EVALUATION AND MANAGEMENT
OF AMENORRHEA
Mazen Freij, MBBS MRCOG
Assistant Professor at JUH
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Know the definition of Amenorrhea and
Oligomenorrhea
Understand the endocrine, genetic and
anatomical basis for these disorders
Primary amenorrhea
No menses by age 14, absence of 2º sexual characteristics.
No menses by age 16 , presence of 2º sexual characteristics.
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Secondary amenorrhea
No menses for 3 months  if previous menses were
regular.
No menses for 6 months  if previous menses were
irregular
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Oligomenorrhea
Interval of more than 35 days between
periods
Neural control
Dopamine
(-)
Chemical control
Norepiniphrine
(+)
Endorphines
(-)
Hypothalamus
±
Gn-RH
Ant. pituitary
? –
FSH, LH
Estrogen
Ovaries
Uterus
Menses
Progesterone
AMENORRHOEA
AN APPROACH FOR DIAGNOSIS
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HISTORY
PHYSICAL EXAMINATION
BLOOD TESTS
ULTRASOUND EXAMINATION
Exclude Pregnancy
Exclude Cryptomenorrhea
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
Imperforated hymen
FSH Serum level
Low / normal
Hypogonadotropic
hypogonadim
High
Gonadal
dysgenesis
- FSH, LH, Prolactin, TSH
- Provera 10 mg PO daily
x 5 days
Prolactin
 TSH
+ Bleeding
No bleeing
- Mild hypothalamic
dysfunction
- PCO (LH/FSH)
Further
Work-up
(Endocrinologist)
Review FSH result
And history (next slide)
Amenorrhea
Utero-vaginal absence
Karyotype
46-XY
46-XX
Andogen
Insenitivity
(TSF syndrome)
Rokitansky syndrome)
Normal breasts
& absent sexual
hair
Normal breasts
& sexual hair
Amenorrhea
PRIMARY AMENORRHEA
SECONDARY AMENORRHEA
. Ovarian failure
. Hypogonadotrophic
Hypogonadism.
. PCOS
. Congenital lesions
(other than dysgenesis)
. Hypopituitarism
Hyperprolactinaemia
. Weight related
. Polycystic ovary syndrome
. Premature ovarian failure
. Weight related amenorrhoea
. Hyperprolactinaemia
. Exercise related amenorrhoea
. Hypopituitarism
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Classic turner’s syndrome (45XO)
- Turner variants (45XO/46XX),(46X-abnormal X)
- Mixed gonadal dygenesis (45XO/46XY)
• Sexual infantilism and short stature.
• Associated abnormalities, webbed neck,coarctation of
the aorta,high-arched pallate, cubitus valgus, broad
shield-like chest with wildely spaced nipples, low
hairline on the neck, short metacarpal bones and
renal anomalies.
• High FSH and LH levels.
• Bilateral streaked gonads.
• Karyotype - 80 % 45, X0
- 20% mosaic forms (46XX/45X0)
• Treatment: HRT
Turner’s syndrome
(Classic 45-XO)
Mosaic (46-XX / 45-XO)
Ovarian dysgenesis
Normal hight
Normal external and internal genital
organs (infantile)
Low FSH and LH
30-40% anosmia (kallmann’s
syndrome)
Treat with HRT
• delayed bone age
( X-ray Wrist joint)
• Positive family history
• Diagnosis by exclusion and
follow up
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1o or 2o Amenorrhea is often first sign
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A body mass index (BMI) <17 kg/m²
menstrual irregularity and amenorrhea
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Hypothalamic suppression
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Low estradiol  risk of osteoporosis
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Treatment :  body wt. (Psychiatrist referral)
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Second most common cause of Primary
amenorrhea.
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Normal breasts and Sexual Hair Normal
looking external female genitalia
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Karyotype 46-XX
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15-30% renal abnormalities.
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Treatment : Vaginal creation
(Dilatation VS Vaginoplasty)
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Normal breasts but no sexual hair
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Normal looking female external genitalia
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Absent uterus and upper vagina
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Karyotype 46, XY
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Male range testosterone level
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Treatment : gonadectomy after puberty + HRT
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Endocrine causes.
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Genetic causes.
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Anatomic causes.
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A. History of leukemia during infancy
B. Short stature
C. History of delayed puberty in the family
D. All of the above
E. None of the above
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FSH of 60 IU/L (normal 0.33–10.54)
B. Estradiol of 100 pg/ml (normal 40–410)
C. LH of < 0.2 IU/L (normal 0.69–7.15)
D. All of the above
E. None of the above
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A. Turner Syndrome
B. CAH
C. Rokitansky Syndrome
D. Imperforsted Hymen
E. PCOS
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A. Imperforated hymen.
B. Turner Syndrome
C. Androgen insensitivity.
D. Rokitansky syndrome
E. Hypogonadotropic hypogonadism
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What is the definition of Primary Amenorrhea?
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19 year old presented with primary
amenorrhea, normal breast development but
no pubic hair, absent uterus. The most likely
diagnosis is:
A. Rokitansky syndrome
B. Turner Syndrome
C. Androgen insensitivity
D.Hypogonadotropic Hupogonadism