Amenorrhea

oleh
Dr. H M A ASHARI SpOG

Physiology of menstruation
Normal endometrial shedding ensues as a consequence of
progestagen withdrawal in an endometrium primed by both
estrogen & progestagen.
Estrogen & progestagen are secreted by the ovary under the
influence of pituitary gonadotrophins (FSH & LH), which in
turn are stimulated by hypothalamic GnRH

Aksis
Hipothalamushipofisisovarium-uterus

Two cells two

gonadotrophins
theory

Menstruation
Spontaneous, revealed menstruation therefore
requires:

Hypothalamic GnRH secretion

Pituitary FSH & LH secretion
Ovarian estrogen & progestagen secretion
Endometrium
Patent cervix & lower genital tract

Disorders at any the above levels will have the potential to disrupt
menstruation

CNS-Hypothalamus-Pituitary
Ovary-uterus Interaction
Neural control
Dopamine
(-)

Chemical control
Norepiniphrine
(+)

Endorphines
(-)

Hypothalamus

Gn-RH
Ant. pituitary

FSH, LH
Estrogen

Ovaries
Uterus

Menses

Progesterone

Amenorrhea
Amenorrhea is a sign of a disorder not a
diagnosis
Because any abnormality of menstruation
may be associated with pregnancy,
pregnancy always must be ruled out as a
cause for the absence of menses

Definitions
Primary amenorrhea
Failure of menarche to occur when expected in relation to
the onset of pubertal development
No menarche by age 16 years with signs of pubertal
development.
No onset of pubertal development by age 14 years.
Secondary amenorrhea

Absence of menstruation for 3 or more months in a

previously menstruating women of reproductive age.

Common causes of primary amenorrhea

The Practice Committee of
the American Society for
Reproductive Medicine
FERTILITY AND
STERILITY
VOL. 82, SUPPL. 1,
SEPTEMBER 2004

Common causes of secondary amenorrhea

The Practice Committee of
the American Society for
Reproductive Medicine
FERTILITY AND
STERILITY
VOL. 82, SUPPL. 1,
SEPTEMBER 2004

Causes of amenorrhea
Physiological
Prepuberty, pregnancy, lactation, postmenopause

Pathological prevalence: 3-4%

Local genital causes
Congenital--eg, testicular feminisation
Acquired--eg, Asherman's syndrome

Hypothalamic
Congenital--eg, Kallmann's syndrome
Acquired--eg, weight loss, craniopharyngioma

Pituitary
Tumour--eg, prolactinoma
Infarction--eg, Sheehan's syndrome

Ovarian
Congenital--eg, gonadotrophin-receptor defect, resistant ovary syndrome
Acquired--eg, radiation

Causes of amenorrhoea

William L. Ledger*, Jonathan Skull

Current Obstetrics & Gynaecology (2004)
14, 254260

Disorders leading to amenorrhea

Site of disorder

Diagnosis

Investigations

Hypothalamus

Hypothalamic hypogonadism (rare)

Weight-related amenorrhea (common)

FSH, LH & E2 all low

FSH, LH & E2 low

Pituitary

Pituitary adenoma (common)

Sheehans syndrome (rare)

PRL raised, FSH, LH & E2 low

LH, FSH & E2 low

Endocrine-thyroid

Hypothyroidism (rare)

TSH raised, T4 low or normal

Ovary

Gonadal dysgenesis (rare)

PCOS (common)
POF (rare)

FSH, LH high, E2 low

LH high, FSH normal, androgens
high normal
FSH, LH high, E2 low

Muellerian tract

Absence of uterus (rare)

Ultrasound & progesterone challenge

Genital tract

Imperforate hymen (common)

Ashermans syndrome or endometrial
fibrosis (rare)

Physical examination & ultrasound

HSG & AAFB testing

Amenorrhea & androgen excess

Amenorrhea can be divided into 2 groups:
amenorrhea without evidence of associated androgen
excess

hypothalamic-pituitary dysfunction (stress, weight loss, exercise)

Hyperprolactinemia
Non-gonadal endocrine disease
Systemic illness

Amenorrhea with evidence of androgen excess (eg,

hirsutism, virilization, sexual ambiguity)
PCOS
Cushings syndrome
Congenital adrenal hyperplasia (late onset)

AMENORRHOEA
AN APPROACH FOR DIAGNOSIS
HISTORY
PHYSICAL EXAMINATION
ULTRASOUND EXAMINATION
Exclude Pregnancy
Exclude Cryptomenorrhea

Clinical evaluation
History
Emotional stress, family history of possible genetic anomalies or
diabetes, galactorrhea, symptoms of thyroid disorder, weight loss,
hirsutism or menopausal symptoms

Physical examination
Body dimensions & habitus
Distribution & extent of terminal androgen-stimulated body hair
Extent of breast development (Tanner) & the presence or absence of
any breast secretions
External & internal genitalia, with emphasis on evidence of exposure
to androgens & estrogens

Basal concentrations of FSH, LH, TSH & prolactin

Pelvic ultrasound

Estrogen + progestin challenge test?

Method:
Oral conjugated estrogen, 2,5 mg daily for 25 days + oral
MPA 5-10 mg for the last 10 days of estrogen therapy

Induce bleeding if the endometrium is normal

Determine with certainty if the outflow tract is intact

Cryptomenorrhea
Outflow obstruction to menstrual blood
Imperforate hymen
Transverse vaginal septum with functioning uterus
Isolated vaginal agenesis with functioning uterus
Isolated cervical agenesis with functioning uterus
Intermittent abdominal pain
Possible difficulty with micturition
Possible lower abdominal swelling
Bulging bluish membrane at the introitus or absent vagina
(only dimple)

Imperforate hymen

Uterovaginal anomalies

Embryology of the female urogenital tract

Noncommunicating vertical fusion

defect of the transverse vaginal
septum

Modified FerrimanGallwey (FG) hirsutism scoring

system for nine body areas

Facial hirsutism in a 17-year-old

woman with PCOS

Gross & cut appearance of typical

polycystic ovaries. Multiple small
follicular cysts are apparent in the cut
section

Prolactinoma

Coronal CT scan of patient with prolactinoma (left) shows a large suprasellar

adenoma (arrow). CT scan of same patient (right), made after 2 weeks of
treatment with bromocriptine (2,5 mg, 3 times a day) shows significanct
regression in size

Once Pregnancy and cryptomenorrhea are excluded:

The patient is a bioassay for

endocrine abnormalities

Four categories of patients are identified

1. Amenorrhea with absent or poor
secondary sex Characters
2. Amenorrhea with normal 2ry
sex characters
3. Amenorrhea with signs of
androgen excess
4. Amenorrhea with absent uterus
and vagina

Diagnostic workup
for amenorrhea
Veldhuis JD.
Hospital Practice 1988;23:40-56

Investigation of women with amenorrhea

AMENORRHOEA , By: Baird, David T., Lancet, 00995355, 07/26/97, Vol. 350, Issue 9073

Suggested flow diagram aiding in the

evaluation of women with amenorrhea
The Practice
Committee of the
American Society
for Reproductive
Medicine
FERTILITY AND
STERILITY
VOL. 82, SUPPL. 1,
SEPTEMBER 2004

Conclusions
Amenorrhea is a symptom not a diagnosis.
Comprehensive history and clinical examination in
conjunction with a few carefully chosen investigations are
sufficient to make an accurate diagnosis in the vast majority
of cases.
Successful management depends not only on identification
of the underlying cause, but also on the needs and concerns
of the individual woman.
The absence of menses in itself has no deleterious effect on
health, but amenorrhea may be a presenting symptom of an
underlying disorder (eg, pituitary tumor or hypo-estrogenism)
that requires treatment.