Amenorrhoea

Is the absence of menstruation. Its a symptom and not a disease.

Physiological

Pathological

Primary -before puberty

Secondary -during pregnancy -during lactation -following menopause Concealed (cryptomenorrhoea)

Real

Congenital -imperforate hymen -transverse vaginal septum -atresia of upper third of vagina and cervix Acquired -stenosis of cervix -secondary vaginal atresia

Primary

Secondary

At least 5 basic factors involved in the onset and continuation of normal menstruation: Normal female chromosomal pattern Co-ordinated hypothalamus-pituitaryovarian axis Responsive endometrium Active support of thyroid and adrenal glands Anatomical patency of outflow tract

PRIMARY AMENORRHOEA

The causes are grouped as follows: Disorders of hypothalamic-pituitaryovarian axis Developmental defect of genital tract Abnormal chromosomal pattern Dysfunction of thyroid and adrenal cortex Metabolic disorders Systemic illness Unresponsive endometrium

Hypothalamus

GnRH

Anterior pituitary

LH FSH

Oestrogen Progesterone Ovary Endometrium

Hypothalamic causes:-Chronic illness -Anorexia -Excessive exercise -Stress Pituitary causes:-hyperprolactinaemia -hypothyroidism -breastfeeding -kallmans syndrome Ovarian causes:-

-Polycystic ovarian syndrome -premature ovarian failure -chemotherapy & radiotherapy -Depot medroxyprogesterone acetate ( DMPA) -menopause

Uterine causes:-Pregnancy -cervical stenosis

Disorders of hypothalamopituitary ovarian axis

Hypogonadotrophic hypogonadism e.g. delayed puberty, Kallmans syndrome, CNS tumours and rarely polycystic ovarian disease. Hypergonadotrophic hypogonadism e.g. premature ovarian failure, individuals with 17 alpha hydroxylase deficiency and galactosemia.

Developmental defect of genital tract

Imperforate hymen Transverse vaginal hymen

Atresia of upper third of vagina and cervix

Complete absence of vagina Absence of uterus

Abnormal chromosomal pattern

Turners syndrome Androgen insensitivity syndrome

Clinical features
Family history of female relatives with late onset of menses is suggestive of constitutional delay. Androgen insensitivity is also suggestive of family history. Excessive exercise and any change in weight should be inquired. Chronic illness or medications should be asked about. An imperforate hymen or vaginal septum with a history of amenorrhoea and cyclical abdominal pain.

Examination
The important feature is the presence or absence of secondary sexual characteristics like breast development, pubic and axillary hair. Absence of these features suggests Turners, hypothalamic cause or hypothyroidism.
Check weight and height to calculate BMI

Note any features of Turners (webbed neck,short stature etc)

Prolactinoma..abnormal visual fields Hypothyroidism

Androgen excess (hirsutism and acne)

Investigations
Should be initiated in a girl who has no menses by the age of 16 if no secondary sexual characteristics are present AND at 14 if there is no secondary sex development.

Urine pregnancy test to rule out possible pregnancy. Thyroid function and prolactin levels. Serum gonadotrophin, testosterone and oestradiol levels. FSH & LH levels. Karyotyping Ultrasound scan

Management
Reassure girls with constitutional delay that they will menstruate spontaneously. Thyroxine for hypothyroidism Bromocriptine or surgery for prolactinoma. Exercise should be limited in exerciseinduced-amenorrhoea and weight gain should be encouraged if body mass index is < 19. Osteoporosis should be prevented by giving combined oral contraceptive pills.

 Vaginal reconstruction for complete agenesis of vagina. In Turners or other gonadal dysgenesis, short term use of oestrogen and progesterone is prescribed at least for development of breasts. In androgen insensitivity syndrome(AIS), the ectopic gonads are to be removed after the secondary characters are well developed.

For hypothalamo-pituitary-ovarian defects are treated by induction of menstruation or ovulation.

SECONDARY AMENORRHOEA
is the absence of menstruation for 6 months or more

after previously regular menses

COMMON CAUSES

Hypothalamus -stress -Sudden weight change -Anti-Ht drugs

Pituitary Ovary - Adenoma (hyperprolactinoma) -Polycystic ovarian disease - Sheehans syndrome -Premature ovarian failure

Uterine -Intrauterine adhesions

Systemic -Malnutrition

-Hypothyroidism
-Diabetes

History
Preceded by hypomenorrhoea or oligomenorrhoea Sudden change in environment/ weight loss, emotional stress Intake of antihypertensives Acne, change in voice, hirsutism. Inappropriate galactorrhoea Prolonged lactation Medical history of TB Family history of premature menopause

Examination
Nutritional status Look for signs of polycystic ovarian syndrome (hirsutism, obesity and acne), hypothyroidism and prolactinoma (check visual fields). Marked obesity In abdominal examination- presence of striae and masses. In pelvis examination for enlargement of clitoris and adnexal masses.

Investigations
o A pregnancy test is usually indicated.

o LH, FSH, testosterone, estradiol to check for polycystic ovarian syndrome, androgen secreting tumour and premature ovarian failure.
o T3 & T4 levels to check for hypothyroidism. o Serum prolactin levels, CT/MRI for cases of suspected prolactinoma.

Management
Combined oral contraceptive pill for polycystic ovaries. If obesity becomes a problem, weight loss usually restores menses and fertility.

For premature ovarian failure, hormone replacement therapy to prevent osteoporosis. Fertility is only possible by ovum donation and in vitro fertilization ( IVF).

 Exercise induced amenorrhoea advice on change in lifestyle and diet. Prolactinomas managed by bromocriptine or cabergoline. Surgery is only indicative if resistant to medications.
Thyroxine replacement for hypothyroidism. Contraceptive related amenorrhoea is restored by expectancy.