Study of Primary Amenorrhea with etiology in out door patient of Rupganj Upazilla Health Complex

Background : Amenorrhea means without menstruation. Primary Amenorrhea is the absence of menstruation by 16 years of age in the presence of normal secondary sexual characteristics or by 14 years of age if secondary sexual characteristics have not developed. Objectives : To explore the prevalence of Primary Amenorrhea with etiology in outdoor patient with limited investigation sources Methods : This was a cross sectional study conducted at Rupganj Upazila Health Complex (UHC) from January 2014 to June 2016. During this period total 2500 patients attended at Gynae out patient department (OPD). Among them 45 patients was sorted out with Primary amenorrhea. History and physical examination was done for presence or absence of secondary sexual characteristics, external genital abnormalities. Investigations were ultrasonogram (USG), Hormonal test were Follicle stimulating Hormone (FSH), Lutilizing hormones (LH), Serum Prolactin, Thyroid Stimulating Hormone. Karyotyping done. Data were analysed by using SPSS version 20. Result : In our study prevalence of Primary Amenorrhea was 1.8%. Among them infantile uterus was 17.78%, imperforated hymen was 13.33%. Turner mosaic 11.4%, mullarian agenesis 6.66%, gonadal agenesis-4.45%. hypothyroid 8.89%, hyperprolactenemia-8.89%, and 11.11% patients were with positive progesterone challenge test without anatomical and hormonal abnormalities. Conclusion : Considering the study result, Infantile uterus was the most prevalent etiological factor of amenorrhoea followed by imperforated hymen and Turner mosaic. Key word : Primary Amenorrhea, infantile uterus, imperforated hymen, Turner mosaic. DOI: http://dx.doi.org/10.3329/nimcj.v9i2.38911 Northern International Medical College Journal Vol. 9 No. 2 January 2018, Page 300-303 the highest levels (hypothalamus). The most common etiology of Primary Amenorrhea isgonadal dysgenesis (40%), Hypothalamic Amenorrhea (30%). The genital examination is abnormal in 15% of patients with Primary Amenorrhea. In rare condition more than one component of hypothalamuspituitaryovary (HPO) axis and genital tract are affected. Other than each 20% hypoprolactenemea and 30% chance of weight related Amenorrhea. The etiologic factors of primary amenorrhoea Group IEnd organ failure/ outflow tract obstruction a) Mullerian agenesis b) Transverse vaginal septum Introduction Primary Amenorrhea is one of the common reproductive disorder affecting females. It leads to the absence of menarche in the reproductive age group in females. Reported incidence of Primary Amenorrhea is 1-3% of women in reproductive age group. There are many causes which leads to Primary Amenorrhea including genetic aberrations. Various factors such as anatomical, genetic and hormonal factors reported to influence Primary Amenorrhea. The recommended evaluation for amenorrhea aimed to divide the reproductive system into components like genital outflow tract, uterus, the ovary, the pituitary and to asses the functional integrity of each, starting at the lowest level (the genital outflow tract) and upto Original Article Study of Primary Amenorrhea with etiology in out door patient of Rupganj Upazilla Health Complex S Sultana et al. January 2018 Volume 9 Number 2 301 hypogonadotropic hypogonadism includes (a) Congenital abnormalities (b) Endocrine disorders


Introduction
Primary Amenorrhea is one of the common reproductive disorder affecting females. It leads to the absence of menarche in the reproductive age group in females. Reported incidence of Primary Amenorrhea is 1-3% of women in reproductive age group. There are many causes which leads to Primary Amenorrhea including genetic aberrations. Various factors such as anatomical, genetic and hormonal factors reported to influence Primary Amenorrhea. 1 The recommended evaluation for amenorrhea aimed to divide the reproductive system into components like genital outflow tract, uterus, the ovary, the pituitary and to asses the functional integrity of each, starting at the lowest level (the genital outflow tract) and upto Eugonadism may result from anatomic abnormalities includes congenital absence of the uterus and vagina (CAUV-16%) and Cervical Artesia (0.4%) intersex disorders include androgen insensitivity (1.5%), 17 ketoreductase defficiency (0.4%) and inappropriate feedback (5.3%). 9 We conducted this study to evaluate the etiology of primary amenorrhoea in women attending at a Primary health care centre in Bangladesh.

Methods
The study design was descriptive cross sectional and conducted at Rupganj Upazilla Health Complex (UHC) from 2014 January to June 2016. Total 2400 patients were attended at Gynae OPD among them 45 patients with primary amennorrhoea were sorted out following nonprovability purposive sampling. First and foremost, it is imperative to rule out pregnancy. Additional diagnosis of Primary Amenorrhea usually result from genetic or anatomic abnormality. The relative prevalence of Primary Amenorrhea includes hypergonadotropic hypogonadism (48.5%), hypogonadotropic hypogonadism (27.8%) and eugonadism (pubertal delay) with normal gonadotrophin (23.7%). 7 The hypergonadotropic hypogonadism category includes (a) patients with abnormal sex chromosome (i.e. turners syndrome) who make up 29.7% of all Primary Amenorrhea cause and those (b) Patient with normal sex chromosomes. The later group includes both patients who are 46xx(15.4%) and those 46xy(3.4%). 8

Northern International Medical College Journal
increased in 10 (22.22%) patients, increased TSH in 4(08.89%) patients, increased serum Prolactin level in 4(08.89%) patients. (Table III)   The current study revealed hormonal analysis of FSH, LH, Prolactin, TSH were normal in 48% cases and rest cases showed increased level of different hormon. Similar result was found in study done by Z. Nazir et al. 10 In our study, karyotyping was done in 18 patients. Among them Karyotyping) were done from Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder (BIRDEM) and Bangabandhu Sheik Mujib Medical University (BSMMU). Hormonal assay done to sort out endocrine disorder. Ultrasonogram (USG) was done to find out any abnormalities of internal genital organ-infantile uterus, Mullerian agenesis, gonadal agenesis, imperforated hymen etc. Karyotyping was done to find out chromosomal anomaly.
Those patient who were within normal BMI and presence of secondary sexual characteristics and normal biochemical findings were given progesterone challenge test Data collected from individual history and data sheet. Prior to data collection ethical clearance was taken from authority and informed consent was taken from patients. Confidentiality and privacy was maintained while data collection was done. Data were cleaned, edited and analyzed by using SPSS version 20. The frequency was calculated and percentage was done to find out the prevalence of etiology.

Result
Among 45 patients 43 patients (95.55%) was found with secondary sexual characteristics (Breast development, Pubic and axillary hair and with normal external genitalia). 2 (4.45%) patients found without secondary sexual characteristics but with normal external genitalia. (Table-1  Among 45 patients of Primary Amenorrhea 5(11.11%) with all hormonal, USG finding normal and progesterone challenge test was positive, that is, they have normal menstrual flow after withdrawing of 7 days progesterone orally. All of the patients (45) family history was negative for any gynaecological issues. A study by M. Behera was also found similar result. 9

Conclusion
Considering the study result, Infantile uterus was the most prevalent etiological factor leading to amenorrhoea followed by imperforated hymen and Turner mosaic.