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