Prof.

Dr Salam Jibrel MD
AGU 5 year Medical
Amenorrhoea: Absence of menstruation.
Physiological amenorrhoea: Absence of
menstruation due to physiological causes:
1. Pre-puberty.
2. Puberty.
3. Pregnancy.
4. Lactation.
5. Menopause.
Primary amenorrhoea: Female who fail to
develop secondary sexual characteristics by
14 years of age or who fail to menstruate by
16 years of age.
Secondary amenorrhoea: Cessation of
menstruation for more than 6 months in a
female during her reproductive age (15 – 49
years).
Cryptomenorrhoea: Menstruation not
showing through the introitus.
 CNS-Hypothalamus-Pituitary
Ovary-uterus Interaction
Neural control Chemical control

Dopamine Norepiniphrine Endorphines

)-( )+( )-(

Hypothalamus
Gn-RH
± Ant. pituitary ? –
FSH, LH
Estrogen Ovaries Progesterone

Uterus

Menses
 Chromosomal sex (normal 46 XX or XY).
 Gonadal sex ( testes or ovary).
 Internal genital sex (Uterus, cervix and upper
vagina or vas deferens, epididymis, and
seminal vesicles).
 External genital sex ( vulva and lower vagina
or penis and scrotum).
Classification of causes:
 Reproductive outflow tract abnormalities.
 Ovarian disorders.
 Pituitary disorders.
 Hypothalamic disorders.
 Other endocrine disorders.
 Mullerian agenesis.
 Transverse vaginal septum
 Testicular feminization syndrome
 Imperforate hymen
 Cervical stenosis
 Asherman’s syndrome
Mullerian agenesis:
 A cause of P. amenorrhoea or cryptomenorrhoea.
 Depends on the degree of agenesis.
 Results from congenital absence of vagina or
uterus or both.
 Chromosomal sex is 46 XX.
 The ovarian function is usually normal (normal
female with normal secondary sexual characters).
 The diagnosis could be confirmed by pelvic
examination and ultrasound exam and
chromosomal study.
Transverse vaginal septum:
 A cause of cryptomenorrhoea.
 Results from an embryological failure of the
lower third of the vagina to canalize.
 Usually the rest of the female genital tract is
normal.
 Chromosomal sex is 46 XX.
 Normal ovarian function (normal SSC).
 Diagnosis by pelvic examination and
ultrasound scan.
Testicular feminization syndrome:
 A cause of P. amenorrhoea.
 Due to congenital defect of androgen receptors
despite normal circulating testosterone.
 Chromosomal sex is 46 XY.
 Gonadal sex is testes.
 Female external genitalia and small blind vagina,
with normal female SSC.
 No internal genitalia (no vagina and uterus).
 Diagnosis by pelvic and ultrasonic exam and
chromosomal analysis.
Imperforate hymen:
 A cause of cryptomenorrhoea.
 Due to absent orifice in the vaginal hymen
 Normal chromosomes and normal ovaries.
 Normal female internal and external genitalia.
 At puberty, the female will complain from monthly
pain due to collection of menses in the genital tract
with some time acute retention of urine.
 On pelvic examination, there is a bulging
haematocolpos.
 On abdominal examination, there is palpable
enlarged uterus due to haematometra.
Imperforate hymen
Cervical stenosis:
 A rare cause of secondary amenorrhoea.
 Found after cervical surgery.
 Radiation therapy.
 Following cervical infection.
 Deep cervical cautery.
 Diagnosis based on clinical findings.
Asherman’s syndrome:
 A cause of secondary amenorrhoea.
 Result from intrauterine adhesions.
 Usually occurs after vigorous uterine

curettage.
 Diagnosis by HSG and Hysteroscopy.
 True gonadal agenesis
 Gonadal dysgenesis (Turner’s syndrome)
 Premature ovarian failure
 Resistant ovary syndrome
 Anovulation
True gonadal agenesis:
 A cause of p. amenorrhoea.
 Due to failure of the germ cells to reach the gonads
from the wall of the hind gut.
 The gonads are rudimentary (streak gonads).
 Chromosomal sex is 46XX or 46XY.
 Normal height.
 External and internal sex is female but infantile.
 No SSC.
 Diagnosis by laparoscopy and chromosomal study
and high FSH and LH.
Gonadal dysgenesis (Turner’s syndrome):
 A cause of p. amenorrhoea.
 Chromosomal sex 45XO.
 Undifferentiated gonads (streak gonads).
 Short stature.
 Other anomalies.
 Diagnosis by chromosomal study and High
FSH and LH.
 Turner’s syndrome

)Classic 45-XO( Mosaic (46-XX / 45-XO)

Ovarian dysgenesis
Premature ovarian failure:
 A cause of s. amenorrhoea.
 Early menopause before 40 years of age.
 High FSH and LH.
 The cause may be familial, irradiation,

chemotherapy and autoimmune disease.

Resistant ovary syndrome:
 A cause of infrequent menses.
 High FSH and LH despite the presence of

viable follicles within the ovary.

 Results from a defect in the LH/FSH receptor.
 Mostly it is a temporary condition.
Anovulation:
 Chronic anovulation may cause

oligomenorrhoea and amenorrhoea.

 Polycystic ovary syndrome is the commonest

cause.
 Other endocrine disorders may be a cause.
Pituitary adenomas:
 A cause of s.amenorrhoea.
 Result in hyperprolactinaemia.
 Most of these tumor are microadenomas,

but some may be large in size resulting in

compression on optic chiasma.
 Diagnosis by high prolactin level and CT

scan or MRI.
Hypopituitarism (Sheehan’s syndrome):
 A cause of s. amenorrhoea.
 This occurs mostly after delivery complicated

by sever PPH or APH.

 Diagnosis by clinical presentation and low

pituitary hormones.
Functional hypogonadotrophic
hypogonadism:
A cause of s. amenorrhoea. Causes includes:
1- Exercise: common in athletes. A minimum
of 17% body fat by weight is required for
initiation of menarche and 20% is required
to maintain menses. High circulating
endorphins can reduce GnRH production.
2- Stress: Emotional stress
3- Weight loss: Weight loss below 15-20% of
ideal body weight result in menstrual
disturbances and amenorrhoea. Anorexia
nervosa is the extreme form.
4- Pseudocyesis: False pregnancy. This
condition is associated with high prolactin
and LH.
5- Drug induced amenorrhoea: Depo-
provera, Danazol, GnRH agonists, post pill
amenorrhoea ( occurs in 1%).
Nonfunctional hypogonadotrophic
hypogonadism:
 Space-occuping lesions: such as

craniopharyngiomas, tuberculosis and

sarcoidosis.
 Kallmann’s syndrome:P. amenorrhoea,

infantile sexual development and anosmia.

 Hypothyroidism: TSH is usually
elevated which result in an
elevated prolactin level.
 Cushing’s syndrome: Increased

adrenal activity leads to a

hyperandrogenic state.
Congenital adrenal hyperplasia:
 A condition results in p. amenorrhoea with
virilizing signs of external genitalia of a
normal female (46XX).
 Due to enzyme defect in adrenal gland (21-
hydroxylase) needed for production of
cortisol which results in the production of
excessive amounts of androgen.
 This affect the external genitalia resulting in
to glitoral enlargement and labial fusion.
History:
 To exclude physiological causes.
 Ask about symptoms of menopause.
 Ask if primary or secondary.

Questions related to p. amenorroea:

 Developmental history.
 Cyclical symptoms.
 History of chronic illness.
 Excessive weight loss or gain.
 Excessive exercise.
 History of anosmia.
Questions related to s. amenorrhoea:
 Age of menarche.
 Menstrual and contraceptive history.
 Past medical and surgical history.
 Menopausal symptoms.
 Medications.
 Family history of premature menopause.
 Galactorrhoea or virilzing signs.
 Psychological history.
 Recent emotional stress.
 Height.
 Secondary sexual characteristics.
 Weight.
 General signs of endocrine disorders.
 Galactorrhoea and visual field disturbance.
 Pelvic examination to exclude outflow

abnormalities.
 Signs of other endocrine disorders.
 This depends on history and examination.
 To exclude pregnancy.
 Prolactin level.
 Thyroid function tests.
 Gonadotrophin level: elevated in ovarian failure and
low in hypopituitarism and hypothalamic disorders.
 Androgen profile as in PCOS, Adrenal hyperplasia
and adrenal tumors.
 Chromosomal study.
 CT scan and MRI to exclude ovarain, pitutary and
hypothalamic tumors.
 Depends on the cause.
 Premature ovarian failure: HRT.
 Anovulation: cyclical hormone therapy or

induction of ovulation.
 Hyperprolactinaemia: Caberguline or surgery.
 Pan hypopituitarism: HRT.
 Hypogonadotrophic hypogonadism: Cyclical
HRT then gonadotrophic hormone for
induction of ovulation.
 Outflow disorders: surgical.
 Gonadal digenesis: HRT and removal of

gonads for risk of malignancy.

 Osteoporosis: significant risk of developing osteoporosis. This
increased risk persists even if normal menses are resumed. (Oestrogen
deficiency)
 Cardiovascular disease
 increased risk of cardiovascular disease
 Women with polycystic ovary syndrome have an increased risk of
developing cardiovascular disease, hypertension, and type 2 diabetes

 Endometrial hyperplasia: increased risk of endometrial

hyperplasia and endometrial carcinoma .
 Infertility: no ovulation.
 Psychological distress: anxiety, concerns about loss of
fertility, loss of femininity, or worry about an unwanted
pregnancy. The diagnosis of Turner's syndrome,
testicular feminization, or developmental anomaly can
be traumatic for both girls and their parents .