1. AMENORRHOEA II

2. PRIMARY AMENORRHOEA
Amenorrhoea without sec sex characters
• E from ovaries → Breast development
• No breast dev – No E → Amenorrhoea
↓
Hypogonadism
Hypergonadotrophic
Hypogonadotrophic

3. Hypergonadotrophic Amenorrhoea
• 30% have genetic
abnormalities
• Most common – Turner’s
Syndrome
– 45 XO (accelerated atresia of
follicles)
– Short stature
– Webbed neck
– Shield chest
– Cubitus valgus
– Associated conditions
• Coarctation of aorta
• Horse-shoe kidney
• Autoimmune thyroiditis

4. Hypergonadotrophic Amenorrhoea
• Pure Gonadal Dysgenesis
– Swyer syndrome – XY female
• Mixed Gonadal Dysgenesis
– Streak gonad & testis
• Enzyme Deficiency (Defect in steroid synthesis)
– Congenital adrenal hyperplasia
• Premature ovarian failure
– Galactosemia, chemotherapy, radiation

5. Hypogonadotrophic Amenorrhoea
• Physiological / Constitutional Delay
• Kallman’s Syndrome
– Amenorrhoea, sexual infantilism, anosmia
• Inflammation, Trauma, Tumour, Vascular
lesions
• CNS tumour
Diagnosis – History, Clinical, Investigation
Treatment – Replacement therapy, Surgery

6. PRIMARY AMENORRHOEA
Amenorrhoea with sec sex characters
• Anatomic abnormalities
– Obstruction
– Absence of uterus(M-R-K-H syndrome)
• Assoc with pelvic or horse shoe kidney,
double urinary collecting system, skeletal
abnormalities

7. PRIMARY AMENORRHOEA
• Androgen Insensitivity
(Testicular feminisation
syn) : problem of
androgen receptors
– Male pseudohermaphrodite
– AMH present : no uterus,
only blind vagina
– Well dev breast with pale
areola & immature nipple
– Scant or absent pubic /
axillary hair

8. MANAGEMENT
•
•
•
•
Removal of obstruction
Cervix absent or hypoplastic – TAH
Short vagina – Dilatation or reconstruction
Gonad containing Y chromosome –
Gonadectomy
– In androgen insensitivity done after pubertal
development

9. ASHERMAN’S SYNDROME
Endometrial destruction →Sec amenorrhoea
Cause : Overzealous curettage,
metroplasty, myomectomy, uterine art
embolisation
Diagnosis : HSG, Hysteroscopy
Treatment : D & C, Hysteroscopic
adhesiolysis → Foley’s catheter +
Oestrogen

10. PITUITARY DISORDERS
• Tumour
– Prolactinoma
– Acromegaly, Cushing’s Disease
– Craniopharyngioma, meningioma, glioma
• Infarction (Sheehan’s Syndrome)
• Inflammation
• Radiological / Surgical ablation

11. PITUITARY TUMOURS
• Mechanism of action
– Decrease secretion of GnRH
– Mass effect
• Compression of pituitary stalk and prevent delivery
of GnRH
• Empty sella syndrome
• Diagnosis : S/S specific to hormone
Headache, visual symptoms
Imaging
• Treatment : Dopamine agonist, Surgery

12. HYPOTHALAMIC DISORDER
• Commonest cause of hypogonadotrophic
amenorrhoea
• Diagnosed by exclusion of pituitary lesions
• Low or normal gonadotrophins
• Stress, wt loss, psy disorder, exercise
• Ultimate cause – GnRH suppression
• LPD → anovulation → amenorrhoea

13. GnRH REGULATION
• ↓ GnRH
– Endogenous opiods, dopamine
– CRH
– GABA
– ↑ Neuropeptide Y
– ↓ Leptin
• ↑ GnRH
– Catecholamines
– Acetylcholine

14. EFFECT OF BODY FAT
• Critical level of body
– 17 % for initiation of menses
– 22 % for sustaining menses
• “ Fat talks to the brain via leptin”
• “ When available energy is excessively
diverted as in exercise or when insufficient
as with eating disorders, reproduction is
suspended in order to support essential
metabolism for survival”.

15. ANOREXIA NERVOSA
• Wt loss of 25% or wt below 15% of
normal
• Intense fear of becoming fat
• Altered perception of one’s body
image
• Amenorrhoea
• Food restriction, induced vomitting,
laxative use, intense exercise
• Cold & heat intolerance, lanugo hair,
hypotension, bradycardia, yellow
skin,diabetes insipidus, binge eating
• Can be life threatening →
Psychotherapy