1999 Obstetrics & Gynaecology

By Duy Thai

PHYSIOLOGY OF MENSTRUATION & AMENORRHOEA

Normal menstruation
• The whole menstrual cycle occurs at several levels
1. Anterior pituitary
• FSH early on
• LH resulting in ovulation
• LH to maintain the corpus luteum
2. Ovaries
• Small follicle which grows under influence from FSH
• Surge of LH results in ovulation
• Remaining granuloma cells form corpus luteum
3. Endometrium
• Oestradiol creates a thin endometrial layer which proliferates and thickens (proliferative
phase)
• Formation of corpus luteum results in production of progesterone which prevents further
hyperplasia. Induces formation of more mature, secretory endometrium
• Oestrogens also promote formation of a thin, water cervical mucous favouring entry of
sperm
• LH levels fall off during luteal phase, unless conception occurs, which maintains the corpus luteum (via
βHCG)
• Pre ovulatory bursts of oestrogen initiates the LH surge.
• Progesterone rises through the luteal phase, peaking at day 21, then drops off as the corpus luteum
dies. This fall in progesterone results in sloughing of the endometrium and menstrual bleeding.

Amenorrhoea
1. Definition
• Absence of menstruation
• Cycles usually 28 days
• Oligomenorrhhoea if cycle frequency is between 6 weeks and 6 months
2. Classification
A. Primary amenorrhoea
B. Secondary amenorrhoea
3. Aetiology
A. Hypothalamus (GnRH)
• Congenital
• Constitutional amenorrhoea
• Familial tendency
• Rare syndromes
• Nutritional/exertion
• Excess weight loss/gain
• Elite sports people
• Psychological stress
• Drugs
• Especially antipsychotics which result in increased prolactin
• Endocrine
• Hyperprolactinaemia
• Hypothyroid
• Excess androgens (polycystic ovarian syndrome)
• Pregnancy, OCP
B. Pituitary (LH, FSH)
• Neoplasm
• Adenomas
• Craniopharyngiomas
• Surgical removal
• Radiotherapy
• Inflammatory – basal meningitis
• Autoimmune
• Vascular – Sheehans syndrome

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 1999 Obstetrics & Gynaecology
By Duy Thai

• Infarction of pituitary in association with hypotension post partum. 1st thing to

notice is failure of lactation
• Endocrine
• Pill
• Hyperprolactinaemia
C. Ovaries
• Congenital
• Chromosomal abnormalities (e.g. Turners)
• Developmental – Primary gonadal dysgenesis: phenotypically female but
karyotypically male, but no testosterone in utero
• Familial
• Trauma, surgical, radiotherapy
• Autoimmune
• Metabolic storage diseases
• Haemochromatosis
• Less common in women due to natural blood loss
• Galactosaemia
• Cytotoxic medications
D. Uterus
• Congenital absence
• Ashermans syndrome
• Definition
• Inflammation causing intrauterine adhesions resulting in destruction of
endometrium
• Aetiology
• Curettage + infection, e.g. infection following abortion/pregnancy
• Endometrial ablation to reduce heavy periods
• Presentation
• Present with amenorrhoea or light periods
• Investigations
• Hysteroscopy
• Hysterosalpingogram
• Hormone withdrawal
• Sequelae
• Amenorrhea
• Infertility
• Miscarriage
• Placenta accreta
• Treatment
• Hysteroscopic division of adhesions
• Keep cavity open with intrauterine cavity device
• Oestrogen
E. Cryptomenorrhoea
• Definition
• Menstruation is occurring but is not being revealed
• Cause – Genital tract occlusion
• Cervical atresia
• Congenital stenosis/adhesions
• Post surgical – core biopsy, diathermy
• Vaginal obstruction
• Vaginal septum
• Imperforate hymen
• Labial fusion
• Symptoms
• Amenorrhoea
• Cyclical pain
• Symptoms related to aetiology

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 1999 Obstetrics & Gynaecology
By Duy Thai

• Signs
• Lower abdominal mass
• Diagnosis will often be revealed on speculum examination

Assessment of a patient with amenorrhoea

1. History
• Primary or secondary
• Any weight loss
• Psychosocial stressors
• Pastime – excessive exercise
• Galactorrhoea
• Symptoms of hypothyroidism
• Constipation, cold intolerance
• Depression
• Dry skin
• Symptoms/signs of androgen excess
• Hirsuitism
• Acne
• Past gynaecological/obstetric history for uterine/vaginal procedures
2. Examination
• If suspect pituitary tumor – check for bi temporal hemianopia
• Inspect vagina and introitus
• Bimanual examination looking for ovarian tumor
• If virgin, do not perform PV
• Do ultrasound
3. Investigations
• FSH, LH
• To exclude an ovarian cause
• FSH will be high in ovarian failure due to lack of negative feedback inhibition
• Prolactin
• TFT
• β HCG
• Androgens

• 80% of causes of amenorrhoea are

• Stress
• Exercise Diagnoses of exclusion since will have no abnormalities on Ix
• Weight
• Constitutional
• Hypothalamic/pituitary causes will have abnormalities on hormonal investigations
• If suspect pituitary causes, perform skull X ray and prolactin levels
• Ovarian causes will have ↑ FSH (& LH)
• Do pelvic U/S or CT

Teatment of amenorrhoea
• Treat the cause
• If due to stress/weight/diet/exercise
• Do nothing, reassure and educate
• If change in lifestyle is not immediately possible and the person wishes to conceive, may
induce ovulation
• If due to ovarian failure
• Remove ovaries if neoplastic
• If wish to become pregnant, consider donor egg and IVF
• If have no periods, no oestrogen and progesterones, need to consider HRT
• Will prevent osteoporosis and adverse lipid profiles – prevent stroke, heart disease

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