Simplifikasi Amenore

Hanom Husni Syam

Department of Obstetric & Gynaecology

University of Padjadjaran
Amenore Primer
 Secondary amenorrhea

• In a woman who has been menstruating the

absence of periods for a length of time
equivalent to a total at least 3 of the previous
cycle intervals or 6 months of amenorrhea
Segregates Cause of Amenorrhea
Compartment IV
Disorder of the
hypothalamus

Compartment III
Disorder of the anterior
pituitary

Compartment II
Disorder of the ovary

Compartment I
Disorder of outflow tract or
uterine target organ
…………. Amenore Primer
Amenore Primer
…………. Amenore Sekunder
 Step 1
Amenorrhea
TSH
Prolactin
Progestasional challenge Hyperprolactinemia

Elevated TSH Hypothyroidism

The purpose of progestasional challenge is to asses :
- the level of endogenous estrogen
- the compatence of the outflow tract

+ Withdrawal bleeding
Normal prolactin
Normal TSH

Anovulation
What is the conclusion of the positive progestasional
challenge test ???

• Intact outflow tract

• Existence and development of the
endometrium lining (Uterus)
• Proper quantity of (E)
• Normal follicle development (Ovary)
• Normal stimuli which provided by the
sequence and magnitude of the
gonadotropins (FSH + LH) (Pituitary)
• Good interactive complex
mechanism which released the
GnRH (Hypothalamus)
Step 2 - Withdrawal bleed
E
1 21

12 21 P
Estrogen and Progestin cycle

+ Withdrawal bleed - Withdrawal bleed

Inadequate amounts End organ

of estrogen problems

Outflow tract problems : discontinuity or

disruption of the Mullerian tube or destruction of
Step 3 the endometrium (overzealous curretage, infection)
 Step 3
FSH-LH assay

Low Normal High

Heterogeneity of the 1. Tumor
glycoprotein
2. Single gonadotropin
hormones.
deficiency
The molecules of
Distinguish between a gonadotropin have
3. Gonadotropin secreting
pituitary or CNS- pituitary adenoma
increased amounts
hypothalamic amenorrhea of sialic acid in the 4. Perimenopausal period
carbohydrate
5. Resistant or
portion, therefore it
insensitivity ovarian
will be qualitatively
syndrome
altered and
biologically inactive 6. Premature ovarian
failure
7. Galactosemia
8. P450C17 enzyme
deficiency
Central Defects
 Stress

CRH  Somatostatin 

Endorphins  ACTH  TRH 

GnRH  Cortisol  TSH 

T4 

T3 
 Primary Amenorrhea
• No period by age 14 in the absence of growth
or development of secondary sexual
characteristics

• No period by age 16 regardless of the

presence of normal growth and development
with the appearance of secondary sex
characteristics
Stages of breast and pubic hair development
Controls of Prolactin
secretion
Prolactin is made in the pitutary
lactotrophs and released in pulsatile
manner  reflects the pulsatile
release of controlling hypothalamic
hormones
Prolactin secretion is the result of a
complex interactions between PIF
and PRF
Hypothalamus

TRH >>>

Pituitary

Prolactin >>> T3 / T4 <<<