Amenorrhea

Dr. Rania Abdeen

 Definition
Amenorrhea is defined as the absence of menstruation.
• 1) Primary amenorrhea
• is when girls fail to menstruate by 16 years of age.

• OR Menstruation has not occurred by the age of 14 in

the absence of secondary sexual characters

2) Secondary amenorrhea is absence of menstruation for

more than six months in a normal female of
reproductive age that is not due to pregnancy,
lactation or the menopause.
 Etiology
➢ Hypothalamic disorders .

➢ Pituitary disorders .

➢Ovarian disorders .

➢Anatomical disorders .
 Hypothalamic disorders
1)Excessive exercise, weight loss
the occurrence of amenorrhoea associated with a drop
in body fat, seen in eating disorders such as anorexia
nervosa and in strenuously exercising athletes.
2)stress can switch off hypothalamic stimulation of the
pituitary.
3) Hypothalamic lesions (craniopharyngioma, glioma)
can compress hypothalamic tissue or block dopamine.
4) Head injuries.
 Hypothalamic disorders
• 5) Kallman's syndrome (X-linked recessive
conditions resulting in deficiency in GnRH
causing underdeveloped genitalia).associated
with anosmia

6) Systemic disorders including sarcoidosis,

tuberculosis resulting in an infiltrative process in
the hypothalamo-hypophyseal region.
7) Drugs: Progestogens, HRT or dopamine
antagonists.
8)chemotherapy or radiotherapy for malignant or
auto-immune disorders
 Pituitary disorders
1) Pituitary Adenomas of which prolactinoma is
most common.

2) Pituitary necrosis, e.g. Sheehan's syndrome

(due to prolonged hypotension following
major obstetric hemorrhage).
3) Iatrogenic damage (surgery or radiotherapy).
4) Congenital failure of pituitary development.
 Ovarian disorders
1) Anovulation (polycystic ovarian syndrome)
2) Premature ovarian failure (POF).
POF is defined as cessation of periods before
40 years of age.
It is usually unexplained, but may be due to :
➢ Chemotherapy .
➢ Radiotherapy .
➢ Autoimmune disease .
3)Congenital: Complete androgen insensitivity in
an XY female. Turner syndrome (XO) presents
with primary amenorrhoea, while women with
mosaic Turner (XX/ XO) may present with
secondary amenorrhoea
 Anatomical disorders
Genital tract abnormalities .
1) Asherman's syndrome over-curettage of the endometrium.
2) Congenital: Mullerian agenesis •
Congenital absence of the uterus is due to faulty development of the
Müllerian ducts (Meyer– Rokitansky–Kuster–Hauser syndrome).
3)Transverse vaginal septum and Imperforate hymen.
These two conditions lead to cryptomenorrhoea, where cyclic bleeding
and pain occur every month, but the bleeding is not revealed
4)Trauma: Surgical removal (hysterectomy)
5)Inflammation: Postpartum or post-abortive infection
Imperforated hymen
 Clinical findings

A general inspection of the patient:

Body mass index (BMI),
Secondary sexual characteristics (hair growth,
breast development) and
Signs of endocrine abnormalities (hirsutism,
acne, abdominal striae, moon-face, skin
changes) .
 Clinical findings

• If the history is suggestive of a pituitary lesion,

an assessment of visual fields is indicated.
• External genitalia and a vaginal examination
should be performed to detect structural
outflow abnormalities → haematcolpos.
or atrophic changes due to hypo- oestrogenism.
History and examination of patient with amenorrhea
Information required Relevant factors Possible diagnoses

Developmental history Delayed/incomplete Congenital malformation or

including menarche chromosomal abnormality

Oligomenorrhoea PCOS
Menstrual history Secondary amenorrhea POF

Infertility PCOS
Reproductive history Congenital malformation

Cyclical pain without Congenital malformation

Cyclical symptoms menstruation Imperforate hymen

Hirsutism PCOS
Hair growth

Weight Dramatic weight loss Hypothalamic malfunction

Difficulty losing weight PCOS
 History and examination of patient with amenorrhea
Information required Relevant factors Possible diagnoses
Lifestyle Exercise, stress Hypothalamic
malfunction

Past medical history Systemic diseases, e.g. Hypothalamic

sarcoidosis malfunction

Past surgical history Evacuation of uterus Asherman’s

Drug history Dopamine antagonists, Hypothalamic

(metoclopramide). malfunction
HRT.
Headache Pituitary adenoma

Galactorrhoea Prolactinoma

Visual disturbance Pituitary adenoma

 Investigation of amenorrhea
• Blood can be taken for FSH , LH, and
Testosterone:
Raised LH or raised testosterone could be
suggestive of PCOS.
Raised FSH may be suggestive of POF.
• A raised prolactin level may indicate a
prolactinoma.
• Thyroid function should be checked if
clinically indicated.
• AMH (anti Müllerian hormone) tests of
 Investigation of amenorrhea
• An USS can be useful in detecting polycystic
ovaries.
• MRI should be carried out if symptoms are
consistent with a pituitary adenoma.
• Hysteroscopy is not routine, but is a suitable
investigation where Asherman’s or cervical
stenosis is suspected.
• Karyotyping is diagnostic of Turner’s.
 MANAGEMENT OF AMENORRHOEA

Causes of amenorrhoea Management

Low BMI Dietary advice and support

Hypothalamic lesions, e.g. glioma. Surgery

Dopamine agonist (e.g. cabergoline or

Hyperprolactinoma \prolactinoma bromocriptine) or surgery if medication
failed.
MANAGEMENT OF AMENORRHOEA

POF HRT or COCP

PCOS Mangement of PCOS

Adhesiolysis and IUD insertion at time

Asherman's of hysteroscopy( to prevent
recurrence of adhesions)

Cervical stenosis Hysteroscopy and cervical dilatation .

Thank you