APPROACH TO DIAGNOSIS OF PRIMARY AMMENORRHOEA

NAME OF PATIENT :- Age :-
Address :-
History :-
* Exclude pregnancy
* Differentiate - primary or secondary amenorrhoea
* History of neurological symptoms, headache, visual distrubences, emotional stress
* Ability to smell
* Hirustism, voice changes
* History of weight changes
* History of abdominal pain especially cyclical lower abdominal colicky pain
* History of medication / substance abuse
* Exercise
Past history of illness
* Tuberculosis
* Surgery
* Radiotherapy
* Chemotherapy
Menstrual history :-
* History of spotting per vaginum
* Secondary sexual characters
Family history:-
* Age of menarche and fertility of sisters, mother
* History of endocrine / genetic disorders
* History of tuberculosis
* Height of family members
Maternal ingestion of hormones
* Maternal history of miscarriages
* History of congenital anomalies

EXAMINATION :-
General Physical Examination :-
* Height Weight Arm Span
* Nutritional Status Thyroid Enlargement Breast
* Galactoorrhoea Axially Hairs
* Any Stigmata Of Turner Syndrome
* pulse temp Bl.Pressure
Signs of hyperandrogenism :- acne / hiruitism / striae / central obesity / voice changes / temporal heir recession

Cardiorespiratory Examination :-
* any evidence of tuberculosis
¨ Abdominal Examination :-
* Lump abdomen
· Pelvic Examination :-
* Pubic Heir Study
* External Genitalia Any Visible Abnormality Like Clitoromagly
* Any Abnormality Of Outflow Tract
* Estrogen Status
Investigation :-
BLOOD EXAMINATION:-
Hb. TDLC ESR

BL.Group bl.suger VDRL

URINE EXAMINATION:-

* Laproscopy
*
* Transabdominal Sonography
*
* Karyotyping :- All Hypergonodotrophic Patients( Turner ‘S Syndrome, XY Pure Gonadal Dysgenesis )
*
* Radiographic Study To Find Skeletal & Renal Malformation
( Ectopic Kidney, Renal Agenasis , Horse Shoe Kidney , Abnormal Collecting Ducts.)




Suggested Role Of Transabdominal Sonography (TAS) In The Workup Of Primary Amenorrhoea :-

Absent/ Minimal Secondary Sexual Characters
Normal Isosexual Development

Infantile Uterus
Normal Overies
Vagina Streak Overies
Absent Uterus
Normal Overies
Normal UTRUS With Endometrial
Lining
Normal Overies

Normal Overies
Gonadal Dysgensis
Mullarian Agenasis
Endocrine Disorders, Obstructive
Lesions,
Tuberculosis

Hypogonadotrophic Hypogonodosim
Hypertrophic Hypogonadism



If Ovaries are not seen on USG ,then cytogenic studies and / or laparoscopic study is needed to ascertain the cell line of gonad and to remove intraabdominal gonad if Y cell line is present.












Classification Of Primary Ammenorrhoea :-
Hypertrophic Hypogonadism
· Chromosomal Incompetent Ovarian Failure Include Classic Turner , All Other X Deletion And 45X / 46 XY.
· Chromosomal Competent Ovarian Failure
· True Agenesis
· Premature Ovarian Failure ( Radiation, Chemotherapy , Auto Immune)
· Galactosaemia
· 46 XY
Hypogonadotrophic Hypogonadism
Reversible
· physiological delay
· Weight loss / anorexia nervosa / heavy exercise /
· primary hypothyroidism
Irreversible
CONGENITAL
· isolated GNRF deficiency
· partial or total hypo pituitarism
· congenital CNS defect

ACQUIRED
· Hyperprolactenemia
· Pituitary Adenoma
· Empty Cella
· Craniopharyngioma
· Other Intracranial Tumours
· Trauma
Eugonadal
· Anatomical :- Uterovaginal Agenasis, Imperforated Hymen (Including Transverse Septum)
· Polycystic Ovaries
· Testicular Feminisation
· Noonan’s Syndrome
Virilism:
· Adrenal Hyprplasia
· Tumour( Adrenal/ Ovarian)
· Alfa Reductase Deficiency
· Absent Anti-Mullarian Factor
· True Hermaphrodite