Secondary Amenorrhea 2024 PDF

Secondary Amenorrhea Dr.Khalida Hassan Muho Specialist OB\GYN Objectives To know the definitions of secondary amenorrhoea To know the different causes for secondary amenorrhoea To know how to diagnose premature ovarian failure. To be able to approach systematically and arrange s...

Secondary Amenorrhea Dr.Khalida Hassan Muho Specialist OB\GYN Objectives To know the definitions of secondary amenorrhoea To know the different causes for secondary amenorrhoea To know how to diagnose premature ovarian failure. To be able to approach systematically and arrange suitable investigations for a case of amenorrhoea Understand the principles of management of a case of amenorrhoea including the management of fertility problems. Case scenario : A 33-year-old woman complains of 7 months of amenorrhea following a spontaneous abortion. She had a dilation and curettage at that time. Her past medical and surgical histories are unremarkable. She experienced menarche at age 11 years and notes that her menses have been every 28 to 31 days until recently. Her general physical examination is unremarkable. The thyroid is normal to palpation, and breasts are without discharge. The abdomen is not tender. The pelvic examination show a normal uterus, closed and normal appearing cervix ,and no adnexal masses. A pregnancy test is negative. Most likely diagnosis : Intrauterine adhesions(Ashermans syndrome). Next diagnostic test: Hysterosalpingogram(or hysteroscopy). CLASSIFICATION OF AMENORRHEA AMENORRHEA PHYSIOLOGICAL PATHOLOGICAL Pre-puberty Primary Pregnancy related Secondary Menopause CONTROL OF MENSTRUAL CYCLE HYPOTHALAMUS PITUITARY ENDOCRINE OVARIAN OUTFLOW TRACT AXIS  Secondary amenorrhea : is absence of menstruation for more than six months in a normal female of reproductive age that is not due to pregnancy, lactation or the menopause Women with secondary amenorrhoea must have a patent lower genital tract an endometrium that is responsive to ovarian hormone stimulation and ovaries that have responded to pituitary gonadotropins.  Secondary Amenorrhea - - ETIOLOGY ENDOCRINE HYPOTHALAMUS-PITUITARY Pituitary tumour Hypothyroidism Sheehan’s Cushing’s syndrome Hypothalamic dysfunction Premature ovarian OVARIAN failure Asherman’s PCOS OUTFLOW TRACT syndrome Surgical removal Hysterectomy  Secondary amenorrhoea is best classified according to its aetiological site of origin and can be subdivided into disorders of the hypothalamic-pituitary-ovarian- uterine axis and generalized systemic disease  Classification of secondary amenorrhoea Uterine causes Asherman's syndrome Cervical stenosis Ovarian causes Polycystic ovary syndrome Premature ovarian failure Hypothalamic causes(hypogonadotrophic hypogonadism) Weight loss Exercise Chronic illness Psychological distress Idiopathic  Pituitary causes Hyperprolactinaemia Hypopituitarism Sheehan's syndrome Causes of hypothalamic/pituitary damage(hypogonadism) Tumours Cranial irradation Head injuries Sarcoidosis Tuberculosis Chronic debilitating illness  Systemic causes Weight loss Endocrine disorders(thyroid disease, Cushings syndrome,ect.) Uterine causes of secondary amenorrhoea Asherman's syndrome Asherman's syndrome is a condition in which intrauterine adhesions prevent normal growth of the endometrium. This may be the result of an over- vigorous endometrial curettage affecting the basalis layer of the endometrium or adhesions that may follow an episode of endometritis. It is thought that oestrogen deficiency Intrauterine adhesions may be seen on an HSG. Alternatively, hysteroscopic inspection of the uterine cavity will confirm the diagnosis and enable treatment by adhesiolysis. Following surgery, a 3-month course of cyclical progesterone/oestrogen should be given. Some clinicians insert a foley catheter into the uterine cavity for 7-10 days postoperatively or an intrauterine contraceptive device for 2-3 months in order to prevent recurrence of adhesions.  Cervical stenosis Cervical stenosis is an occasional cause of secondary amenorrhoea. It was relatively common following a traditional cone biopsy for the treatment of cervical intraepithelial neoplasia. It still occasionally occurs following curettage of the uterus which inadvertently damages the endocervix. Treatment for cervical stenosis  Ovarian causes of secondary amenorrhoea Polycystic ovary syndrome Is the commonest cause of secondary amenorrhoea and is the only major cause of amenorrhoea that is not associated with oestrogen deficiency. Premature ovarian failure(POf) is the cessation of periods accompanied by a raised gonadotrophin level prior to the age of 40 years. It may occur at any age. The exact incidence of this condition is unknown vary at between 1% and 5% of the female population. Chromosomal abnormalities have been found in 70% of patients with primary amenorrhoea and in 2-5% of women with secondary amenorrhoea due to premature ovarian failure. Ovarian failure, occurring before puberty is usually due to a chromosomal abnormality or a childhood malignancy that required chemotherapy or radiotherapy.  Overall, the most common cause of premature ovarian failure is autoimmune disease, with infection, previous surgery, and chemo- and radiotherapy also contributing to the aetiology.  Ovarian autoantibodies can be measured and have been found in up to 69% of women with poF. HRT is advisable in order to reduce the consequences of oestrogen deficiency in the long term. Younger women with premature loss of ovarian function have an increased risk of osteoporosis and risk of cardiovascular disease. Oestrogens have been shown to have beneficial effects on cardiovascular status in women. Pituitary causes of secondary amenorrhoea Hyperprolactinaemia is the commonest pituitary cause of amenorrhoea. There are many causes of a mildly elevated serum prolactin concentration, including stress, and a recent physical or breast examination. If the prolactin concentration is greater than l000 mlU/L then the test should be  Hyperprolactinaemia may result from a prolactin-secreting pituitary adenoma or from a non-functioning 'disconnection, tumour in the region of the hypothalamus or pituitary which disrupts the inhibitory influence of dopamine on prolactin secretion. Other causes include hypothyroidism, PCOS and several drugs (e.g.the dopaminergic antagonist phenothiazines, domperidone and metoclopramide)  Galactorrhoea may be found in up to one-third of patients with hyperprolactinaemia. Approximately 5% of patients present with visual field defects. The management of hyperprolactinaemia by use of a dopamine agonist, of which bromocriptine is the most widely used. Of course, if the  Most patients show a fall in prolactin levels within a few days of commencing bromocriptine therapy and a reduction of tumour volume within 6 weeks. Bromocriptine dose of 2.5 -7.5 mg daily (in two or three divided doses). Longer acting preparations (e.g. twice-weekly cabergoline) may be prescribed to those patients who  Surgery, in the form of a trans- sphenoidal adenectomy. is reserved for cases of drug resistance and failure to shrink a macroadenoma or if there are intolerable side effects of the drugs (the most common indication).  Hypothalamic causes of secondary amenorrhoea Hypothaiamic causes of amenorrhoea may be either primary or secondary.  Primary hypothalamic lesions include craniopharyngiomas, germinomas, gliomas and dermoid cysts. These hypothalamic lesions either disrupt the normal pathway of prolactin inhibitory factor (dopamine), thus causing hyperprolactinaemia, or compress and/or destroy hypothalamic and pituitary tissue. Treatment is usually surgical, with additional radiotherapy if required. HRT is required to mimic ovarian func­tion, and if the pituitary gland is damaged either by the lesion or by the treatment, replacement thyroid and adrenal hormones are required. Secondary hypogonadotrophic hypogonadism (HH) may result from systemic conditions including sarcoidosis and tuberculosis as well as following head injury or cranial irradiation.  Sheehan's syndrome, the result of profound and prolonged hypotension on the sensitive pituitary gland, enlarged by pregnancy, may also be a cause of HH in someone with a history of a major obstetric haemorrhage. It is essential to assess the pituitary function fully in all these patients and then instigate the appropriate replacement therapy. Systemic disorders causing secondary amenorrhoea Chronic disease may result in menstrual disorders as a consequence of the general disease state, weight loss or by the effect of the disease process on the hypothalamic-pituitary axis.  Some diseases affect gonadal function directly. Women with chronic renal failure have a discordantly elevated LH, possibly as a consequence of impaired clearance. Prolactin is also elevated in these women owing to failure of the normal inhibition by dopamine. Liver disease affects the level of circulating sex hormone-binding globulin and thus hormone levels, thereby disrupting the normal feedback mechanisms. Metabolism of various hormones including testosterone are also liver-dependent, both menstruation and fertility return after liver transplantation.  Endocrine disorders such as thyrotoxicosis AND Cushing's syndrome are commonly associated with gonadal dysfunction. Autoimmune endocrinopathies may be associated with POF because of ovarian antibodies. Diabetes mellitus may result in functional hypothalamic-pituitary amenorrhoea. Management of these patients should concentrate on the underlying systemic problem and on preventing complications of oestrogen deficiency. If fertility is required, it is desirable to achieve maximal health and where possible to discontinue teratogenic drugs. Weight-related amenorrhoea Weight can have profound effects on gonadotrophin regulation and release. Weight and eating disorders are also common in women. A regular menstrual cycle will not occur if the BMI is