Case Comference

1
Case Comference
Amenorrhea
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2
Case 1
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???????? ????? ???????? ???????????? 1st
Admission ??? ??. ????? ???????????????????????
OPD Card
cc. ????????????? 1 ??????????
3
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4
History taking
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???? 4. ??????????????? 5. ??????????????? -
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5
History
Present illness 2 ??????????????????.
????????? lower back ??????? ?????? 3-4
?????????????????? 10-12 ???/????? ????????????
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?????????? ??.???????? ??? X-ray ?????????????
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6
History
1 ??????????????????. ???????????????????????????
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?????????????? ???????? ???????? 3-4 ???????
?????????????????????????? 3-4 ??? ?????? ?????
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??????????????????? ?????????????????? 4 ????????
(?? 1 ?????) ??? ???????????????????
7
History
Past history ?

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Family history

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8
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9
History
Puberty, including a growth spurt, development
of axillary and pubic hair, apocrine sweat
glands, and breast development Family history
of delayed or absent puberty. Patient's height
relative to family members. Neonatal and
childhood health. Symptoms of
virilization. recent stress , diet, exercise
habits and illness.
10
History
Drugs associated with amenorrhea such as
heroin and methadone. Galactorrhea ,drug
increasing serum prolactin concentrations ( ie.
metoclopramide and antipsychotic drugs).
Symptoms of other hypothalamic-pituitary disease,
including headaches, visual field defects,
fatigue, or polyuria and polydipsia
11
History

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• ??????????????????? ????????? 13 ??
• ?????? ?????????????? ????????? 12 ??
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• Thelarche 12 ??, Adrenarche 13??

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Problem List

• Primary amenorrhea
• Low back pain
• Suprapubic pain
• Nausea and vomiting

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Primary amenorrhea ?
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Primary amenorrhea
1. No periods by age 14 in the absence of growth
or development of secondary sexual
characteristics . 2. No periods by age 16,
regardless of the presence of normal growth and
development with the appearance of secondary
sexual characteristics.
15
Physical examination
Evaluation of pubertal development,
including current height, weight and arm span
Assessment of breast development ( Tanner
staging ) A careful genital examination
clitoral size, pubertal hair development
intactness of the hymen, depth of the vagina ,
and presence of a cervix , uterus , and
ovaries. Examination of the skin for
hirsutism, acne , striae , vitiligo and
increased pigmentation. Evaluation for the
classic physical features of Turner syndrome
16
Physical examination
GA A young Thai Female, good conciousness ,146
cm. in height, 41cm. in weight. Skin no signs
of virilization. HEENT Mild pale conjunctiva,
no icteric sclera. Heart Normal S1 S2, no
murmurs. Lung Clear, no adventitious
sounds. Breast Normal breast development
.(4sttannerstage)
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Physical examination
Abdomen suprapubic mass (soft, smooth surface
,not tender ) no distension,no guarding ,
rebound tenderness , liver and spleen cannot
be palpable. Extrimity No edema. Pelvic
examination MIUB normal Vagina
Blind vaginal pouch
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Problem List

• Primary amenorrhea
• Low back pain
• Suprapubic pain
• Nausea and vomiting
• Pelvic mass
• Blind vaginal pouch

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Menstrual mechanism
Environment
CNS Hypothalamus GnRH Pituitary FSH
LH Ovary Uterus Menes
Compartment IV
Compartment III Compartment II Compartment
I
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Etiology of amenorrhea
Compartment I Compartment II
Compartment III IV

• Anatomy anomalies of Mullerian structure
• -obstuction -absent

• Ovarian failure
• - Genetics - Radiation - Chemotherapy
• - Infection - Infarction
• Anovulation

• Pituitary-hypothalamic lesion
• - Tumors - Infection - Infaction

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Etiology of amenorrhea
Compartment IV

• Alternation of GnRH secretion
• - stress( psychological physiological)
• - malnutrition
• - Feedback from abnormal levels of hormone
• (androgens , esrogens , thyroid hormone,
• glucocoricoids, GH , TSH , ACTH and
  prolactin)

22
Primary amenorrhea
ETIOLOGY usually the result of a genetic or
anatomic abnormality. However, all causes of
secondary amenorrhea can also present as primary
amenorrhea. Chromosomal abnormalities
causing gonadal dysgenesis 45 percent
Physiologic delay of puberty
20 percent
Mullerian agenesis
15
percent Transverse vaginal septum or
imperforate hymen 5
percent Absent production of GnRH by the
hypothalamus 5 percent
Anorexia nervosa
2
percent Hypopituitarism

2 percent Reindollar, RH, Byrd, JR,
McDonough, PG. Delayed sexual development a
study of 252 patients. Am J Obstet Gynecol1981
140371.
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Investigation of primary amenorrhea
Compartment I Compartment II Compartment
IIIIV
ultrasound
FSH,LH assay Karyotype determination

• Hormonal profiles(TSH,prolactin,FSH,estrogens
• ,androgens,glucocorticoids.)
• Coned-down view of sella tercica
• CI/MRI
• IGF-1

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Compartment ?
Compartment I

• Cyclic pain
• Pelvic mass
• Blind vaginal canal

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Diffirential diagnosis

• Mullerian anomaly
• Imperforate hymen
• Transverse vaginal septum
• Mullerian agenesis (Mayer-Rokitansky-Kuster
• -Hauser syndrome)
• Androgen insensitivity
• True hemaphrodites

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Imperforate hymen VS Transverse vaginal septum
Lack of distension at the introtus with
valsavas manuver.
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Investigation ?
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Investigation
Ultrasound There are pelvic masses as figure.
The upper portion is 5.94.97.8 cm (suspected
to be uterus) . The lower portion is
13.912.39.4 cm(suspected to be vagina). There
are medium echogenicity content in the masses.
The right adnexal mass was noted in diameter of
6.03.3 cm. Imp.1. Hematocolpos obstruction of
vagina outlet. 2. Rt.adnexal mass was
hydrosalpinx and was to be rule out
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Transverse vaginal septum

• Cyclic suprapubic pain
• Blind vaginal canal
• Hematocolpos

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Management?
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Management

• Counseling
• Investigation for associate anomaly
• Incision drainage
• Construction of neovagina

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Transverse vaginal septum

• Associate anomaly
• Urinary tract anomaly (33)
• Skeletal anomaly (12)
• -Spine anomalies
• -Absense digit syndactyly

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Investigation
IVP Kidneys is normal in size ,contour and
position. Right pelvocalyceal system is normal.
Duplication of pelvocalyceal system of left
kidney was noted without hydronephrosis. Two
left ureters joins at S1 level. Spine X-ray
normal.
34
Operative proceduce

• ID was done to create false tract
• then hematocolpos was collected
• about 500 ml.
• Foley catheter was placed to irrigate
• vagina uterus and was retained to
• drain the remaining fluid.

35
Progress note

• Post op.(16/9/44)
• S ?????????????????? ????????????????
  ??????????????
• ov/s BP 120/80 mmHg PR 88 /min
• RR 16 /min BT 37 C
• HEENT not pale
• Heart Normal S1 S2, no murmurs.
• Lung Clear, no adventitious sound.
• Abdomen soft, not tender

36
Progress note
Extrimity no edema collect fluid from
vagina 50 cc. A transverse vaginal septum S/P
ID day 0 P - Observe vaginal bleeding -
consult plastic surgery to create new vagina
- adequate analgesics
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Progress note

• Post op. Day 1(17/9/44)
• S ?????????????????? ????????? ???
• O v/s BP 110/70 mmHg PR 72 /min
• RR 18 /min BT 37 C
• HEENT not pale
• Heart Normal S1 S2, no murmurs.
• Lung Clear, no adventitious sound.
• Abdomen soft, not tender

38
Progress note
Extrimity no edema collect fluid from vagina
80 cc. A transverse vaginal septum S/P ID
day 0 P - Observe vaginal bleeding -
start oral diet - consult plastic surgery
to create new vagina
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Progress note

• Post op. Day 3(19/9/44)
• S ?????????????????? ????????? ????????????
• O v/s BP 110/70 mmHg PR 80 /min
• RR 18 /min BT 37 C
• HEENT not pale
• Heart Normal S1 S2, no murmurs.
• Lung Clear, no adventitious sound.
• Abdomen soft, not tender

40
Progress note
Extrimity no edema collect fluid from vagina
80 cc. A transverse vaginal septum S/P ID
day 0 P - Off foley catheter - Regular
diet - consult plastic surgery to create
new vagina
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Amenorrhea
Secondary sexual charactheristics
absent
Present
Normal uterus
Absent uterus
Abnormal genitalia
Normal genitalia

• 5-alpha reductase deficiency
• 17,20 desmolase deficiency
• 17 alpha hydroylase deficiency

High FSH

• Mullerian anomaly
• Androgen insensitivity
• True hemaphrodites

TSH,PRL
karyotype
XX Y lines XO(Turners)
Lownormal FSH
Normal TSH Normal PRL
abnormal TSH or abnormal PRL

• Kallmansyndrome
• Physiologic delays
• hypothalamic/pituitary dysfunction
• CNS tumors

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Normal TSH Normal PRL
High FSH
Normal FSH
Low estrogen
Normal estrogen
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Case closed!
44
Primary amenorrhea
Secondary sex characteristics Genitalia
Disease normal abnormal
Mullerian anomaly Androgen
insensitivity True hemaphrodites normal n
ormal ?????? secondary amenorrhea abnormal nor
mal Gonodal dysgenesis Kallmansyndrome
Physiologic delays abnormal abnormal 5-alph
a reductase deficiency 17,20 desmolase
deficiency 17 alpha hydroylase deficiency