This document discusses amenorrhea, which is the absence of menstruation. It describes physiological amenorrhea that occurs before puberty, during pregnancy and breastfeeding, and after menopause. It also describes pathological amenorrhea, including primary amenorrhea which is the absence of menstruation without previously established cycles, and secondary amenorrhea which is the absence of menstruation for 3-6 months in women with previous regular cycles. It provides classifications and potential causes of primary and secondary amenorrhea, as well as evaluations and treatments.

1. AMENORRHOEA
Amrit Khanal
Chitwan medical College

2.  PHYSIOLOGICAL AMENORRHOEA:
 Prior onset of puberty
 During pregnancy
 Lactation
 After menopause
 PATHOLOGICAL AMENORRHOEA

3.  Primary amenorrhea
 absence of normal menstruation in a patient
without previously established cycles
No menses by age 14 + absence of 2º sexual
characteristics.
= No menses by age 16 + presence of 2º sexual
characteristics.

4.  Secondary amenorrhea
No menses for 3 months  if previous menses were
regular.
= No menses for 6 months  if previous menses
were irregular

5. NORMAL MENSES REQUIRES
 Outflow tract
 Endometrium
 Hormones estrogen and progesterone from
the ovary
 LH/FSH (anterior pitiutary)
 GNRH (Hypothalmus)
 Inhibitory and stimulatory functions

6. CLASSIFICATION OF PRIMARY AMENORRHOEA
1. Hypergonadotropic primary
amenorrhoea
a. Abnormal sex chromosomes: turner’s
syndrome(45ox),mosaics,abnormal x.
b. Normal sex chromosome:
 46xx pure gonadal dysgenesis
 46xy gonadal dysgenesis- Swyer’s syndrome,
testicular feminizing syndrome.
 Gonadrotropin-resistant ovary syndrome – savage
syndrome

7. 2.EUGONADOTROPHIC PRIM AMENORRHOEA
A. Absence of mullerian development:
 Androgen insensitivity syndrome(testicular feminization)
 Mullerian agenesis- rokitansky-kuster-hauser
syndrome(absence of uterus/ vagina)
B. Normal mullerian development:
 Female or true intersex
 Polycystic ovary syndrome
C. Cryptomenorrhoea-imperforate hymen,
vaginal septum

8. 3.HYPOGONADOTROPIC PRIM AMENORRHOEA
 A. Hypothalamic causes:
 Delayed menarche and puberty
 Hypothalamic hypogonadism(kallman’s syndrome)
 Psychogenic causes, weight loss, stress, anorexia nervosa,
malnutrition
 B. Pituitary causes :
 Pituitary underdevelopment
 Neoplasms- prolactinomas, craniopharyngiomas, adenomas,
empty sella turcica
 Hypopituitary states- simmonds diesase, chiari- frommel
syndrome, forbes albright syndrome,pineal gland tumor
 C. severe systemic disease like tuberculosis
 D. other endocrinal disorders-thyroid or adrenal gland

9. CRYPTOMENORRHOEA
 1. CONGENITAL CRYPTO
 2.ACQUIRED CRYPTO

10. CRYPTOMENORRHOEA(CONG)
 Primary Amenorrhoea
 common cause : intact hymen or vaginal
septum(Failure of complete canalization of lower end
of mullerian duct in the region of the sinovaginal bulb.
 Rarely due to congenital atresia of cervix
 A history :
 cyclic abdominal colicky pain without the discharge of
ordinary mensestrual bleeding
 retention of urine,
 presence of a palpable abd. lump( up to 2.5 lits
blood)
 visualization of a tense bluish bulging membrane on
separation of the labia

11.  HEMATOCULPUS: BLOOD IN VAGINA (bluish
buldge of membrane due to retained blood
 HEMATOMETRA: blood in uterine cavity
HEMATOSALPINX: blood in tube
Gentle pressure on the abdominal tumor will
transmit a thrill to the vaginal membrane and
cause it to bulge more distinctly

12.  Ultrasound scan of the pelvis: confirms the
diagnosis.
 Management: Simple cruciate incision of the
hymen permits free drainage of the collected
menstrual blood
 leads to normal reproductive function.

13.  Rarely crptomenorrhoea cause by failure of
canalization of entire vagina
 Usually associated with renal anomalies
 Septate vagina or atresia vagina requires
excision and vaginoplasty
 Artificial vagina is made by creating a space
between the urethra and bladder infront and
the rectum behind until the cervix is reached

14.  The vaginal septum :recognized from the
imperforate hymen by pinkish concave
covering (in contrast to bluish convex bulge
in the latter).
 The vaginal septum, i.e. atresia, requires a
more extensive dissection and vaginoplasty.
The atresia in the upper vagina and cervix
often restenoses after surgery and eventually
requires hysterectomy.

15. ACQUIRED CRYPTOMENORRHOEA
 All operation on cervix: amputation , cone
biopsy and trachelorrhaphy– stenosis
 Cervical cautry and diathermy: occlusion
 Radium treatment for malignant condition
 Too vigorous currettage: cervical obstruction
 All: hematometra
 Precaution: all operation are preceded by a
through cervical dilatation

16. AETIOLOGY OF SECONDARY AMENORRHOEA
1. GENITAL TRACT:
 Acquired obstruction(gynatresia): cervical
stenosis or atresia following electrocautrization,
chemical burns, cervical amputation in
fothergill’s repair,genital tuberculosis
 Asherman’s syndrome: excessive curratage,
infection, endometrial tuberculosis
 Vesicovaginal fistula

17. 2.OVARIAN CAUSES
 Surgical removal
 Radiotherapy
 Autoimmune disease
 Multiple induction ovulation in infertility-premature
menopause
 Pcod
 Resistant ovarian syndrome- due to absent FSH
receptor
 Infection: mumps, TB,
 Masculinizing ovarian tumors
 Premature menopause

18. 3. NUTRITIONAL CAUSES
 Anorexia Nervosa,buliminia
 Extreme obesity
 Excessive weight loss in athelets and ballet
dancer

19. 4. PITUITARY CAUSES
 Simmond’s disease, sheehan’s syndrome
 Hyperprolactemia
 Tumors: prolactinoma, chromophobe
adenoma, cushing’s disease
 Empty sells syndrome
 Drugs; tranquillizers, OCP, metoclopromide,
dopamine blockers, antihypertensive,
antideepressants, cimetidine, phenothiazine

20. 5. HYPOTHALAMUS
 GNRH deficiency
 Vigorous exercise
 Pseudocycosis
 Brain tumors

21.  6. SUPRARENAL CAUSES
 Addison’s disease
 Adrenogenital syndrome
 Suprarenal tumors
 7. THYROID:
 Hypothyroidism, chest wall lesions
 Graves’ disease
 Other causes:
 Diabetes
 TB
 Renal disease
 Severe anemia, malnutrition

22. INITIAL WORKUP OF AMENORRHEA
. History and physical examination (clinical
evaluation of estrogen status)
2. R/O pregnancy
3. Measure plasma FSH, prolactin, TSH
4. Progestin administration

23.  Tanner staging.(secondary sexual
characteristic)
 Breast present ?
 Uterus present ?
 PV exam.
 Rule out possibility of pregnancy.

25. CLINICAL PRESENTATION
 History
 milestones, development, diet, exercise, wt change
 drug use (antipsychotics, hormones, narcs, anti-HTN’s
 systemic disease (hypothyroidism, adrenal insuff., GH
excess)
 past surgery, glactorrhea, hirsutism
 gyn/ob hx (hemorrhage, D&C, infection)
 genetic history

26. CLINICAL PRESENTATION
 Physical
 ht, wt, vitals
 signs of thyroid dz (protuberant eyes, enlarged gland,
puffy face, heat/cold intolerance)
 secondary sex changes
 thelarche (breast devel): avg. age 10.8 yrs; indication
of estrogen exposure
 adrenarche (pubic/axillary hair development): avg.
age 11 and indicates ovarian and adrenal androgen
production and end organ response
 decreased breast size or vaginal dryness indication
decreasing estrogen exposure (or increasing androgens)
 presence of a cervix (confirms presence of a uterus)

27. CLINICAL APPROACH TO 2º AMENORRHEA
 β-hCG level should be obtained:
 rule out pregnancy (commonest cause of 2º
amenorrhea).
 Progesterone challenge  to assess
estrogen status.
 Medroxy-progesterone acetate 10 mg OD
X 1 week  look for withdrawal bleeding:

28. CONT
 (+)ve test if any bleeding occurs within 2-7
days  always due to anovulation.
 Do S-Prolactin & TSH  rule out correctable
cause.
e.g. pituitary prolactinomas / hypothyroidism.
 Mx:
 Treat underlying cause.
 Periodic cyclic progestins  prevent endometrial
hyperplasia from unopposed estrogen.
 Ovulation induction with Clomiphene citrate
 if pregnancy is desired.

29. CONT
 (-)ve test if no bleeding occurs:
  hypo-estrogenism / outflow tract obstruction.
 Combined Estrogen-Progesterone Challenge
Test (EPCT) clarifies etiology of amenorrhea.
 EPCT should be administered to see whether
withdrawal bleeding occurs:
 Conjugated estrogen 1.25 mg PO for 21 days
followed by medroxy-progesterone acetate 10
mg PO X 1 week.
 Or OCP

30. Estrogen should be provided to prevent
sequelae of estrogen deficiency, along
with cyclic progestins to prevent
endometrial hyperplasia, regardless of
the specific cause.
 (-)ve test if no bleeding occurs:
  always due to outflow tract obstruction.
 Mx: Obtain hystero-salpingo-gram (HSG).
 identify site of obstruction (e.g. cervical stenosis).
 rule out endometrial adhesions (Asherman’s synd).

31. POLYCYSTIC OVARIAN SYNDROME
 Wide range of presentation
 Menstral irregularities/Anovulation
 Hirsuitism
 Infertility
 Insulin resistance/Hyperinulinemia
 Obesity

32. PCO
 A state of persistent anovulation
 Elevated circulating levels of testosterone,
androstenedione, DHEAS, DHA, 17
hydroxyprogesterone and estrone
 The ovary secretes normal levels of estradiol

33. ULTRASOUND FINDINGS OF PCO
 Multiple follicles around the periphery of the
ovary (this is a finding not the cause-25% of
normal women can have this fining)
 Ultrasound is not necessary to make the
diagnosis

34. LAB TEST FOR PCO
 Testosterone
 Androstenedione
 DHEAS
 +/- 17OHP
 Prolactin
 TSH
 HCG if needed-
 Fasting Blood sugar
 Fasting Insulin level
 LH/FSH

35. TREATMENT OF PCO IN PATIENTS NOT WANTING
TO CONCEIVE
 Weight loss (decreases insulin and androgen
levels)
 Glucaphage start with 500mg BID
 Oral contraceptives unless contraindicated
 Spironolactone 100-200mg per day for
hirsuitism
 Progesterone if not a candidate for BCP’s

36. TREATMENT OF PATIENTS THAT WANT TO
CONCEIVE
 Ovulation induction with clomid 50mg X5
days start cycle day 3-5
 Glucophage 500mg BID
 May need to induce a withdrawal bleed prior
to ovulation induction

37. SHEEHAN'S SYNDROME
 Simmond's disease: related to pregnancy (obstetrics hemorrhage or
shock
 Sheehan's syndrome: following severe postpartum haemorrhage causes
pituitary necrosis by arterial thrombosis of its vessels and causes
panhypopituitarism.
 The woman fails to lactate following delivery, remains lethargic,
poikilothermic and shows signs of hypothyroidism and cortisol
deficiency.
 Amenrrhoea; axillary and pubic hair is lost ; skin pigmintation is also
deficient
 Blood sugar is low
 Bimanual examination: hypoplastic uterus
 She requires appropriate hormonal support.
 A young woman may require ovulation induction drugs to achieve
conception.

38. RESISTANT OVARIAN SYNDROME
 Resistant ovarian syndrome: autoimmune disease,
ovaries fail to respond to gonadotropin hormones and
induce amenorrhoea.
 The ovaries show plasma cells and lymphocyte
infiltration.
 Biopsy, however, is not necessary for the diagnosis.
FSH level is high.
 may be prudent to study antithyroid, rheumatoid
factors and antinuclear antibodies to establish
autoimmune disease.
 Pregnancy with donor egg in in vitro fertilization (IVF)
is possible.