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Amenorrhoea

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by

Tome Erasmus

on 28 January 2017

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Transcript of Amenorrhoea

Amenorrhoea
1. Outflow tract
Hymen Imperforatum
Transverse septum
Mullerian tube abn
Mayer-Rokitansky-Kauster-Hauser
Cx stenosis
Non-communicating horns
3. Hypothalamus/Pituitary
Tumors
Prolactinoma
Craniopharyngyoma
Stalk compression

Abn GnRH secretion
Eating disorder
Stress
Excercise

Kallmann Syndrome (hypogonadotrophic hypogonadism)
Primary
Secondary
1. Physiological
Pregnancy
Lactation
Peri-menarche
Peri-menopause
5. Ovarian
PCOS


Ovarian failure
Primary (Dysgenesis, mosaic Turners)
Iatrogenic (Surgical, radiation, chemo)
POF (<40y)
3. Endocrine
4. Medication
causing hyperprolactinemia
dopamine antagonist (phenothiazine, metochlopramide)
dopamine depleting (methyldopa, reserpine)

CHC

Progestogens

Corticosteroids
6. Outflow tract
Acquired/Iatrogenic

Asherman's Syndrome
Cx Stenosis
Infection (TB)
2. Ovarian dysfunction
Chromosomal abnormalities
Gonadal dysgenesis (46XY, Swyer, AIS)
Ovarian failure
Turner Syndrome (45X0)

PCOS (very scarce)
Definitions
Primary
14y without secondary characteristics
16y with normal secondary characteristics

Secondary
6 months if previously normal
12 months if previously irregular (oligomenorrhoea)
2. Hypothalamus/Pituitary
i) Psycho-neuroendocrine
stress
pseudocyesis
underfeeding
ii) GnRH deficiency
Ideopathic
Kallmann
iii) Destruction
Tumors (craniopharyngioma)
Stalk transsection
Infections (TB, Sarcoidosis)
iv) Prolactinoma
micro
macroadenoma (> 10mm)
Hypothyroidism:
increased TRH -> Prolactin
Hyperthyroidism:
weightloss, amenorrhoea
Addisons
CAH
Adrenal
Thyroid
Diagnostic Criteria
Rotterdam criteria (2/3)
Ovulatory dysfx (Oligo/ anovulation

Hyperandrogenism (Clinical / biochemical)

Polycystic ovary on ultrasound (>12 follicles 2-9mm)
Associated challenges
Metabolic
Insulin resistant (DM),
Cardiovasc risk (hpt, lipid profile)

Anovulation
irregular menses, subfertility

Endometrial Ca risk
unopposed estrogen

Hirsutism
Mood disorders
Sleep apnoea
Management
PCOS
Hirsutism
Metabolic
Weight loss
Screen for diabetes
Insulin resistance - Metformin
Ovulatory dysfx/ Infertility
Weight loss
5 - 10% leads to spontaneous ovulation

Ovulation induction (x5)
Letrozole vs Clomifene
LBR: 30% vs 20%
Twins: 3% vs 7%
50% more likely - LB with Letrozole than CC
Stair step
metformin for clomifene resistant pt
Amenorrhoea/Irreg menses
CHC
Endometrial Ca risk
Screen (family history, >40y)

Progesterone
Hirsutism
CHC (combined hormonal contraception)

cyproterone acetate
drosperidone
Metformin
Benefit:
Metabolically
Menstrual abnormalities ?

No proven benefit
hirsutism
acne
infertility
PCOS 80%
Exclude other causes

Free testosterone >5,2 -
investigate further, exclude tumor
Ferriman Gallway
Symtom not Dx
TV U/S
HCG

Prolactin
FSH/LH
TSH/T4
MRI
Androgen
Karyotyping
Pathophysiology of PCOS
Simplified
Varicella zoster
chr renal failure
Sheehan
Pituitary infarct
Massive PPH
SHBG
Obesity
If OI fails:
Gonadotropins = Lapsc ovarian drilling
more OHSS vs less twins
IVF
Obesity and Reproductive sequelae
Associated with increased:

Congenital abnormalities
miscarriages
GDM
Hpt
Delivery complications
VTE
Role of Metformin in ART
1. Not substitute for lifestyle changes

2. Clomid better than Metformin
Clomid better clomid +metformin

3. CC resistant: nnt = 5

4. Gonadotropins: Metformin reduces cycle cancellation and OHSS

5. IVF/ICSI: decreases OHSS, = LBR

6. M/C: metformin does NOT decrease m/c (no benefit)

7. S/E: GIT (N&V), abd pain, diarrhea, flatulence

8. Endometrial CA: might decrease risk?
Meta-analysis 2015:
metformin = placebo
PR
LBR
spontaneous m/c
does not improve ART outcome

BUT: less OHSS (RR 0,4)
Excessive terminal hair growth in male pattern
Causes of hirsutism
Ovarian
PCOS -80%

Hyperthecosis

Ovarian tumor (0,2%)
50% will be malignant
Adrenal
Non-classical CAH (<5%)
Cushings Syndrome
Glucocorticoid resistance
Adrenal tumor
Pregnancy associated
Luteoma of pregnancy
Hyperreactio luteinalis
Aromatase deficiency in fetus
Other
Ideopathic hisutism (ovulatory, normal serum testosterone) 8%

Ideopathic hyperandrogenism (no category) 16%

Medication: (danazol, minoxidil, testosterone, valproate, phenitoin)

Endocrine other:
hyperprolactineamia, hypothyroidism, GH excess, IR
>8
>3
XY, functioning testes
Primary amenorhoea
DSD
Lifestyle
decrease IR :
increased SHBG
decreased androgen production
Cosmetic
Shaving, chemical
plucking, waxing
Pharmacological
not LNG
preferably anto-androgenic progestin (DRSP, CPTA
Hirsutism treatment approach
Weight loss
Stop smoking
effect CHC
worsens s/e
1. CHC
2. Anti-androgen
Spironolactone
Flutamide
Finasteride
3. GnRHa with Estrogen addback
4. Consider adding metformin
- controversial
1. Topical Eflornitine bd
2. Short term hair removal
3. Long term
laser (alexandrite, diode)
pulsed light therapy
electrolysis
Examination
Full transcript