenorrhea, Hirsutism +++ Late-onset BW 51 Virilization ++ Simple virilizing BW 47 Virilization, Salt loss + Salt-loosing Aboubakr Elnashar
  13. 13. Centripetal obesity 79-97 Facial plethora 50-94 Glucose intolerance 39-90 Weakness, proximal myopathy 29-90 Hypertension 74-87 Psychological changes 31-86 Easy bruisability 23-84 Hirsutism 64-81 Oligomenorrhea or amenorrhea 55-80 Acne, oily skin 26-80 Abdominal striae 51-71 Ankle edema 28-60 Backache, vertebral collapse, fracture rare Clinical manifestations % ❑ Cushing syndrome Aboubakr Elnashar ❑ Crushing’s Syndrome Aboubakr Elnashar
  14. 14. III. Aboubakr Elnashar ❑ Turner syndrome Turner’s stigmata ▪ Sexual infantilism ▪ Short stature ▪ Webbed neck ▪ Spaced nipples ▪ Cubitus valgus ▪ Shield chest ▪ Pigmented nevi ▪ Coarctation of aorta ▪ Renal anomaly ▪ Streak gonads Turner’s Karyotype XO XO/XX XXp- XXr Aboubakr Elnashar
  15. 15. Aboubakr Elnashar Turner's S. Aboubakr Elnashar
  16. 16. Mosaic (46-XX / 45-XO) (Classic 45-XO) Turner’s syndrome Aboubakr Elnashar 4. DIAGNOSIS I. History ▪Present 1. Sexual activity, risk of pregnancy 2. Type of contraceptive used. 3. Galactorrhoea 4. Androgenic symptoms: weight gain, acne, hirsutism 5. Menopausal symptoms: night sweats, hot flushes 6. Issues with eating or excessive exercise. ▪Past 1. Drug use: dopamine antagonists 2. Genital tract surgery: intrauterine instrumentation Aboubakr Elnashar
  17. 17. II. Examination ▪General: 1. BMI <17/>30 2. Hirsutism 3. Stigmata of endocrinopathies: thyroid Turner's syndrome. 4. Evidence of virilization: deep voice, male pattern, balding, cliteromegaly 5. 2° sexual characteristics (Tanner staging). Aboubakr Elnashar ▪ Abdominal: ▪ Masses due to tumours ▪ Genital tract obstruction. ▪ Pelvic 1. Imperforate hymen 2. Blind ending vaginal septum 3. Absence of cervix and uterus. Aboubakr Elnashar
  18. 18. ▪ Progestin challenge test: ▪ (MPA 5mgX5d or P in oil 100 mg /3d X 3) ▪ +ve: Anovulation ▪ -ve: E + P: ▪ -ve: outflow or uterine failure → HSG, hysteroscopy, IVP & laparoscopy. ▪ +ve: Ovarian failure or pituitary-hypothalamic dysfunction. Aboubakr Elnashar Progesterone challenge test Bleeding No bleeding Chronic anovulation e.g PCOS Combined oestrogen & progesterone Bleeding No bleeding Ovarian failure Serum FSH Primary Secondary Uterine factor Aboubakr Elnashar
  19. 19. ▪ limitations. 1. Women with high androgen levels, (such as occurs with PCOS and CAH,) may have an atrophic endometrium and may fail to bleed. Specifically, up to 20% of women in whom estrogen is present will fail to bleed following progesterone withdrawal (Rarick, 1990) 2. Estrogen levels may fluctuate both in hypothalamic amenorrhea and in the early stages of ovarian failure: patients with these disorders may have at least some bleeding after progesterone withdrawal. Namely, menses may be observed after progesterone administration in up to 40% of women with hypothalamic amenorrhea due to stress, weight loss, or exercise and in up to 50% of women with POI (Nakamura, 1996). This bleeding derives from endometrium that grew prior to amenorrhea onset. ▪ Use of this test is best restricted to those situations in which accurate serum hormone measurements are unavailable. Aboubakr Elnashar II. Investigations: ▪ modified by patient history and physical examination. ▪Lab: ▪Pregnancy test. All reproductive-aged women with amenorrhea and a uterus are assumed pregnant until proven otherwise ▪Prolactin should always be tested ▪TSH ▪FSH/LH: ▪ inc in POF ▪ dec in hypothalamic causes ▪ not useful in PCOS ▪ Testosterone& (SHBG): most useful for PCOS. Aboubakr Elnashar
  20. 20. ▪Pelvic ultrasound: •congenital abnormalities •Asherman's syndrome •Haematometra •PCOS morphology •Physiological activity or endometrial atrophy in POF. ▪Karyotype if uterus absent or suspicion of Tumer's syndrome ▪Specific tests for endocrinopathies where there is clinical suspicion. Aboubakr Elnashar William gynecology, 2019) Aboubakr Elnashar
  21. 21. Aboubakr Elnashar IHH = idiopathic hypogonadotropic hypogonadism Aboubakr Elnashar
  22. 22. Aboubakr Elnashar Aboubakr Elnashar
  23. 23. 5. MANAGEMENT ▪Must be guided by the diagnosis and fertility wishes. ▪Obese or under wt: attain normal BMI. ▪Hyperprolactinaemia: Cabergoline or surgery ▪PCOS: Cyclical withdrawal bleeds (COCP ) ▪POI: HRT ▪Genital tract obstruction: ▪ cervical dilation ▪ hysteroscopic resection ▪ incision of hymen. ▪Endocrinopathies & tumours: TT ▪Major congenital abnormalities, AIS: multidisciplinary teams Aboubakr Elnashar Imperforate hymen Hymenotomy or curiciate incision Aboubakr Elnashar
  24. 24. Thanks Aboubakr Elnashar Oligomenorrhoea Aboubakr Elnashar Aboubakr Elnashar
  25. 25. DEFINE ▪Cycles are longer than 32 days ▪anovulation or intermittent ovulation. ❑Transient oligomenorrhoea common stress' or emotionally related causes usually self-limiting. Aboubakr Elnashar CAUSES ▪Similar to many of the causes of 2 º amenorrhoea: 1. PCOS is the commonest cause 2. Borderline low BMI. 3. Obesity without PCOS. 4. Ovarian resistance: anovulation e.g. incipient POF. is rare, but important, 5. Milder degrees of hyperprolactinaemia 6. Mild thyroid disease. Aboubakr Elnashar
  26. 26. MANAGEMENT What does the patient want? Regular periods or fertility? 1. Provide reassurance. 2. Treat any underlying causes 3. It is not uncommon for no cause to be found, but serious pathology must be excluded. 4. Attain normal BMI (weight loss or gain as appropriate). Aboubakr Elnashar ▪Provide regular cycles: 1. COCP or cyclical progestagens 2. PCOS a minimum of 3 periods/yr {avoid the risk of endometrial hyperplasia due to unopposed oestrogen}. ▪Full fertility screening should be performed if ovulation induction is required Aboubakr Elnashar
  • blalalmulaiki1

    Jul. 22, 2021
  • karimasaker

    Jun. 18, 2021
  • dawodmohamed

    May. 2, 2021
  • RashmiSingh601

    Apr. 14, 2021
  • karimagadsaker

    Apr. 13, 2021
  • ZamzamSeedi

    Apr. 5, 2021
  • EmanBassiouny1

    Apr. 3, 2021
  • ahmedhema5

    Apr. 3, 2021
  • MAHMO0O0O0OD

    Apr. 2, 2021
  • medhatghanem52

    Apr. 2, 2021

Aboubakr Elnashar

Vistos

Vistos totais

563

No Slideshare

0

De incorporações

0

Número de incorporações

0

Ações

Baixados

22

Compartilhados

0

Comentários

0

Curtir

10

×