This document provides an overview of amenorrhea, beginning with definitions and classifications of primary and secondary amenorrhea. It then discusses the pathophysiology of the hypothalamic-pituitary-ovarian axis and menstrual cycle. The main causes of amenorrhea are outlined, including physiological causes as well as disorders of the hypothalamus, pituitary, thyroid, adrenals, ovaries, and uterus. The document describes the clinical evaluation of amenorrheic patients, including taking a thorough medical history and conducting a physical exam and laboratory investigations. Finally, medical and surgical treatment options are presented depending on the underlying cause of the amenorrhea.

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BY
DR.AKINBI OLUBAYODE.O
AMENORRHOEA

2. INTRODUCTION
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• Proper function of the Hypothalamic-Pituitary ovarian
system is required for normal menstruation.(GnRH-
LH/FSH-EST./PROG).
• Regular and predictable menstrual cycles occur if the
ovarian hormones estradiol and progesterone are
secreted in an orderly fashion in response to stimulation
by the hypothalamus and pituitary.
• The occurrence of menstruation also requires healthy and
intact outflow tract
• AMENORRHOEA occurs if the above are not met

3. DEFINATION
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• Amenorrhoea, derived from the Greek words men (month) and rein
(to flow), denotes the absence or suppression of menstruation.
• Amenorrhoea is a symptom, not a disease, and it has a variety of
causes.
• Traditionally, amenorrhoea is classified as primary or secondary.
• PRIMARY AMENORRHOEA is defined as the absence of
menstruation by the age of 14 years in the absence of 20 sexual
characteristics, or the absence of menstruation by 16 years.
• The median age of menarche is 10-15 years and weight 51.1kg.

4. DEFINATION CTD
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• SECONDARY AMENORRHOEA is defined as secondary when
no menses have occurred for 6 months in a woman who
previously had normal menstrual function, or for 12 months if her
cycles were irregular.
• OTHER TERMS:
1. OLIGOMENORRHOEA (INT.>35DAYS
2. HYPOMENORRHOEA (SCANTY VOLUME& SHORT
DURATION OF FLOW
3. POLYMENORRHOEA (INT.<21DAYS)
4. HYPERMENORRHOEA (PROLONGD FOR >10DYS)

5. PATHOPHYSIOLOGY
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• The menstrual cycle is an orderly progression of coordinated
hormonal events in the female body that stimulates growth of a
follicle to release an egg and prepare a site for implantation if
fertilization should occur. Menstruation occurs when an egg
released by the ovary remains unfertilized.
• The menstrual cycle can be divided into 3 physiologic phases:
follicular, ovulatory, and luteal. Each phase has a distinct
hormonal secretory milieu. Consideration of the target organs of
these reproductive hormones (hypothalamus, pituitary, ovary,
uterus) is helpful for identifying the disease process responsible
for a patient’s amenorrhea.

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Fig. 1.0

7. ETIOLOGY
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1. PHYSIOLOGICAL AMENORRHOEA: Puberty (in young girls),
Pregnancy(in women of reproductive age groups), Post menopause (in
elderly women)
2. HYPOTHALAMIC DISORDER
• Eating disorder (a minimum of 17% body fat is required for the onset
of menarche and 22% body fat for maintenance or resumption of
normal menstrual function
• Exercise induced amenorrhea (6% to 18% of women who are
recreational runners)
• Medication
• Stress
• Chronic illness
• Kallmanns syndrome

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3. PITUITARY DISORDER
• Hyperprolactinaemia (10–40% of women with
hyperprolactinaemia present to their physician with
amenorrhea).
• Prolactinoma
• Isolated gonadotrophin deficiency
• Craniopharyngioma (They are epithelial tumors arising from
the craniopharyngeal duct in the sellar or parasellar region).

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4. THYROID DISORDER
• Hypothyroidism
• Hyperthyroidism
5. ADRENAL DISORDER
• Congenital adrenal hyperplasia
• Cushing syndrome
6. VAGINAL ANOMALY
• Imperforate hymen
• Transverse vaginal septum
• Vaginal agenesis

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7. UTERINE ANOMALY
• Androgen insensitivity
• Mullerian agenesis (The syndrome, often referred to as
Mayer– Rokitansky–Kuster–Hauser syndrome, is the
second most common cause of primary amenorrhea).
• Uterine adhesion (Asherman syndrome is the presence
of intrauterine synechiae or scarring preventing normal
growth of endometrium, typically from a previous infection,
endometrium curettage or endometritis).
• Cervical agenesis

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8. OVARIAN DISORDER
• Gonadal dysgenesis (Turner's syndrome 45XO)
• Ovarian insufficiency or premature ovarian failure
(Onset of menopause before 40 years).
• Chemotherapy or radiation injury
• Ovarian insensitivity syndrome (Savage's
syndrome)
• Polycystic ovarian syndrome

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Polycystic ovarian syndrome
PCOS is a syndrome of ovarian dysfunction along with the cardinal
features of hyperandrogenism and polycystic ovary morphology
Its clinical manifestation include menstrual irregularities,signs of
androgen excess and obesity
• They are oligo-ovulatory or anovulatory and have oligomenorrhea
or amenorrhea.
• In typical cases, the ovaries are enlarged, with white, thickened
capsules beneath which are multiple cystic follicles in various
developmental stages.
• High incidence of related Hyperprolactinemia.
• Serum LH levels are chronically elevated:LH;FSH INCREASES
TO 2:OR 3:1
• The constant, tonic LH stimulation of the ovaries results in
abnormal follicular stimulation—hence the polycystic appearance

13. CLINICAL EVALUATION OF THE AMENORRHOEIC
PATIENT
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• HISTORY TAKING
• PHYSICAL EXAMINATION
• INVESTIGATIONS
• TREATMENT

14. HISTORY
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• Pregnancy is the most common cause of amenorrhea.
• Ask about sexual activity
• Use of contraceptive methods
• Difficulty with dates; menstrual calendar X 3 months.
• Absence of breast development or pubertal growth 14 years is
abnormal.& requires investigation.
• Breast development, pubertal growth spurt, and adrenarche are
delayed or absent in persons with hypothalamic pituitary failure.

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• Normal growth and pubertal development plus
primary amenorrhea may suggests:
• Imperforate Hymen(cyclical abd.pain+heamatocolpos)
• Rokitansky Syndrome(lap.shows rudimentary uterus)
• Test.Feminisation syndrome(blind end vaginal, absent
uterus, XY KARYOTYPE
History of evacuation, post abortal infection, post partum
endometritis, major myomectomy, endometrial
procedures may suggest Asherman

16. OVARIAN DISORDER
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• Symptoms of vaginal dryness, hot flashes,
night sweats, or disordered sleep may be a
sign of ovarian insufficiency or premature
ovarian failure.
• History of chemotherapy or radiation
• Hormonal contraceptives use in recent times
• Recent surgery .e.g TATH+BSO
• Sometimes no clear cut symptom or sign

17. HYPOTHALAMIC DISORDER
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• Intracranial tumor; galactorrhea, headaches,
or ↓↓peripheral vision
• Impaired sense of smell +primary
amenorrhea& failure of normal pubertal
development = Kallmann syndrome
• Dieting with excessive restriction of energy
intake, especially fat restriction, may lead to
loss of menstrual regularity and associated
bone loss.

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• Strenuous exercise related to a wide variety of athletic
activities can be associated with the development of
amenorrhea.
• Abuse of drugs such as cocaine and opioids have
central effects that may disrupt the menstrual cycle.
• Anorexia nervosa;intense fear of fatness and a body
image that is heavier than observed.

19. EXAMINATION
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• GENERAL EXAMINATION.
• SECONDARY SEXUAL CHARACTERISTICS.
• EXAMINATION OF THE EYE-VISUAL FIELD.
• ABDOMINAL EXAMINATION.
• PELVIC EXAMINATION

20. INVESTIGATION
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• Pregnancy test.
• Ultrasound, CT, MRI.
• Hormonal assay- LH, FSH, prolactin and androgens
• Thyroid function tests.
• Karyotype.
• Autoimmune screen

21. TREATMENT
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• Depends on the cause of amenorrhoea.
• The most common cause of primary amenorrhoea is
constitutional delay.
• MEDICAL.
• SURGICAL

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MEDICAL THERAPY:
• Dopamine agonists e.g Bromocriptine for treatment
of Hyper.PRL(build the dose up to 2.5mg tds)
• Hormone replacement therapy; In cases of Estrogen
deficiency(estrogen + 10-14 days of
medroxyprogesterone)
• Ovulation Induction in those desiring pregnancy:
clomiphene, FSH/LH combination, GnRH analogue.
• Treatment of Hyperandrogenism(5α-reductase
inhibitors e.g spironolactone, cyproterone acetate,
Finasteride)
• cocp+depo provera :rx of hirsuitism

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• SURGICAL THERAPIES:
• GONADECTOMY; XY DYSGENESIS
• TUMOR EXCISION FOR LARGE ADENOMAS
• RECONSTRUCTIVE SX:VAGINOPLASTY, PROGRESSIVE VAGINAL.
DILATATION
• ADHESIOLYSIS(HYSTEROSCOPY, MANUAL SHARP
DISSECTION)+FOLEYS CATHETER OR LIPPES LOOP
• OVARIAN DIATHERMY:4-POINT DIATHERMY AT 40W FOR 4SEC.
• IVF : FOR TURNERS&OTHER GONADAL DYSGENETIC CASES
• ELECTROLYSIS RX.FOR HIRSUITISM
• WEIGHT REDUCTION ORAL CONTRACEPTIVES,OVULATION
INDUCTION FOR PCOS

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