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# Types:
1- Primary amenorrhea (2.5%):
- No menstruation by the age of 14 years in the absence of
secondary sexual characteristics, which includes: thelarchae
(enlarged breasts), puberchae (growth of pubic and axillary’s
hair).
- No menstruation by the age of 16 years with the presence pf
secondary sexual characteristics.
2- Secondary amenorrhea (3 – 100%):
- The stopping of the menstruation process for 6 months in a
woman with regular periods or 1 year in a women with
irregular period.
# Causes:
1- Physiologic causes:
- Pre-pubertal.
- Pregnancy.
- Lactation.
- Postmenopausal.
- Following hysterectomy.
2- Anatomical and pathological causes:
- Disorders of outflow tract (hymen, vagina and uterus).
- Disorders of ovary.
- Disorders of anterior pituitary gland.
- Disorders of hypothalamus can cause primary or secondary.
1
Disorders of out flow tract
A. Cryptomenorrhea:
Congenital obstruction caused by:
1- Imperforate hymen (most common).
2- Vaginal atresia or septum.
2
C. Testicular feminization (androgen insensitivity):
Congenital abnormality characterized by:
1- A 44XY genotype (actually male).
2- Female phenotype because of the androgen insensitivity.
3- There are non functional testis (Y chromosome).
4- Inherited as X-linked recessive disorder resulting in the absence
of cytosol androgen receptors.
5- Features of the patient:
- Normal growth and development.
- Breast is well developed.
- 50% of the patients have palpable inguinal hernia containing
testis.
- Absence of axillary and pubic hair.
- Labia minora are under developed.
- Testis is in the abdomen or inguinal canal (no
spermatogenesis).
- Testosterone level is normal but no response to it because of
the absence of the androgen receptors.
- High chance of testicular malignancy (30%). So, you have to
remove the testis after puberty because it’s needed pre-
puberty for development and growth.
- Primary amenorrhea.
- No uterus, tubes or ovaries. And the vagina ends blindly.
# Treatment
1- Never tell her that she’s not a female.
2- Remove the testis after puberty.
3- Tell her she will not have children.
4- Hormone replacement therapy (estrogen: estradiol). Continuous
administration cause there is no uterus. If there is uterus you give
cyclic estrogen to prevent endometrial cancer.
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3
D. Asherman’s syndrome:
Destruction of endometrium by over curettage leading to removal of
endometrium, which is replaced by fibrosis (synechiae). Other causes
include:
1- PPH, which end with D & C.
2- Repeated infections (endometritis).
3- TB of uterus.
4- Schistosoma of uterus (very rare now).
# Presentations:
1- Secondary amenorrhea.
2- History of repeated D & C followed by amenorrhea.
3- Hystrosalpingogram.
# Treatment Hysteroscopy and cut the adhesions and put TUCD for
1 week to prevent re-adhesions and allow regeneration of endometrium.
4
Disorders of the ovary
E. Turner’s syndrome:
A chromosomal defect where we get 45XO (gonadal desgenesis). It
leads to primary amenorrhea in 99% 0f cases. Some times we get
secondary amenorrhea in the mosaic pattern of the disease (XX/XO)
where there is a functioning uterus and can have children. Usually these
patients:
1- Short stature.
2- Webbed neck and wide chest.
3- Increase chance of cortication of the aorta.
4- Streak ovary and fibrotic.
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5
# Diagnosis:
To differentiate between resistant ovary syndrome and premature
ovarian failure we depend on:
1- Age of the patient.
2- Biopsy of the ovary by laparotomy to check the follicles (if present
then resistant ovary if not then it would be premature failure),
# Treatment:
1- If she wants to get pregnant you must give her induction of
ovulation.
2- If she does not want to get pregnant you give her progesterone to
stop this steady release of estrogen.
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6
Disorders of pituitary gland
# Hyperprolactinemia
Normal levels of prolactin are 150 – 400 mg/l.
# Caused by:
1- Physiologic:
- Stress.
- Pelvic examination.
- Intercourse.
- Venipuncture (to take blood sample).
- Surgery (especially in the chest).
- Sleep.
- Pregnancy and lactation (level of prolactin increase 10x the
normal).
2- Drugs:
- Phenothyazine group.
- Methyldopa.
- Antihistamine.
- Estrogen.
- Morphine and narcotics.
- Contraceptive pills.
- Reserpine.
3- Pathologic:
- Adenoma: micro (<1cm) or macro (>1cm).
- Primary hypothyroidism because it tends to increase TSH
which also increase prolactin.
4- Idiopathic More than 50% of the cases.
# Presents with:
1- Galactorrhea (milk production).
2- Secondary amenorrhea.
3- Or non-ovulating cycle- infertility.
# Treatment:
1- Dopamine agonist (Bromocriptine)
2- Try to diagnose pituitary adenoma with x-ray of the skull, CT scan
and MRI.
7
# Other causes (usually theses cause secondary
amenorrhea):
1- Stress.
2- Metabolic disorders.
3- Missed abortion.
4- Psychological.
5- Anorexia nervosa and athletics where body fat decreases by 20%
and increase muscle weight leading to an increase in androgens. So,
we might get amenorrhea.
6- Depression.
7- Congenital adrenal hypoplasia, where there is less sex hormones
because of 21-hydroxylase deficiencies.
8- Lauren – Levis syndrome: the Gonadotropin and growth hormones
are affected. She has boyish features.
9- Frohelish syndrome. Patients have low intelligence.
10-Kallamar syndrome.
Anovulation
No ovulation at all.
Oligo-ovulation (infrequent) where in one cycle there is ovulation
and in 3 others there are not and so on.
The commonest cause is polycystic ovarian disease.