Amenorrhea

Dr.Raveendra Mv
DNB Family Medicine Resident- CIHSR
• Common gynecological presentation
• Incidence of pathological amenorrhea – 3-4% in reproductive age group.
• Amenorrhea is a normal state prior to puberty, during pregnancy and
lactation, with certain hormonal medications such as continuous
administration o combination oral contraceptives(COCs), and following
menopause
 Evaluation
• An adolescent:
(1) who by age 13 has not menstruated or shown other evidence
of pubertal development,
(2) who has reached other pubertal milestones but has not
menstruated by age 15 or within 3 years of thelarche.
• Secondary amenorrhea of 3 months or
• Oligomenorrhea involving fewer than nine cycles a year
 Classification
• Numerous classification systems

Onset Cause Hidden or apparent

Primary Physiological False
Secondary Pathological True

• The one we are going to discuss --- Classifying into Anatomical and
Hormonal causes of amenorrhea.
Anatomical causes
Hormonal causes
Hypergonadotropic hypogonadism
Hypogonadotropic hypogonadism
Hypogonadotropic hypogonadism
Eugonadotropic amenorrhea
 Evaluation

History

Physical examination

Investigations
 History
• Pubertal stages achieved ?
• Menses begun? – Interval, duration, amount, Pattern changes
• H/o- Pelvic infection,Radiotherapy,chemotherapy
• Surgical history – Pelvic surgeries
• new-onset headaches or visual changes may suggest a tumor
of the CNS or pituitary gland
• Bilateral milky breast discharge may reflect hyperprolactinemia
 History
• Thyroid disease can be associated with heat or cold intolerance, weight
changes, and sleep or bowel motility abnormalities
• Hirsutism and acne are o ten seen with PCOS or with non classical CAH
• Cyclic pelvic pain would suggest a reproductive tract outlet obstruction
• Hot flushes and vaginal dryness point to POF
 Physical examination
• General appearance: Low BMI with tooth enamel erosion – Eating disorders.
• Signs of Turner syndrome are evaluated, including short stature, webbed
neck, shield-shaped chest, and others.
• Midline facial defects, such as cleft palate, are consistent with a
developmental defect o the anterior pituitary gland.
• Hypertension in a prepubertal girl may reflect mutation in the CYP17 gene
• Skin is inspected for acanthosis nigricans, hirsutism, or acne, which may indicate
PCOS or other hyperandrogenism causes
• Clinical features of Hypothyroidism, Hyperprolactinemia, Cushing syndrome.
• Examination o the genitalia:
• -Sparse or absent axillary or pubic hair may reflect either lack
of adrenarche or androgen insensitivity syndrome
-Elevated androgen levels will result in a male pattern of genital hair growth
Investigations
 Treatment
• Depends on its etiology and patient goals such as a desire to treat hirsutism or seek pregnancy.
• Anatomical abnormalities often requires surgical correction
• Hypothyroidism – Thyroid hormone replacement
• Hyperprolactnemia- Dopamine agonists( If Macroadenoma –Sx)
• Estrogen replacement therapy in cases of Hypogonadism
• Eating disorders or Excessive exercise => Behavioral modification
• PCOS – Cyclical Progestrone/Spirinolactone/ COC/metformin
• Non classical CAH – Low dose corticosteroids
• Infertility:
• -> Adequate treatment of Hyperprolactinemia/Hypothyroidism => Normal
ovulation => Conception.
• -> Anatomical abnormalities => Surgical correction.
• -> PCOS – Treated with Clomiphene citrate
• -> If Behavioral modifications fails => Refer to infertility specialist.
• -> POF is not reversible=> ART or surrogacy
Thankyou…