1. CLINICAL GUIDELINES FOR EVALUATION AND MANAGEMENT OF AMENORRHEA Dr. JEHAD YOUSEF FICS, FRCOG ALHAYAT ART CENTER AMMAN – JORDAN

3. CNS-Hypothalamus-Pituitary Ovary-uterus Interaction Neural control Chemical control Dopamine (-) Norepiniphrine (+) Endorphines (-) Hypothalamus Gn-RH Ant. pituitary FSH, LH Ovaries Uterus Progesterone Estrogen Menses – ± ?

9. Imperforate hymen

10. Once Pregnancy and cryptomenorrhoea are excluded: The patient is a bioassay for Endocrine abnormalities Four categories of patients are identified 1. Amenorrhoea with absent or poor secondary sex Characters 2. Amenorrhoea with normal 2ry sex characters 3. Amenorrhoea with signs of androgen excess 4. Amenorrhoea with absent uterus and vagina

11. AMENORRHOEA Absent or poor secondary sex Characteristics FSH Serum level Low / normal High Hypogonadotropic hypogonadim Gonadal dysgenesis

13. FSH Low / normal High Hypothalamic-pituitary Failure Ovarian failure  If < 25 yrs or primary amenorrhea  karyoptype  If < 35 yrs  R/O autoimmune disease ?? Ovarian biopsy head CT- scan or MRI - Severe hypothalamic dysfunction - Intracranial pathology

14. Amenorrhoea Utero-vaginal absence Karyotype 46- XX Mullerian Agenesis (MRKH syndrome) Androgen Insenitivity (TSF syndrome) . Gonadal regressioon . Testocular enzyme defenciecy . Leydig cell agenisis 46- XY Normal breasts & sexual hair Normal breasts & absent sexual hair Absent breasts & sexual hair

16. Asherman’s syndrome

17. Amenorrhoea Signs of androgen excess Testosterone, DHEAS, FSH, and LH DHEAS 500-700 mug/dL DHEAS >700 mug/dL TEST. >200 ng/dL  Serum 17-OH Progesterone level Late CAH Adrenal hyperfunction U/S ? MRI or CT Ovarian Or adrenal tumor Lower elevations  PCOS (High LH / FSH)

18. Amenorrhoea PRIMARY AMENORRHOEA . Ovarian failure 36% . Hypogonadotrophic 34% Hypogonadism. . PCOS 17% . Congenital lesions (other than dysgenesis) 4% . Hypopituitarism 3% . Hyperprolactinaemia 3% . Weight related 3% SECONDARY AMENORRHOEA . Polycystic ovary syndrome 30% . Premature ovarian failure 29% . Weight related amenorrhoea 19% . Hyperprolactinaemia 14% . Exercise related amenorrhoea 2% . Hypopituitarism 2%

20. Gonadal dysgenesis XO/XY 46- XX(Pure) 46-XY (Swyer) XX/XO or abnormal X XO Karyotype ± Nil ± Classical Somatic stigmata Short Tall - Short - Normal Short Hight - Streak - Testes Streak Streak Streak Gonad Ambiguous Female Female Female Phenotype Mixed Dysgenesis True gonadal Dysgenesis Turner Variant Classic Turner’s

22. Mosaic (46-XX / 45-XO) ( Classic 45-XO) Turner ’s syndrome

23. Ovarian dysgenesis

27. Polycystic ovary syndrome

41. THANK YOU FOR YOUR ATTENTION Dr. Jehad Yousef F.I.C.S, F.R.C.O.G