Primary amenorrhea is the absence of menstruation by age 16, while secondary amenorrhea is the absence of menstruation for three or more months. Amenorrhea can be caused by ovulatory issues like genetic abnormalities or acquired uterine issues, or by anovulatory issues involving the hypothalamus, pituitary gland, ovaries, or excess androgen levels. Evaluating a patient for amenorrhea involves taking a medical history and performing an examination and lab tests to diagnose the underlying cause. Treatment focuses on managing symptoms, minimizing long-term health effects, and inducing ovulation if desired for pregnancy.

1. AMENORRHEA
PREPARED BY:
MARYAM ABDULWAHID

2. Primary amenorrhea is failure of menses to occur by one
of the following:
•Age 16 or 2 yr after the onset of puberty.
•About age 14 in girls who have not gone through puberty.
Secondary amenorrhea cesation of menestruation for ≥ 3
mo or ≥ 3 typical cycles.

4. Ovulatory
A/Congenital genital abnormalities
Imperforate hymen
Transverse vaginal septum
Cervical stenosis
Vaginal or uterine aplasia (eg, Müllerian
agenesis MRKHS, Testicular feminization syndrome )
B/ Acquired uterine abnormalities
Asherman syndrome
Endometrial TB

5. Anovulatory
• Hypothalamic dysfunction (stress, wt lose, exercise, Kallman’s syndrome)
• Pituitary disorders (Sheehan's syndrome, microadenoma,
macroadenoma, prolactinoma)
• Ovarian disorders (gonadal dysgenesis, polycystic ovary syndrome
,premature ovarian failure(enzyme defect, resistant ovaries, autoimmune, post
infection, radiotherapy)
• Androgen excess ( late onset congenital adrenal hyperplasia, Cushing
syndrome)

6. APPROACH

7. HISTORY
• Age of onset of menarche
• Presence or abscense of cyclical symtomps
• symptoms of puberty (eg, breast development, growth spurt,
presence of axillary and pubic hair)
• Exessive wt lose , Exesive exercise
• acne, hirsutism, and deepening of the voice (androgen excess)
• galactorrhea, headaches, and visual field defects (pituitary
disorders)
• fatigue, weight gain, and cold intolerance (hypothyroidism)
• hot flushes, vaginal dryness, sleep disturbance, fragility fractures,
and decreased libido (estrogen deficiency)

8. Drug history
• (eg, antihypertensives, antipsychotics, opioids, tricyclic
antidepressants), cancer chemotherapy drugs
(eg,busulfan , chlorambucil, cyclophosphamide)
• sex hormones that can cause virilization (eg, androgens, estrogens,
high-dose progestins) and questions about recent use of
contraceptives.
•PMH
•PSH

9. Physical examination
• Height: turner syndrom are short, androgen insensivity
are tall,
• Signs of development of secondary sexual charecteristics
• Signs of abnormal virilization
• Visual field disturbance or papilledeme.
• Pelvic examination

10. Investigations
EXCLUDE PREGNANCY
•PT
•Prolactin
•TSH
•Testosterone

11. FSH&LH
• High FSH with normal 2nd
sexual char. Ovarian failure
• High FSH with absent gonadal dysgenesis
• Low FSH with normal hypothalamic pituitary failure
• Low FSH with absent hypogonado.hypogona.

12. Progesterone challenge test
• Provera 10mg once daily for 7-10 days.
• Bleeding Anovulatory (PCOS)
• No bleeding give estrogen for 21days followed by
progestron
• Bleeding hypothalamus-pitutary-ovarian axis
• No bleeding endometrial lesion or outflow tract
obstruction . Hysterosalpengography or hystroscopy

13. TREATMENT
• Treating symptoms and managing long-term effects of estrogen
excess (eg, prolonged bleeding, persistent or marked breast
tenderness, risk of endometrial hyperplasia and cancer) by giving
progestron
• Treating symptoms and long-term effects of estrogen deficiency (eg,
osteoporosis)
• Minimizing hirsutism and long-term effects of androgen excess (eg,
cardiovascular disorders, hypertension)
• If a Y chromosome is present, bilateral oophorectomy .
• Inducing ovulation if pregnancy is desired

14. Key points
•Always exclude pregnancy.
•Primary amenorrhea in patients without normal secondary sexual
characteristics is usually anovulatory.
•If patients have primary amenorrhea and normal secondary sexual
characteristics pelvic ultrasonography .
•If patients have signs of virilization, check for conditions that cause
androgen excess.
•If patients have symptoms and signs of estrogen deficiency (eg, hot
flushes, night sweats, vaginal dryness or atrophy), check for premature
ovarian failure.
•If patients have galactorrhea, check for conditions that cause
hyperprolactinemia (eg, pituitary dysfunction, use of certain drugs).

15. THANK YOU
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