Amenorrhoea: Causes and Management

AMENORRHOEAAMENORRHOEA
Prof. Dr Nik Hazlina Nik HussainProf. Dr Nik Hazlina Nik Hussain
School of Medical SciencesSchool of Medical Sciences
USMUSM

IMPORTANCEIMPORTANCE
– MENSTRUAL DISORDERS PRESENTEDMENSTRUAL DISORDERS PRESENTED
AS THE CHIEF COMPLAINT.AS THE CHIEF COMPLAINT.
– MENSTRUAL HISTORY MUST ALWAYSMENSTRUAL HISTORY MUST ALWAYS
BE TAKEN IN FEMALE PATIENT.BE TAKEN IN FEMALE PATIENT.
MENSTRUALMENSTRUAL
ABNORMALITIESABNORMALITIES

DISORDERSDISORDERS
–1)1) AmenorrhoeaAmenorrhoea- absence of- absence of
menstruation for 6 months ormenstruation for 6 months or
moremore
–2)2) Excessive/ MenorrhagiaExcessive/ Menorrhagia --
bleed more than usual amountbleed more than usual amount
regularly or irregularlyregularly or irregularly
–3)3) DysmenorrhoeaDysmenorrhoea - pain- pain
associated with menstruationassociated with menstruation
MENSTRUALMENSTRUAL
ABNORMALITIESABNORMALITIES

AMENORRHOEA
Investigations:
Serum
Hormones
Karyotype
Imaging
Laparoscopy
Physical
Examination:
General
Systems
Pelvic
Rectal
Management:
History
Physical
Examination
Investigation
Aetiology
Definition
Classification

PRIMARY AMENORRHOEAPRIMARY AMENORRHOEA
– No mensesNo menses
– AgeAge 14 years14 years oldold
– Absent secondary sexualAbsent secondary sexual
characteristicscharacteristics
– OROR
– No mensesNo menses
– AgeAge 16 years16 years oldold
– Normal secondary sexualNormal secondary sexual
characteristicscharacteristics

Secondary AmenorrhoeaSecondary Amenorrhoea
–Absence of mensesAbsence of menses
–ForFor 6 months6 months
–oror > 3 times the previous cycle> 3 times the previous cycle
intervalsintervals
–In a woman whoIn a woman who hashas
menstruated beforemenstruated before

Causes of AmenorrhoeaCauses of Amenorrhoea
CNS AmenorrhoeaCNS Amenorrhoea
Pituitary causesPituitary causes
Ovarian diseasesOvarian diseases
Uterovaginal diseasesUterovaginal diseases
Systemic illnessSystemic illness

Psychogenic
Exercise
Destructive
Anorexia nervosa
Lawrence Moon Biedl
Sheehan syndrome
Hyperprolactinemia
Pit tumor
Cong. defect
Premature
ovarian failure
PCOS

AMENORRHOEA(cont.)AMENORRHOEA(cont.)
Imperforate hymen
Vaginal agenesis
Transverse vaginal septum
Ashermann’s syndrome
Cervical stenosis
Adrenal dysfuntion
Thyroid dysfunction
Chronic systemic disease
TB,DM, Obessity

1) CNS amenorrhoea1) CNS amenorrhoea
–PPsychogenicsychogenic
–EExercisexercise
–DDestruction lesionestruction lesion
–AAnorexia nervosanorexia nervosa
–LLawrence-Moon-Biedlawrence-Moon-Biedl (MRP )(MRP )

CNS AmenorrhoeaCNS Amenorrhoea
I) Psychogenic AmenorrhoeaI) Psychogenic Amenorrhoea
– e.g. change in environment is stressfule.g. change in environment is stressful
– Mx. Requires early and simpleMx. Requires early and simple
reassurancereassurance
– Good patient -doctor relationshipGood patient -doctor relationship
importantimportant
– No response after 6/12 of psychologicalNo response after 6/12 of psychological
therapy ,consider hormonal therapytherapy ,consider hormonal therapy
– In case desiring pregnancy, require toIn case desiring pregnancy, require to
investigate causeinvestigate cause

II) Exercise amenorrhoeaII) Exercise amenorrhoea
– 20%20%
– due to imbalance calorie intakedue to imbalance calorie intake
against energy expenditureagainst energy expenditure
– increased FSH/LH and variableincreased FSH/LH and variable
oestrogenoestrogen
– may need ERT,may need ERT,
OCP,Provera/ProgestogenOCP,Provera/Progestogen
CNSCNS
Amenorrhoea(cont.)Amenorrhoea(cont.)

III) Anorexia nervosaIII) Anorexia nervosa
–purpose not eatingpurpose not eating→→ DietDiet
–young girl or artist ,try toyoung girl or artist ,try to
keep trend with the fashionkeep trend with the fashion
–very thinvery thin
CNSCNS
Amenorrhoea(cont.)Amenorrhoea(cont.)

Anorexia nervosaAnorexia nervosa
Diagnostic criteriaDiagnostic criteria
age under 25 yearsage under 25 years
Anorexia with weight loss of 25%Anorexia with weight loss of 25%
original B.W.original B.W.
A distorted body image andA distorted body image and
obsessive eatingobsessive eating
No other psychiatric problemNo other psychiatric problem

At least 2 following complications:At least 2 following complications:
– lanugo hairlanugo hair
– amenorrhoeaamenorrhoea
– bradycardiabradycardia
– periods of overactivityperiods of overactivity
– bulimiabulimia
– vomitingvomiting
AnorexiaAnorexia
nervosa(cont.)nervosa(cont.)

A loss of weight of 10-15% ofA loss of weight of 10-15% of
normal weight for height lead tonormal weight for height lead to
amenorrhoeaamenorrhoea
In West- prevalence in pubertalIn West- prevalence in pubertal
females is about 1: 200females is about 1: 200
need multidisplinary approachneed multidisplinary approach
Rx.-regain weightRx.-regain weight
AnorexiaAnorexia
nervosa(cont.)nervosa(cont.)

2) Pituitary causes2) Pituitary causes
–Sheehan’s syndromeSheehan’s syndrome
–HyperprolactinemiaHyperprolactinemia
–PituitaryPituitary
Tumours(Prolactinoma)Tumours(Prolactinoma)

Pituitary causesPituitary causes
I) Sheehan’s syndromeI) Sheehan’s syndrome
– infarction of pituitary due to severeinfarction of pituitary due to severe
APHAPH or more commonlyor more commonly PPHPPH
– enlarged pituitary duringenlarged pituitary during
pregnancy,sensitive to ischaemiapregnancy,sensitive to ischaemia
– clinical manifestation seen whenclinical manifestation seen when
75% of gland destruction75% of gland destruction

Clinical picture of Sheehan’s:Clinical picture of Sheehan’s:
– amenorrhoeaamenorrhoea
– absence of lactationabsence of lactation
– loss of energy, fatigueloss of energy, fatigue
– hypotensionhypotension
– features of oestrogen lackfeatures of oestrogen lack→→ lossloss
of pubic and axillary hair, loss ofof pubic and axillary hair, loss of
weightweight
Pituitary causes(cont.)Pituitary causes(cont.)

– Diagnosis of Sheehan’s syndromeDiagnosis of Sheehan’s syndrome
peripartum events in historyperipartum events in history
↓↓ FSH,LH , Prolactin, OestradiolFSH,LH , Prolactin, Oestradiol
– Treatment:Treatment:
ERT( Oestrogen replacement therapy)ERT( Oestrogen replacement therapy)
If pregnancy desired , need ovulationIf pregnancy desired , need ovulation
induction .induction .
L-thyroxine may be neededL-thyroxine may be needed
Corticosteroid if adrenals impairedCorticosteroid if adrenals impaired

II) ProlactinomasII) Prolactinomas
most commonly occuringmost commonly occuring
pituitary tumourspituitary tumours
microprolactinomas- < 10 mmmicroprolactinomas- < 10 mm
diameterdiameter
macroprolactinomas-> 10 mmmacroprolactinomas-> 10 mm
diameter together with pituitarydiameter together with pituitary
sellar destructionsellar destruction

Prolactinoma(Investigations)Prolactinoma(Investigations)
– Serum ProlactinSerum Prolactin
– TFTTFT
– Renal profileRenal profile
– MRI to see the pituitary fossa forMRI to see the pituitary fossa for
suprasellar involvement &tumoursuprasellar involvement &tumour
– visual field ( bitemporalvisual field ( bitemporal
hemianopia )hemianopia )

Prolactinoma(Treatment)Prolactinoma(Treatment)
– whether micro or macroadenoma , thewhether micro or macroadenoma , the
primary mode of treatment is –primary mode of treatment is –
Bromocriptine or Cabergoline/ Dostinex.Bromocriptine or Cabergoline/ Dostinex.
– Normalisation of PRL in 75%Normalisation of PRL in 75%
– Shrinkage of tumour size in 70%Shrinkage of tumour size in 70%
– In pregnancy, macroadenoma mayIn pregnancy, macroadenoma may ↑↑ inin
size causing temporary blindnesssize causing temporary blindness
– check visual field regularlycheck visual field regularly

III) HyperprolactinemiaIII) Hyperprolactinemia
Hormones-OCP, Oestrogen,TRHHormones-OCP, Oestrogen,TRH
Neuroleptics-Neuroleptics-
Phenothiazines,Opiates,Antidepressant,Phenothiazines,Opiates,Antidepressant,
HaloperidolHaloperidol
Antihypertensives- Aldomet, ClonidineAntihypertensives- Aldomet, Clonidine
AnaestheticsAnaesthetics
Antiemetic-MetochlorpramideAntiemetic-Metochlorpramide
Pathological-Adenomas,RenalPathological-Adenomas,Renal
failure,Hypothyroidfailure,Hypothyroid

3) Ovarian diseases3) Ovarian diseases
– A) Congenital defects- dysgenesis,A) Congenital defects- dysgenesis,
androgen insensitivityandrogen insensitivity
– B) Premature ovarian failureB) Premature ovarian failure
– C) Polycystic ovarianC) Polycystic ovarian
syndrome(PCOS)syndrome(PCOS)

Ovarian DiseasesOvarian Diseases
A) Ovarian congenital defectsA) Ovarian congenital defects
– I) Gonadal dysgenesisI) Gonadal dysgenesis
– Turner’s syndromeTurner’s syndrome 45XO45XO
– ElevatedElevated FSH, LHFSH, LH
– Very low oestrogenVery low oestrogen
– Rx. - Oestrogen therapyRx. - Oestrogen therapy

Ovarian cong. defectsOvarian cong. defects
– II) Androgen insensitivityII) Androgen insensitivity
– Absence of androgen receptorsAbsence of androgen receptors
during embryonic sexualduring embryonic sexual
developmentdevelopment→→ male fetusmale fetus
develops as femaledevelops as female
– Elevated FSH, LH, Testosterone,Elevated FSH, LH, Testosterone,
– Karyotype 46 XYKaryotype 46 XY
OvarianOvarian
Diseases(cont.)Diseases(cont.)

B) Premature ovarian failureB) Premature ovarian failure
– cessation of menses at young agecessation of menses at young age
< 40< 40
– Elevated FSH, LHElevated FSH, LH
– Idiopathic , autoimmune,Idiopathic , autoimmune,
chemotherapy radiotherapy orchemotherapy radiotherapy or
inflammationinflammation
– Rx. - by HRTRx. - by HRT
OvarianOvarian

C) PCOSC) PCOS
– characterized by chronic anovulationcharacterized by chronic anovulation
and hyperandrogenismand hyperandrogenism
– Patient is obese, amenorrhoea,Patient is obese, amenorrhoea,
infertilityinfertility
– Elevated FSH& LH with LH:FSH 3:1Elevated FSH& LH with LH:FSH 3:1
– Elevated androgens( DHEASO4 andElevated androgens( DHEASO4 and
Testosterone)Testosterone)
– Rx. -C.C. to induce ovulationRx. -C.C. to induce ovulation
↓↓ body weightbody weight
OvarianOvarian

4) Uterovaginal diseases4) Uterovaginal diseases
– A) Imperforate hymenA) Imperforate hymen
– B) Vaginal agenesisB) Vaginal agenesis
– C) Transverse vaginal septumC) Transverse vaginal septum
– D) Ashermann’s syndromeD) Ashermann’s syndrome
– E) Cervical stenosisE) Cervical stenosis

Uterovaginal diseasesUterovaginal diseases
Ashermann’s syndromeAshermann’s syndrome
– overcurettage up to basal layer of theovercurettage up to basal layer of the
endometriumendometrium →→ will cause fibrosis, and it willwill cause fibrosis, and it will
be stucked togetherbe stucked together
– intrauterine or intracervical adhesive scarringintrauterine or intracervical adhesive scarring
e.g. overzealous D&Ce.g. overzealous D&C
– Hysterography or hysteroscopy needed forHysterography or hysteroscopy needed for
diagnosis and managementdiagnosis and management
– Surgical resection through hysteroscopeSurgical resection through hysteroscope
– Insert IUCDInsert IUCD
– HRTHRT

5) Systemic illness5) Systemic illness
– A) Adrenal dysfunction-A) Adrenal dysfunction-
Cushing’s,Addison’s, HyperplasiaCushing’s,Addison’s, Hyperplasia
– B) Thyroid dysfunctionB) Thyroid dysfunction
– C) Chronic systemic diseases-C) Chronic systemic diseases-
Liver,Liver,
TB,DM,Obesity,MalabsorptionTB,DM,Obesity,Malabsorption

Tests to identify cause ofTests to identify cause of
FSH , LH- To diagnoseFSH , LH- To diagnose
hypergonadotrophic amenorrhoeahypergonadotrophic amenorrhoea
PRL - to check pituitary tumoursPRL - to check pituitary tumours
Testosterone- for PCOS and virilizationTestosterone- for PCOS and virilization
Se cortisol- for adrenal insufficiencySe cortisol- for adrenal insufficiency
Karyotyping- chromosomal abnormalityKaryotyping- chromosomal abnormality
Oestradiol- to diagnose oestrogenOestradiol- to diagnose oestrogen
deficiency.deficiency.
Ovarian biopsy( if needed)Ovarian biopsy( if needed)

PPAST HISTORY
N puberty milestone
Thelarche, adrenarche
Pubarche, menarche
POH
Hist. Of surgery
Cx of surgery
Medical illness
Menstrual pattern
Menopausal symtoms
Normal menstruation
In family members

Social history Review of system Medication
Stress
Over exercise
Dieting
Headache, vomiting
Visual disturbance
Galactorrhoea
Cyclical abd. pain
Vaginal discomport
Medication
related to
amenorrhoea

Breast
(galactorrhoea)
Pubic hair Axillary hair
2'SCC Thyroid BP BMI
General
CVS CNS Resp Fundoscopy
VisualField
System ic
Exam ination

N o r m a l F e m a le
E x t e r n a l G e n it a lia
V u lv a
S h o r t B lin d
E n d in g V a g in a ?
V a g in a
P e lv ic
C e r v ix & u t e r u s
p a lp a b le /
a b s e n t
R e c t a l
E x a m in a t io n

P r o la c t in
O e s t r a d io l
T e s t o s t e r o n e
L H
F S H
T h y r o x in e
S e r u m H o r m o n e s K a r y o t y p e
B u c c a l S m e a r
K id n e y s
O v a r ie s
U t e r u s
U lt r a s o u n d L a p a r o s c o p y
I n v e s t ig a t io n

Primary AmenorrhoeaPrimary Amenorrhoea
N orm al 2" S C C P u berty d elayed / arrested
(S exual In fan tilism )
D iscord ant P u b ertal
D evelop m en t
C A U S E S

……..Primary..Primary
C o n s titu tio n a l
N o rm a l
R O S
H ig h F S H
P C O S
H ig h L H /F S H
ra tio
H y p e rp ro la c tin a e m ia
H ig h P ro la c tin
F S H /L H /P ro la c tin
N o rm a l g e n ita l
tra c t
T ra n s v e rs e v a g in a l
S e p tu m
Im p e rfo ra te H y m e n
M u lle ria n A g e n e s is
A b n o rm a l
g e n ita l tra c t
N o rm a l 2 ' S C C

Isola ted
G o na do tro ph in d ef.
K alm an syn drom e
C o ng enital
A n orexia N e rvo sa H e avy E xercise S tre ss W e igh t lo ss
A cquired
H ypo go na dotro p hic
H ypo go dism
L ow F S H /L H
G alactosa e m ia
4 6X X
X Y A g e ne sis
X Y enzym e fa ilure
M osa ic/ de le tio n
4 6 X Y
H ig h F S H /L H
N orm a l S ta ture
A cqu ire d
( E m pty S e lla S nd ,
P ituita ry a de n o m a )
C o ng e nita l
( H yd roce ph alu s,
La w ren ce .M .B )
Intracran ial
lesio n
L o w F S H /L H
S h ort S ta tu re
( 1 47 cm )
S exu a l In fa ntilism

V a g in a +
B la d d e r +
U te r u s -
4 6 X Y
A n d r o g e n
In s e n s itiv ity
S y n d r o m e
N o r m a l
B r e a s t,
P u b ic &
A x illa r y
F e m a le P s e u d o h e m a p h r o d ite
( C A H )
4 6 X X
M a le P s e u d o h e m a p h r o d ite
4 6 X Y
N o r m a l
P u b ic &
A x illa r y
H a ir
P o o r B r e a s t
D e v e lo p m e n t
D is c o r d a n t
P u b e r ta l
D e v e lo p m e n t

Amenorrhoea: Causes and Management

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