Download - AMENORHEA
AMENORHEA
dr.Syafril Sanusi, SpOGBagian / SMF Obstetri
GinekologiFKIK Jurusan Kedokteran
Universitas Jenderal Soedirman
Tidak haid selama ≥ 3 bulan Fisiologis : - Prepubertas
- Hamil - Menyusui - Pasca menopause
Amenorhea
Patologis : - Amenorhea Primer - Amenorhea Sekunder
Amenorhea Primerusia 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
☺Pituitary : Semua gangguan di pituitari
akan menyebabkan FSH/LH
- Kallman’s syndrome : congenital lack of GnRH- Pituitary stalk compression : tumors,granulomas,irradiation- GnRH release : Stress, anorexia, hyperprolactinemia, severe weight loss, extreme exercise
-Sheehan’s 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
☺Uterus
- Premature ovarian failure : Menopause before 35 age- Savage’s syndrome : ovarian resistance to FSH/LH- Enzyme defects : most commonly 17α hidroxylase deficiency- Turner’s syndrome (XO karyotipe) : ovarian dysgenesis- Polycystic ovary disease (PCOD) : estrogen levels cause LH levels, which cause abnormal follicular growth and androgen secretion
- Imperforate hymen- Uterine causes have normal levels of FSH/LH- Congenital absence of uterus- Asherman’s syndrome ; Uterine scarring and adhesions following dilation and curretage (D&C)
Patentvagina
No
Work up as secondaryamenorrhea
No
Imperforate hymen,transvere vaginalSeptum, or vaginaagenesis
Breast
Work up as progestin-negativeSecondary amenorrhea
Karyotipe:testicular feminization,Mullerian agenesis,46 XY steroidEnzyme defects,pure gonadalDysgenesis, or anorchia
Uterus
Yes
Yes
Yes No
Wor
kup
for
prim
ary
amen
orrh
ea
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 Asherman’s
syndrom is the cause
♦ Check FSH level :
- if suspect ovarian causes,
- if suspect hypothalamic-pituitary failure
Positive
Gonadal failure
Rule out Asherman’sSyndrome ifnecessary
Hirsute
Severe hypothalamicdysfunction
Polycystic ovarySyndromeRule out ovarian tumorRule out adrenal tumor
Progrestinchallenge
Negative
FSH
Over 40 mlU/mL Under 40 mlU/mL
Nonhirsute
Mild hypothalamicdysfunction
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
Elevated
Microadenoma,hyperplasia
Cone view Normal andProlactine
50-100ng/mL
Repeat prolactinevery 6 monthsCone views every1 – 2 years
CT or MRI scan
Macroadenoma
Treat hypothyroidism
TSH
Normal
Cone view abnormal or
Prolactine over50-100ng/mL
or visual symptom
Wor
kup
for
seco
ndar
y
amen
orrh
ea w
ith
gala
ctor
hea
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