about amenorrhoea

1. Amenorrhoea
By- Annu Maurya

2. Definitions
• Primary amenorrhoea
– Failure to menstruate by age 16
• Secondary amenorrhoea
– Absence of menstruation for >6 months

3. Primary Amenorrhoea – Common Causes
• Constitutional delay
• Chromosomal e.g. 45XO,
46XY
• Pituitary tumour e.g
craniopharyngioma
• Congenital adrenal
hyperplasia
• Genital tract anomaly
• (Plus all the causes of
secondary amenorrhoea)

4. Primary Amenorrhoea – Clues to diagnosis
• Constitutional delay
• Chromosomal e.g.
45XO, 46XY
• Pituitary tumour e.g
craniopharyngioma
• Congenital adrenal
hyperplasia
• Genital tract anomaly
• Secondary sexual
characteristics slow
• Stigmata of Turners S
• Visual field defect
• Virilisation
• Imperforate hymen

5. Primary amenorrhoea – Diagnostic steps
• Height, weight and BP
• Evaluate secondary sexual characteristics
• Look for signs of androgen excess
• Do visual fields
• Chromosomes
• FSH, LH and E2
• Maybe HydroxyPROG, Androgens, PRL, TSH
• Maybe CT pituitary

6. Secondary amenorrhoea – Common causes
• Hypothalamic
• “Stress”
• Weight loss/gain (Anorexia)
• Post Pill and Depo Provera
• PCO Syndrome (1:20 women)
• Premature Menopause
• Idiopathic or genetic (gene identified)
• Iatrogenic
• Resistant ovary syndrome
• Hyperprolactinaemia
• Physiological
• Pituitary adenoma
• Drug-induced
• Remember also pregnancy & progestins!

7. Secondary amenorrhoea – Uncommon causes
• Kallman’s Syndrome
• Sheehan’s Syndrome
• Cushing’s Syndrome
• Other Pituitary Tumours
• Post encephalitis/trauma
• Thyroid disease
• Androgen-producing Tumours
• Asherman’s Syndrome
• Cervical stenosis

8. Secondary amenorrhoea – Clinical evaluation
1
• History
– Life events
– Weight/Exercise history
– Pregnancy
– Drugs
– Galactorrhoea
– Hot flushes
– Headaches/Vision

9. Secondary amenorrhoea – Clinical evaluation
2
• Examination
– Height/Weight BP
– 20 Sexual characteristics
– Hirsutism/Virilisation
– Visual fields
– Galactorrhoea
– Genital tract oestrogenisation
– Cervical stenosis

10. Secondary amenorrhoea – Clinical evaluation
3
• Primary Tests
– FSH LH E2 TSH PRL
– Androgens
– Ultrasound pelvis
– Visual fields
– Progesterone challenge test

11. Secondary amenorrhoea – Clinical evaluation
4
• Secondary Tests
– CT Pituitary
– Other pituitary hormones
– Dexamethasone suppression
– HydroxyPROG
– Hysteroscopy or HSG
– Laparoscopy & ovarian biopsy