Amenorrhea
Osman Donia
Prof. Obstet. Gynaecol.,
Osman Donia
Osman Donia
Definitions & Classification

Amenorrhea: Absence of menses.

Primary amenorrhea: Non occurrence of menarche by age
of:
– 14 with no secondary sex characters
– 16 (18) with secondary sex characters.

Secondary amenorrhea: Absence of menses for 3
successive cycles.
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Amenorrhea
Pathologic
False
Physiologic
True
Imperforate hymen
Vaginal T. septa
Cervix
CNS
Puberty
Hypothalamic
Menopause
Pituitary
Pregnancy
Ovarian
Lactation
Uterine
General
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False amenorrhea
(Cryptomenorrhea)
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Cryptomenorrhea



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Due to outflow obstruction.
The most common cause is imperforate hymen.
Blood accumulate behind the hymen  hematocolpos 
Hematometra  Pelvic hemorrhage.
Diagnosis:
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–

P. amenorrhea with good 2ry sex characters.
PMS.
Urinary symptoms.
Abdominal mass ????.
Local examination is diagnostic.
Treatment: Cruciate incision under anesthesia  Slow
evacuation + antibiotics.
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True amenorrhea
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CNS Causes

Psychological troubles:
– Psychosis # neurosis.
– Pseudocyesis.
– Anorexia nervosa.
Chronic stresses.
 Weight loss.
 Exercise:

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–
–
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Loss of body fat.
Stress of competition.
Hyperthermia and dehydration.
Euphoria of winning causing increased opiates.
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Hypothalamic causes

Destruction:
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–
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Trauma
Inflammation.
Tumors.
Infiltrations.
Drugs:
– Estrogens.
– CNS affecting drugs.

Dysfunction & congenital disorders:
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Chiari Frommel syndrome.
Del Castillo syndrome.
Kallmann syndrome.
Laurence Moon Biedl syndrome.
Frohlich syndrome.
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Pituitary causes

Destruction:
– Infiltrations.
– Tumors.
– Sheehan syndrome.

Drugs:
– Estrogens.
– Prolactin inducing drugs.

Dysfunction and congenital disorders:
– Levi Lorain syndrome.
– Empty sella syndrome.
– Prolactinomas.
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Ovarian causes

Congenital:
– Turner.
– Androgen insensitivity syndrome.

Traumatic:
– Surgical removal.
– Irradiation.

Inflammatory:
– Mumps.
– PID.
– TB.

Neoplasia:
– Benign.
– Malignant.

Dysfunctions:
– PCO.
– Resistant ovary syndrome.
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Uterine causes

Congenital:
– Mullerian agenesis.
– Uterine atresia
– Severe hypoplasia.

Traumatic:
– Surgical removal.
– Irradiation.

Inflammatory:
– Asherman syndrome.
– TB.

Neoplastic:
– Obstructing the cervix.

Dysfunctions:
– Insensitive endometrium.
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General causes

DM:
– Glucose metabolism.
– Ketosis.
– Immunological.

Thyroid:
– Hyper.
– Hypo.

Adrenal:
– Addison.
– Cushing.

Debilitating diseases.
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Causes of 1ry amenorrhea
1- Cryptomenorrhea: All congenital causes.
2- True:
– Psychological disturbances before menarche.
– Congenital diseases in the hypothalamus or pituitary.
– Ovarian dysgenesis and removal or destruction before menarche
(T.B, irradiation).
– Uterine aplasia or severe hypoplasia, T.B or removal before
menarche.
– General cause before menarche.

The most common causes of primary amenorrhea:
– Gonadal dysgenesis.
– Mullerian agenesis.
– Complete AIS.
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Causes of 2ry amenorrhea

Physiological:
– Pregnancy, lactation, after menopause.
Cryptomenorrhea: Any acquired cause.
 True:

– Psychogenic disorders after menarche, Chiari Frommel and Del
Castillo syndromes, drugs, OCs, destruction by trauma, infections,
tumors after puberty.
– Sheehan syndrome, Simmond's disease, destruction and tumors
after puberty.
– Ovarian failure, PCO and ovarian tumors.
– Intrauterine synechia, hysterectomy or T.B endometritis after
puberty.
– Any general cause after puberty.
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Diagnosis of amenorrhea
 History:
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Age, occupation, residence, habits and education.
Primary or secondary amenorrhea.
History of psychogenic disorders.
History of neurological disturbances.
History of endocrinological disorders.
Past history of operations, pelvic infections, T.B, long drug course
or irradiation.
– Family history of similar condition, familial disease.
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Diagnosis of amenorrhea
 Examination:
– Psyche, height, weight and span measure. Nutritional status
should be also evaluated.
– Secondary sexual characters.
– Evidence of neurological disorders specially central lesions.
– Evidence of endocrinological disorders with special reference to
galactorrhea and hirsutism.
– Evidence of general disease as heart, chest, renal or hepatic
disorder.
– Abdominal masses (ovarian, adrenal, renal hepatosplenomegaly
or ascites).
– External genital anomaly or hypoplasia.
– Pelvic examination (PV or PR) for uterine and ovarian
abnormalities.
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Diagnosis of amenorrhea
CNS
Hypothalamus
Pituitary
Ovary
Uterus
Outflow tract
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Diagnosis of amenorrhea

Special investigations – Step I:
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Search for specific disease if suspected.
Pregnancy test.
TSH assay.
Prolactin assay.
Progesterone challenge test:
» If (+)ve withdrawal  Normal outflow tract and well estrogenized
cases  The cause is anovulation.
» If (-)ve withdrawal  Hypoestrogenic state or uterine cause 
step II.
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Diagnosis of amenorrhea

Special investigations – Step II:
– Give estrogen + Progesterone:
» If (-)ve withdrawal  Uterine cause.
» If (+)ve withdrawal  Normal outflow tract and uterus, and there
is ovarian failure  Step III

Special investigations – Step III:
– Measure FSH:
» If high  Ovarian cause.
» If low  central cause.
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Treatment of amenorrhea
Treatment of the cause
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