This document discusses amenorrhoea, or the absence of menstruation. It defines primary amenorrhoea as the failure to menstruate by age 16 and secondary amenorrhoea as the absence of menstruation for more than 6 months. For primary amenorrhoea, common causes include constitutional delay, chromosomal abnormalities, pituitary tumors, congenital adrenal hyperplasia, and genital tract anomalies. Diagnostic steps involve evaluating height, weight, secondary sexual characteristics, signs of androgen excess, visual fields, chromosomes, hormone levels, and imaging tests. For secondary amenorrhoea, common causes are hypothalamic issues, weight changes, pregnancy, medications, polycystic ovary

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