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Flashcards in Amenorree Deck (51):
1

definition


For amenorrhea Refers to the lack of menstrual flow in the period of sexual maturity. So, between
menarche and menopause, excluding the amenorrhea of ​​pregnancy and That by breastfeeding (amenorrhea
physiological), every other amenorrhea is to be Considered patologic.
Moreover, we Distinguish primary amenorrhea, a when at the age of 18 years have not yet Appeared flows
menstrual, and secondary amenorrhea, a when you have amenorrhea for at least 3 months after a period of
regular menstruation.
 

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classification

primary amenorrhea, a when at the age of 18 years have not yet Appeared flows menstrual

secondary amenorrhea, a when you have amenorrhea for at least 3 months after a period of
regular menstruation.

3

Amenorea could be because of:

• anatomical and functional abnormalities of the uterus and / or lower genital tract: amenorrhea uterine and vaginal
• Alterations anatomical and functional borne ovary: ovarian amenorrhea
• Alterations anatomical and functional adenohypophysis and / or hypothalamus: hypothalamic amenorrhea pituitary
• incoordination of the hypothalamic-pituitary-ovarian: amenorrhea alterations mechanisms feedback
• extragenital disorders: endocrine Extragenital, general diseases, metabolic disorders
 

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Amenorrhea source uterine and vaginal. Causes.


Between changes in the uterus and lower genital tract That determinates primary amenorrhea, there are the
congenital malformations,: such as partial or complete agenesis of the vagina, uterine agenesis, cervical atresia,
cable uterine atresia

Also:

  • Rokitansky-Kuster-Hauser syndrome
  • uterine synechiae intracavitary

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what is Rokitansky-Kuster-Hauser syndrome

Rokitansky-Kuster-Hauser syndrome 
caratterizzata by aplasia vagunale and uterine horns atretic. The
ovary, However, are normal with normal development of secondary sexual characteristics. This syndrome,
then, is associated with other malformations of the urinary tract

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what is sinechie uterine intracavitarie?


can be traumatic and post-emergence after revisions
partum or after incomplete abortions (Asherman's syndrome) or arise from infection
endometrial (TBC, Chlamydia, sepsis IUD), or even as a result of intervention on the cervix or in
Diatermo-coagulation. The uterine synechiae That determinates complete obliteration of the cavity or
occlusion of the cervical canal, induces secondary amenorrhea, Unless they start earlier
puberty (tuberculous endometritis), causing primary amenorrhea
 

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what is criptomenorrhea?


In the presence of obstruction of lower genital tract are talking about criptomenorrea; in cases of imperforate hymen the
menstrual blood can not drain out and collects first in the vagina (ematocolpo) and
later in the uterine cavity (ematometra) with onset of menstrual pain recurring
 

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Amenorrhea of ovarian origin

Gonadal dysgenesis (primary Am hypergonadotropin with low estrogen level)

Polycystic ovary syndrome

Early menopause

resistant ovary syndrome

ovarian tumors

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Gonadial dysgenesis

Gonadal dysgenesis (primary Am hypergonadotropin with low estrogen level)

  • dysgeneses in undifferentiated gonad (Turner syndrome and its variants: Lack of ovaries(streak gonads; Female phenotyps; Sexual infantilism
  • differentiated donadal dysgenesis: the damage it causes less severe That. hypoplasia ovarian follicular heritage scarsp
  • syndromes with sexual ambiguity: These include the real and ermafroditismi pseudoermafroditismi male and female.

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syndromes with sexual ambiquity


syndromes with sexual ambiguity: These include the real and ermafroditismi pseudoermafroditismi male and female. Are ailments linked to abnormalities
Chromosomal with discordance between phenotype and genetic sex and / or gonadal you
accompanied by primary amenorrhea. Among the bad pseudoermafroditismi deserves
mention testicular feminization syndrome or syndrome Morris, caratterizzata
by female phenotype with gonads and the hormonal Typically bad
 

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Polycystic ovary syndrome (etiopatogeneze, clinic, diagnostic)

 

  • Aetiopathogenesis unknown
  • Clinic 
  1. Mostly secondary amenorrhea
  2. Anovulatory infertility
  3. Hirsutism and acne ipeandrogenismo
  4. Metabolic syndrome
  • ultrasound Appearance: ovaries appear increased  volume, and with whitish albuginea thick

 

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Polycystic ovary syndrome (hormonal framework)

hormonal Framework
LH increased
FSH normal or low
Reversal of the relationship FSH / LH
Hypersecretion of androgens by the theca cells and stromal ovarian
Increased estrogen, Also Of Those peripheral, produced by adipose tissue and
adrenal gland,: such as estrone: These abnormally high levels of estrogens, Altering
That feedback mechanisms regulate the Increase cyclic gonadotropin,
would be responsible dell'anovulazione with amenorrhea and infertility

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Early menopasue (etiopatogeneze)


Aetiopathogenesis is unknown. We hypothesized That a genetic disorder results in hypoplasia
ovarian follicular patrimony reduced. Other times, However, the normal ovaries appear

morphologically and Contain a normal number of follicles That, for different Reasons
(Viral agents, radiation, autoimmune phenomena) would face rapid and premature
destruction
 

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early menopause (clinic)


In severe cases: primary amenorrhea with hypergonadotropic ipoestrogenica
non-appearance of secondary sexual characteristics
In other cases: Develops before un'oligomenorrea with anovulatory cycles and, then,
secondary amenorrhea ipergonadotropica ipoestrogenica, with the appearance of
estrogen deficiency symptoms typical of climacteric internships
 

15

what is resistant ovary syndrome?


resistant ovary syndrome: is caratterizzata receptor ovarian insensitivity to pituitary gonadotropins, possibly two to congenital deficiency receptor, by the presence of antibodies antirecettori ovarian or chromosomal abnormalities. Manifests, in general, with amenorrhea primary in young donni with pubertal development and normal secondary sexual characteristics

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endocrine framework in resistant ovary syndrome; biopsy


The framework endocrine shows characteristically high levels of gonadotropins and hypoestrogenism: also,
Given the resistance ovarian, administration of gonadotropins is not accompanied by
improvement of the clinical picture.
Biopsy, the number of primordial follicles is normal.
 

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ovarian tumors 


give secondary amenorrhea iperestrogenica, sometimes alternating with menorrhagia. It can
be linked to the presence of functioning tumors of the ovary, Which produces estrogen,: such as tumors
granulosa cell and tecomi. Alternatively, it may be linked to the presence of tumors, as
the arrenoblastoma, That produces androgens: In These cases, in Additions to the menstrual disorders, It has
virilization with appearance of male sexual characteristics
 

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hypothalamic - pituitary amenorrhea

  •  functional hypothalamic amenorrhea associated with disorders
  • amenorrhea related to organic lesions hypothalamic-pituitary
  • Pituitary adenomas prolattinosecernenti
  • iatrogenic causes
  • syndromes associated with galactorrhea
  • Sheehan syndrome
  • empty saddle(balnas) syndrome 

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functional hypothalamic amenorrhea associated with disorders

  • psychogenic amenorrhea
  • psychogenic Anorexia
  • Pseudociesi or imaginary pregnancy
  • post-pill amenorrhea without galactorrhoea

 

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psychogenical amenorrhea


Secondary amenorrhea Arising are, in general, in youth
women undergoing psychological pressure of various kinds (fear, stress tests, or
sports competitions, crash dieting). Are reversible, usually you, the cessation of the stimulus
stressor. Are anche related to insufficient release of hypothalamic GnRH for
central inhibition and are caratterizzata by:
Gonadotropins very low
Estrogen below normal
Anovulation
 

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psychogenic anoreksia


there is a deficiency in the secretion of GnRH with a framework similar to the
previous
 

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Pseudociesi or immaginary pregnancy


very rare in women and OCCURS strongly
depressed and anxious to offspring. Besides secondary amenorrhea arise of syndromes
characteristic of a real pregnancy. The throng obsessive determines, for reduction
dopaminergic activity, hypersecretion of PL and GnRH, causing Increase in LH,
while FSH remains at reduced levels. The plasma levels of estrogen and progesterone are
carried forward to Those of a secretory phase initial
 

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post pill amenorrhea without galattorea


 post-pill amenorrhea without galactorrhoea: is two to the failure recovery mechanisms
feedback hypothalamus-pituitary-ovary
 

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amenorrhea related to organic lesions hypothalamic-pituitary

  • congenital (Kallman sindrome)
  • acquired 

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amenorrhea related to organic lesions hypothalamic-pituitary (congenital)


Congenital: Kallman syndrome: Seems to be two to an alteration in the neurons of the load
core sovraottico and paracentricolare GnRH secreting. It is caratterizzata by:
Anosmi
Hypogonadism
Developmental defects of the facial skeleton
 

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amenorrhea related to organic lesions hypothalamic-pituitary (acquired)


Inflammatory disorders
Alterations traumatic
Neoplastic changes
craniopharyngioma: is associated, as well as to amenorrhea, a growth deficit
to reduced GH secretion
Pituitary adenomas prolattinosecernenti: increased At prolactin is Associated with amenorrhea as high rates of PL interfere with hypothalamic receptors for estrogen, by Altering the feedback mechanisms.
This alteration results in reduction of the concentration of gonadotropins, anovulation and amenorrhea ipoestrogenica. In Additions to, anovulation anche Appears to be linked to direct interference of the PL
ovarian responsiveness to gonadotropins.
 

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iatrogenic causes


Iatrogenic causes: anche hyperprolactinemia can be a result of drugs
as antipsychotics (especially first generation), and ipotensivanti Antiemetics,
That diminish a decrease in the dopaminergic tone and, Therefore, in
increased At release of PL
 

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syndromes associated with galactorrhea


• Chiari-Frammel: OCCURS after childbirth
• Syndrome Argonz Castle: Appears outside of the states gestational
• Sherman syndrome: OCCURS after administration of
Progestogens
• Forbes-Albright syndrome: is linked to the presence of pituitary tumors
 

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Sheehan sindrome


OCCURS Generally after a profuse bleeding post
partum Resulting in hypovolemic shock, ischemia and necrosis Subsequent
anterior pituitary. It is clinically caratterizzata:
• In the first phase (linked to kidney and gonadotrophic lattotropa)
or mammary involution
or wasting Remarkable
or Non-resumption of menstrual bleeding
• In a second phase
or failure tireotropa and corticotropa Resulting signs
• Reversibility: usually fatal in some cases may be less
relevant and reversible
 

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empty saddle sindrom


 a condition is congenital or secondary (or trauma
radiation), in cui the sella turcica is not occupied by the pituitary, but by un'estroflessione
tank sovrachiasmatica
 

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amenorrhea by alterations of feedback mechanisms - definition


They are typical of adolescence and two to immaturity and / or functional incoordination of the hypothalamic
pituitary-ovary, with anovulation and amenorrhea preceded by irregular cycles.
These forms, in general, are associated with ovarian micropolicistosi and usually you are transient. If not,
regress spontaneously and nothing is done spontaneously Has The evolution to the ovary
Polycystic with irreversible amenorrhea.
 

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amenorrhea by alterations of feedback mechanisms - hormonal framework


• LH high
• FSH normal or low
• Reversal of the relationship FSH / LH
• hypersecretion of androgens
 

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amenorrhea source extragenital 


Are secondary to endocrinopathies Extragenital:
• Cushing's disease
• Addison's disease: amenorrhea is late
• Hypothyroidism: amenorrhea may be two to hyperprolactinemia Caused by the stimulus from
part of TRH cell lattotrope
• Hyperthyroidism: estrogenic rates are always higher with alteration of feedback mechanisms.
LH is elevated with normal FSH and determines a condition similar to That of polycystic ovary
with amenorrhea and anovulation
 

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diagnosis (first time)

 

  • It Evaluates the integrity of the uterus and the patency of the lower genital tract.
  • We also evaluate the level of estrogen and prolactin through the MAP test or tests to Progesterone

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MAP or progesteron tests

a progestin is administered orally (MAP 20mg per day for 3 days). Within 7 days a patient will have or not a stream-like menstrual. If you see the flow Excluding
lesions of the lower genital tract and confirm functionality albeit minimal hypothalamus,
pituitary and ovary (the presence of estrogen Has adeguatemente prepared the endometrium). That
Indicates the absence of endogenous progesterone, and then a functional corpus luteum linked
all'anovulazione That could have several causes:
- If prolactin is normal and there is no galactorrhea: incoordination hypothalamic
pituitary-ovary for alteration of feed-back. You can then assume eg. in polycystic
Ovarian Whose diagnosis is based on clinical evidence, the hormonal (high LH, FSH
normal or low and estrogen and androgen levels); anche do an ultrasound and laparoscopy
to exclude functioning tumors.
- If there is instead hyperprolactinemia and / or galactorrhea: you are facing or amenorrhea
hyperprolactinaemic syndromes or amenorrhea and galactorrhea. In longer available cases it is the obligation TAC
of the sella turcica

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diagnosis (second time) - test negative


if the test is negative (no flow) it must be Concluded by a lesion of the flow and / or
lower respiratory genitali.In case of secondary amenorrhea you can assume syndrome
Ascherman or injury type receptor endometrial tuberculosis, the diagnosis will be Placed
on the basis of further Top investigation. In case of primary amenorrhea you-can hypothesize
malformations of the genital tract for Which diagnosis will be needed in Additions to the examination
objective, the determination of the sex chromatin, the ultrasound examination and the
Laparoscopic. The diagnosis will be easy in the presence of simple vaginal obstruction
 

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diagnosis (second time) - test positive


if the test is positive (presence of luxury) you can conclude that:
There are lesions of the genital tracts of outflow
There is an insufficient production of endogenous estrogen
The uterus Subjected to appropriate stimuli ovarian hormones Is Able to menstruate

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diagnosis (third time)


this time is to clarify Whether the inadequate production of estrogen (amenorrhea
ipoestrogenica) must be Attributed to ovarian damage or underactive gonadotrophic
preipofisaria.A this end determination is performed Whose concetrazioni serum gonadotropin, in
normal conditions, FSH Vary for between 5 and 40 mIU / ml for LH and between 5 and 25. A second
dell'eziopatognesi ipoestrogenica amenorrhea rates of gonadotropins will
- very high

-normal

-very low

 

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rates of gonadotropin (very high)


 amenorrhea ipergonadotrope: If the serum levels of gonadotropins and
including FSH will be high, amenorrhea is failure to report ovarica.Se
secondary amenorrhea is it is probably facing an early exhaustion of the
heritage follicular (early menopause) or the syndrome del'ovaio resistant; if
Primary amenorrhea is you will have to think of a gonadal dysgenesis or a tumor
ovarico.L'esame objective of pcs, the karyotype and ovarian biopsy by laparoscopy
will serve to clarify the diagnosis.
 

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rates of gonadotropin (normal)


amenorrhea normogonadotrope: Rates normal serum FSH and LH in pc
amenorrhoeic Shall be Given to the production by the preipofisi gonadotropin
anomalous That Are biologically inactive Because They are not recognized by the receptors
ovarian
 

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rates of gonadotropin (very low)


 Very Low: amenorrhea ipogonadotrope: Very low levels are to take back injury
anatomofunctional pituitary or hypothalamus. In this case to determinates the location and the entity
the lesion is useful to use
clomiphene test:
• If you will be positive with increased At rates of gonadotropins can
exclude significant abnormalities of the hypothalamic pituitary.
• If it is negative you can think of a hypothalamic lesion
 

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GnRH test


 In These cases will serve to clarify Whether there is damage
preipofisario: a positive test (Increase gonadotropin) we will exclude injuries
pituitary. In all cases of amenorrhea ipoestogenica ipogondotropa, finally, will be
need a rx of the sella turcica and the hypothalamic region
 

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Therapy (amenorrhea defect feedback mechanisms) - medica


If there is a desire of the offspring, in order to induce ovulation may be used citrate
clomiphene, Which, causing an Increase of the secretion of FSH stimulates
Resulting in increased At the follicle growth rates of E2 circolante.Si
restores the day I know positive feedback That determines the LH surge and ovulation with
corpus luteum formation. All of this makes possible the presence of pregnancies.
Ovulation can be produced by administering anche HMG (gonadotropins
exogenous) or pure FSH, this can lead to ovarian hyperstimulation, then some
Prefer exogenous gonadotropins after Obtaining the block with pituitary
GnRH analogues
 

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Therapy (amenorrhea feedback mechanisms) - surgery


when you screw with the medical practice is the wedge resection of the ovaries from
practice with microsurgical technique
 

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Therapy (amenoreja hyperprolactinemic)


The treatment of choice is the One That medical uses derivative of rye
Horned dopanimergica acting as bromocriptine, Which lowers serum prolactin
ITS blocking production in the pituitary level, and inhibiting the mitotic activity of cells
produces PRL and even Reduces the size of the prolactinomas is prolattinomi.L'asportazione
very rare
 

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therapy of amenoreja iperestogeniche

amenorrhea iperestogeniche: Surgical removal of the tumor

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TH of Amenoree by alterations of the uterus and / or vagina


Amenoree by alterations of the uterus and / or vagina: If amenorrhea is linked to uterine synechiae therapy
taking out of adhesions by hysteroscopy. When, instead, the amenorrhea is
two to malformations, surgical therapy will
 

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TH of amenoreja ipergonadotrope


amenorrhea ipergonadotrope: In the presence of early menopause or ovary resistant therapy
is the administration of estroprogestrinici in a sequential manner That will need to restore
menstrual flows and prevent clinical manifestations estrogen deficiency anche This applies to list
the gonadal dysgenesis. Therapy in the forms of hermaphroditism is surgical, as well as in
Morris syndrome
 

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TH of amenoreja normogonadotrope

amenorrhea normogonadotrope: It Consists in the use of exogenous gonadotropins

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Th amenoreja hipogonadotrope


In Those functional hypothalamic, elimination of psychogenic disorders is
the solution, if psychotherapy was not successful and was not eager to offspring, then you
administered estroprogestinici.Se was eager to offspring, with antiestrogens and / or gonadotropins.
Organic hypothalamic lesions Should be treated surgically, as well as from amenorrhea
secreting pituitary adenomas, in cases of pituitary necrosis or empty saddle, using
Progestogens.
In cases of non-neoplastic Sellar masses, we must treat the underlying disease, the same way for
amenorrhea causes Extragenital and Those related to endocrine abnormalities. In patients with
Kallman syndrome desirous of offspring is useful administration ledi pulsed GnRH, if you do not
want pregnancy then just a therapy Progestogens
 

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