Amenorrhea

DR. UMI ZULAIKHA MOHAMED

 Definition
Primary amenorrhea
Secondary amenorrhea
 Definition
Amenorrhea: absence of menstruation

Primary amenorrhea:
absence of menses with failure to develop secondary sexual
characteristics by 14 years of age or

fail to menstruate by 16 years of age with normal sexual

characteristic

Secondary amenorrhea: cessation of menstruation for more

than 6 months in a normal female of reproductive age

( reference: Gynaecology by 10 teachers)

Normal Menstrual cycle
regulation
 Amenorrhea

Primary Secondary
Approach to amenorrhea
 Amenorrhea with Immature
Secondary Characteristics

FSH Serum level

Low / normal High

Hypogonadotropic Gonadal
hypogonadism dysgenesis
 Primary Amenorrhea with
Immature Sexual Characteristics

Hypogonadism (gonadal failure)

Gonadal dysgenesis
Irradiation
Chemotherapy
Galactosemia
Note: gonadotropins (FSH/LH) will be
highimilar to menopause
 Gonadal Dysgenesis
Chromosomally abnormal
- Classic turners syndrome (45XO)
- Turner variants (45XO/46XX),(46X-abnormal X)
- Mixed gonadal dygenesis (45XO/46XY)
Chromosomally normal
- 46XX (Pure gonadal dysgeneis)
- 46XY (Swyers syndrome)
 Turners syndrome

1:2500 female birth

Sexual infantilism and short stature.
Associated abnormalities, webbed neck,coarctation of
the aorta,high-arched pallate, cubitus valgus, broad
shield-like chest with wildely spaced nipples, low
hairline on the neck, short metacarpal bones and
renal anomalies.
High FSH and LH levels.
Bilateral streaked gonads.
Karyotype - 80 % 45, X0
- 20% mosaic forms (46XX/45X0)
 Turners syndrome

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

Ovarian dysgenesis
 Management

Low dose estrogen replacement to

mimic natural puberty
Eg progynova 0.5 x 6 months, 1mg 6
months, 1.5mg 6 months, 2mg 6 months
HRT once satisfactory breast
development achieved with attention
to prevention of osteoporosis
 Management

Combine care with cardiology for

cardiac assessment, ophthalmology,

Fertility issues to discuss with patients

Option of donor oocytes but against
ethical/religious
 Primary Amenorrhea with
Immature Sexual Characteristics

Hypogonadotropism
Hypothalamic dysfunction
Kallmann syndrome
Anorexia nervosa
Space-occupying lesion of CNS
Marijuana use
Pituitary damage (surgery/radiation)
Constitutional delay
 Primary Amenorrhea

Is there normal development of

secondary sexual characteristics?
YES
Think
Mullerian anomaly
Androgen insensitivity
Outflow obstruction
Are there secondary sexual
characteristics?
Approach to amenorrhea
 Primary Amenorrhea with Normal
Secondary Characteristics

Mullerian Anomalies
Mullerian agenesis (Mayer-Rokitansky-
Kuster-Hauser syndrome)
Imperforate hymen
Transverse vaginal septum
Mayer-Rokitansky-Kuster-Hauser
Syndrome (utero-vaginal agenesis)
15% of primary amenorrhea
Normal secondary
development & external
female genitalia
Normal female range
testosterone level
Absent uterus and upper
vagina & normal ovaries
Karyotype 46-XX
15-30% renal, skeletal and
middle ear anomalies
Androgen Insensitivity
Normal breasts but no
sexual hair
Normal looking female
external genitalia
Absent uterus and
upper vagina
Karyotype 46, XY
Male range
testosterone level
Treatment :
gonadectomy after
puberty + HRT
 Obstruction of the outflow
tract
Imperforate hymen
Vaginal septum
Vaginal agenesis with functioning
uterus
-Cervical agenesis with functioning
Intermittent/ cyclical abdominal pain
-uterus
Possible difficulty with micturition
-Possible lower abdominal swelling
-Large bulging mass may be felt during palpation
- Bulging bluish membrane at the introitus or
absent
vagina (only dimple)
Imperforate Hymen
 Secondary Amenorrhea
Pregnancy
CNS disorders
Pituitary gland
Thyroid and other endocrine disorder
Ovary
Uterus
Systemic disorders
Renal failure, liver disorders, DM
Medications
 Secondary Amenorrhea

CNS disorders
Chronic hypothalamic anovulation
Stress
Increased exercise levels
Anorexia nervosa
Head trauma
Space-occupying lesions
 Secondary Amenorrhea
Pituitary disorders
Hyperprolactinemia
Prolactinoma
Medications
Hypoprolactinemia
Pituitary resection
Sheehans syndrome
Thyroid disorders
Hyper- or hypothyroidism
 Secondary Amenorrhea
Ovulation disorders
Polycystic ovarian syndrome
Premature ovarian failure
Uterine abnormalities
Ashermans syndrome
Cervical stenosis
Drug-induced amenorrhea
Hormonal contraceptives
GnRH analogues
 Secondary Amenorrhea
Ovulation disorders
Polycystic ovarian syndrome
Premature ovarian failure
Uterine abnormalities
Ashermans syndrome
Cervical stenosis
Drug-induced amenorrhea
Hormonal contraceptives
GnRH analogues
Antipsychotic, anti depressant
 Secondary Amenorrhea

History
Nutrition/exercise habits, weight change
Sexual/contraceptive practice
History of uterine/cervical surgery
Physical exam
Height/weight
Hirsutism
Galactorrhea
Estrogen status of tissues
Laboratory
BhCG PRL & TSH progesterone challenge
FSH if high karyotype
 Premature ovarian failure /
resistant ovarian syndrome
Serum estradiol < 50 pg/ml and FSH > 40
IU/ml on repeated occasions
10% of secondary amenorrhea
Treatment: HRT (osteoporosis, atherogenesis)
 Polycystic ovary syndrome

The most common cause of chronic anovulation

Hyperandrogenism ; LH/FSH ratio

Insulin resitance is a major biochemical feature ( blood

insulin level hyperandrogenism )

Long term risks: Obesity, hirsutism, infertility, type 2

diabetes, dyslipidemia, cardiovasular risks, endometrial
hyperplassia and cancer

Treatment depends on the needs of the patient and

preventing long term health problems
 Sheehans syndrome

Pituitary inability to secrete gonadotropins

Pituitary necrosis following massive
obstetric hemorrhage is most common
cause in women
Diagnosis : History and E2,FSH,LH
+ panhypopituitarism
Treatment :
Replacement of deficient hormones
 Uterine abnormalities

Failed progestrone challenge

Due to severe adhesion / scarring
uterus,
Distruption of the endometrial tissue
Can be cause by overcurrete uterus or
due to inflammation of uterus,
 Secondary Amenorrhea

Treatment goals
Discovery and treatment of underlying
disorder
Hormone replacement
Menses every 1-3 months
Pregnancy
Ovulation induction
GnRH pump
FSH/LH
Thank you.