Laparoscopy in primary amenorrheaMalini A Deshmukh, Pratibha R Vaidya, Nergish D Motashaw
Department of Obstetrics and Gynaecology, K.E.M. Hospital and Seth G.S, Medical College, Parel, Bombay-400 012., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 152811
Source of Support: None, Conflict of Interest: None
The present paper is a laparoscopic study of 66 cases of primary amenorrhoea. Biopsy of the ovaries was also carried out in addition to certain laboratory investigations. There were 43 cases of Mullerian agenesis while only 20 cases showed gonadal dysgenesis. There were 3 cases of genital tuberculosis. Though endocrine studies contribute important information, laparoscopy with gonadal biopsy assists in the diagnosis and prognosis of majority of the patients.
Laparoscopy is an important and indispensable aid to the gynaecologist, in his search for the correct etiology of primary amenorrhoea, in addition to clinical evaluation and certain laboratory investigations.
Clinical examination is not of sufficient value, for a definite diagnosis. Sophisticated endocrine investigations, such as gonadotrophin assays, ovarian stimulation tests with gonadotrophins and leutinising hormone releasing factor, and chromosomal studies are not always possible at all centers, due to lack of laboratory facilities and non-availability of gonadotrophins for diagnostic tests.
Present paper is a laparoscopic study of 66 cases of primary amenorrhoea along with a few laboratory investigations, to determine the etiological factors.
Sixty six cases of primary amenorrhoea were investigated in the following manner, in the K.E.M. Hospital, Bombay. After history and clinical evaluation RBC, Hb, ESR, vaginal cytology, buccal smear, X-ray chest and skull were done in all cases. This was followed by laparoscopy-biopsy of the ovary.
Routine blood tests, and X-rays of chest and skull did not reveal anything significant.
Buccal smears showed +ve Barr body in all except one patient. [Table 1] shows the laparoscopic findings.
There were 37 cases with absent or rudimentary uteria but only 13 cases with streak ovaries.
Type of ovaries
Thirty eight out of 66 cases had normal ovaries, four cases had enlarged ovaries, Eleven cases had small hypoplastic ovaries whereas 12 cases had streak ovaries. There was only one case of absent ovary.
Vaginal cytology showed that the estrogenic effect was good in 23 out of 66 cases; it showed mild deficiency in 6, moderate deficiency in 21 and 15 cases showed atrophy. There was only one case of absent vagina.
These are shown in [Table 2].
Etiology as revealed by laparoscopy This is shown in [Table 3].
More than 1 factor was present in some patients. Black and Govan  investigated 20 patients of primary amenorrhoea, by laparoscopy, gonadal biopsy and chromosomal study. Their findings are also given in [Table 3] for comparison. In the present series, though anatomic anomalies were present in 37 cases, ovaries were normal in 29 patients.
There were 3 cases of genital T.B., diagnosed by circumstantial evidence of blue uterus and rigid tubes; there was no endometrium available for histology and culture in spite of priming the uterus with hormones.
Shearman  regards the evaluation and diagnosis of primary amenorrhoea as an intellectual and interesting exercise. He feels that it is possible to arrive at a fairly firm and provisional diagnosis from the history and clinical examination, and a minimum need to go beyond simple OPD investigations. He considers karyotyping interesting but not essential. He advocates laparoscopy or laparotomy only when there is disparity between the clinical findings especially phenotype and laboratory findings.
Black and Govan  emphasize the value of laparoscopy and gonadal biopsy for the assessment of gonadal function in primary amenorrhoea.
In primary amenorrhoea associated with streak ovaries, though the diagnosis can be obtained by simply looking at the ovaries a final correct diagnosis of ovarian dysgenesis is reached when, at histopathology, only fibrous tissue devoid of follicles is seen.
Black and Govan  consider the estimation of total urinary gonadotrophins of limited value. Although high values indicate underdeveloped ovaries, normal values may be present with inactive ovaries without follicles and high gonadotrophins may be encountered in primary amenorrhoea with apparently normal ovarian function.  Shearman  feels that serial assay of gonadotrophins and effect of gonadotrophins on urinary oestrogens give the same information as demonstration of primordrial follicles to distinguish between primary and secondary ovarian failure.
Similarly in their study of chromosonal patterns abnormal patterns were encountered only in cases of dysgenetic gonads, while with definite ovarian histology with or without follicles, chromosomal patterns were normal.
Genital tuberculosis is a common condition in our country and often the endometrium is atrophic and is not available for histologic study. In such cases visualisation of tubercles, on the peritoneum, intestines, tubes, ovaries, ovarian and tubal biopsy together with the circumstantial evidence of a blue uterus, may help to arrive at the diagnosis.
Laparoscopy therefore will not only ascertain the condition of the internal organs, assist in establishing diagnosis by biopsy wherever necessary but will also save the patient an abdominal operation.
Thus it may be concluded that though endocrine study contributes important information for complete assessment and ultimate management of patients, yet in the majority of cases, laparoscopy and gonadal biopsy assist in diagnosis, prognosis and management of primary amenorrhoea and make the study of functional anatomy of the ovary possible to some extent.
We thank Dr. C. K. Deshpande M.D., Dean, K.E.M. Hosp. & Seth G.S.M. College, Bombay and Dr. V. N. Purandare, Head, Dept. of Obstetrics & Gynaecology, K.E.M. Hospital & Seth G.S.M. College, Bombay for allowing us to present the hospital data.
[Table 1], [Table 2], [Table 3]