AMENORHEA

dr.Syafril Sanusi, SpOG Bagian / SMF Obstetri Ginekologi FKIK Jurusan Kedokteran Universitas Jenderal Soedirman

Tidak haid selama 3 bulan Fisiologis : - Prepubertas - Hamil - Menyusui - Pasca menopause Amenorhea

Patologis

: - Amenorhea Primer - Amenorhea Sekunder

Amenorhea Primer usia 14 tahun : seksual sekunder (-) haid (-) usia 16 tahun : seksual sekunder (+) haid (-)

Diagnosis : Anamnesis

Penyakit Paru : TBC, Asma Obat-obatan : - Obat penenang jangka panjang - Penurun atau Penambah BB - Obat Khemotherapi - Glukokortikoid Stress Berat

Pemeriksaan Klinis : - Pemeriksaan BB, Tinggi Badan, Tanda-tanda pertumbuhan sex sekunder (payudara, bulu ketiak dan pubis) - Pemeriksaan Ginekologik - Pemeriksaan Genitalia interna & externa - Laboratorik - Pemeriksaan kromosom (kariotip) - Pemeriksaan endometrium dilakukan untuk mencari etiologi Amenorhea primer jarang disebabkan oleh kelainan hormonal

ETIOLOGI : Hipotalamus : Semua gangguan di hipotalamus akan menyebabkan FSH/LH

- Kallmans syndrome : congenital lack of GnRH - Pituitary stalk compression : tumors,granulomas,irradiation - GnRH release : Stress, anorexia, hyperprolactinemia, severe weight loss, extreme exercise

Pituitary : Semua gangguan di pituitari akan menyebabkan FSH/LH

-Sheehans syndrome : pituitary infarction resulting from hypotension during delivery, usually resulting from hemorrage - Tumors : either compress stalk (as above) or are prolactin secreting tumors - Hemosiderosis : iron deposition in pituitary that impairs its function

Ovarium : Semua gangguan ovarium akan menyebabkan FSH/LH

- Premature ovarian failure : Menopause before 35 age - Savages syndrome : ovarian resistance to FSH/LH - Enzyme defects : most commonly 17 hidroxylase deficiency - Turners syndrome (XO karyotipe) : ovarian dysgenesis - Polycystic ovary disease (PCOD) : estrogen levels cause LH levels, which cause abnormal follicular growth and androgen secretion

Uterus
- Imperforate hymen

- Uterine causes have normal levels of FSH/LH - Congenital absence of uterus - Ashermans syndrome ; Uterine scarring and adhesions following dilation and curretage (D&C)

Uterus Yes No

Patent vagina No Yes

Karyotipe:testicular feminization, Mullerian agenesis, 46 XY steroid Enzyme defects, pure gonadal Dysgenesis, or anorchia

Imperforate hymen, transvere vaginal Septum, or vagina agenesis

Breast Yes

No

Work up as secondary amenorrhea

Work up as progestin-negative Secondary amenorrhea

Amenorrhea without galactorrhea, administer Progrestin Challenge : give progestin and if menses result, ovaries are secreting estrogen. if the progestin challenge result in menses, then diagnosis is one of the following : PCOD Ovarian or adrenal tumor Hypotalamic dysfunction if progestin challenge is negative : Heteroscopy to determine if Ashermans syndrom is the cause Check FSH level : - if suspect ovarian causes, - if suspect hypothalamic-pituitary failure

Progrestin challenge Negative Positive

Rule out Ashermans Syndrome if necessary

Hirsute

Nonhirsute

FSH

Over 40 mlU/mL

Under 40 mlU/mL

Polycystic ovary Syndrome Rule out ovarian tumor Rule out adrenal tumor

Mild hypothalamic dysfunction

Gonadal failure

Severe hypothalamic dysfunction

Workup for secondary amenorrhea without galactorhea

Amenorrhea with Galactorrhea Check TSH levels, if low Hypothyroidism is the cause if TSH is normal, check prolactin levels Prolactin levels are high, perform a CT/MRI of the brain to confirm a prolactinoma

TSH Normal Elevated

Cone view Normal and Prolactine 50-100ng/mL

Cone view abnormal or Prolactine over 50-100ng/mL or visual symptom

Treat hypothyroidism

Repeat prolactin every 6 months Cone views every 1 2 years

CT or MRI scan

Microadenoma, hyperplasia

Macroadenoma

Treatment of Amenorrhea Hypotalamic causes : - Tumor removal - Weight gain - Stress relief - Exogenous pulsatile GnRH Pituitary causes : - Tumor removal - Bromocriptine ( dopamine agonist inhibits prolactin release ) - Exogenous FSH / LH

Ovarian causes : - ovarian failure in vitro fertilization, oralcontraceptives. - PCOD clomiphene ( an antiestrogen )
Uterine causes : - obstruction surgery

Hiperprolactinemia
Elevated prolactin levels could be due to : Hypothyroidism check TSH level (hypothyroidism causes a rise in prolactin) Central nervous system (CNS) tumors perform head CT / MRI Drugs : - Dopamine antagonist - Methyldopa - Serotonin agonists Spinal cord lesions perform spinal CT/MRI