ASSESSMENT OF A CASE

OF AMENORRHEA

Dr. Mohammed Abdalla

 AMENORRHEA

Amenorrhea is the absence

or abnormal cessation of
menstruation.
 Primary amenorrhea
 is defined either as absence of menses by
age 14 years with the absence of growth
or development of secondary sexual
characteristics .
 OR as absence of menses by age 16
years with normal development of
secondary sexual characteristics.
 Secondary amenorrhea
is defined as the cessation of
menstruation for at least 6 months
or for at least 3 of the previous 3
cycle intervals.
 PHYSIOLOGY
Circulating estradiol stimulates growth of the
endometrium. Progesterone, produced by
the corpus luteum formed after ovulation,
transforms proliferating endometrium into
secretory endometrium. If pregnancy does
not occur, this secretory endometrium
breaks down and sheds as a menstrual
blood.
 PHYSIOLOGY
the age of the first menses varies by
geographic location, as demonstrated by a
World Health Organization study
comparing 11 countries, which reported a
median age of menarche of 13-16 years
across centers.
 PHYSIOLOGY
The number of primordial follicles in the
human ovary peaks during the fifth
gestational month at approximately 7
million. After this initial pool is in place, no
additional primordial follicles are formed. In
some cases, loss of menstrual regularity is
an early sign of declining fertility and
impending premature ovarian failure
 PHYSIOLOGY
by age 20 years, women have established
regular and persistent patterns of menstrual
cycle length with little variation .

on an individual basis Relatively stable and

predictable menstrual cycle length continues
until age 40 years.
 PHYSIOLOGY
 In the first year after menarche, the fifth
percentile for menstrual cycle length is 23 days
and the 95th percentile is 90 days.
 By the fourth year after menarche, the 95th
percentile for cycle length has declined from 90
days to approximately 50 days.
 by 7 years after menarche, cycles are more
stable; the fifth percentile in cycle length is 27
days, and the 95th percentile is 38 days.
 How common is it?
• Secondary amenorrhoea (prevalence about 3%)
• primary amenorrhoea (prevalence about 0.3%)
• Between 10 and 20% of women complaining of
infertility have amenorrhoea [Franks, 1987].
• Up to 50% of competitive runners (training 80 miles
per week) and up to 44% of ballet dancers have
amenorrhoea [Balen, 1999a].
Etiology of PRIMARY
amenorrhoea
 Secondary sexual
characteristics present
• Pregnancy
• Constitutional delay
• Genito-urinary malformation, e.g. imperforate hymen,
transverse vaginal septum, absent vagina with or
without a functioning uterus
• Androgen insensitivity: XY female or testicular
feminization
• Resistant ovary syndrome
 Secondary sexual
characteristics absent
• Hypothalamic dysfunction, e.g. chronic illness, anorexia,
weight loss, 'stress'
• Gonadotrophin deficiency, e.g. Kallman's syndrome
• Hydrocephalus
• Tumours of the hypothalamus or pituitary
• Hypopituitarism
• Hyperprolactinaemia
• Gonadal failure, e.g. ovarian dysgenesis/agenesis,
premature ovarian failure
• Hypothyroidism
 Ambiguous external genitalia

• Congenital adrenal hyperplasia

• Androgen-secreting tumour
• 5-Alpha-reductase deficiency
 Turner's syndrome
• Turner's syndrome is caused by either a
complete absence or a partial abnormality of
one of the two X chromosomes. About 50%
have mosaic forms such as 45X/46XX or
45X/46XY.
• Features :( short stature, web neck,
lymphoedema, shield chest with widely spaced
nipples, scoliosis, wide carrying angle,
coarctation of the aorta, and streak ovaries.)
 Constitutional delay

• In this condition there is no anatomical

abnormality and endocrine
investigations show normal results.
• It is caused by immature Pulsatile release
of gonadotrophin-releasing hormone;
maturation eventually occurs
spontaneously.
 Androgen insensitivity syndrome
(AIS)
 formerly known as testicular feminization,
 46XY

 failure of normal masculinization of the external

genitalia in chromosomally male individuals. This
failure of virilization can be either complete (CAIS) or
partial (PAIS), depending on the amount of residual
receptor function.
 affected individuals have normal testes with normal
production of testosterone and normal conversion to
dihydrotestosterone (DHT), which differentiates this
condition from 5-alpha reductase deficiency.
 5-alpha-reductase deficiency
(5-ARD)
 inability
to convert testosterone to the more
physiologically active dihydrotestosterone (DHT).
Because DHT is required for the normal
masculinization of the external genitalia in utero,
 genetic males with 5-ARD are born with ambiguous
genitalia (ie, male pseudohermaphroditism).
 The described clinical abnormalities range from
infertility with normal male genital anatomy to
underdeveloped male with hypospadias to
predominantly female external genitalia, most often
with mild clitoromegaly.
 5-alpha-reductase deficiency
(5-ARD)
Measuring the clitoris is an effective method
for determining the degree of androgen
effect. The clitoral index can be determined
by measuring the glans of clitoris in the
anteroposterior and transverse diameter. A
clitoral index greater than 35 mm2 is
evidence of increased androgen effect. A
clitoral index greater than 100 mm2 is
evidence of virilization.
 Imperforate hymen
 Imperforate hymen represents the most common and
most distal form of vaginal outflow obstruction.
 Clinical presentations range from an incidental finding
on physical examination of an asymptomatic patient
to discovery on an evaluation for primary amenorrhea
or abdominal or back pain.
 The differential diagnosis of uterovaginal obstruction
includes disorders of vaginal development, such as
transverse vaginal septum or complete vaginal
agenesis, Duplication anomalies of the uterovaginal
tract often involve one tract that is decompressed and
one that is obstructed.
Imperforate hymen
Etiology of secondary
amenorrhoea
 No features of androgen excess present
• Physiological, e.g. pregnancy, lactation, menopause
• Iatrogenic, e.g. depot medroxyprogesterone acetate contraceptive
injection, radiotherapy, chemotherapy
• Systemic disease, e.g. chronic illness, hypo- or hyperthyroidism
• Uterine causes, e.g. cervical stenosis, Asherman's syndrome (intra-
uterine adhesions)
• Ovarian causes, e.g. premature ovarian failure, resistant ovary
syndrome
• Hypothalamic causes, e.g. weight loss, exercise, psychological distress,
chronic illness, idiopathic
• Pituitary causes, e.g. hyperprolactinaemia, hypopituitarism, Sheehan's
syndrome
• Causes of hypothalamic/pituitary damage, e.g. tumours, cranial
irradiation, head injuries, sarcoidosis, tuberculosis
 Features of androgen excess present

• Polycystic ovary syndrome

• Cushing's syndrome
• Late-onset congenital adrenal hyperplasia
• Adrenal or ovarian androgen-producing tumour
 Polycystic ovary syndrome

• This condition is characterized by hirsutism, acne,

alopecia, infertility, obesity, and menstrual
abnormalities (amenorrhoea in 19% of cases).
• Ultrasound examination of the ovaries typically shows
multiple, small peripheral cysts. up to a third of women in
the general population have polycystic ovaries on
ultrasound examination [DTB, 2001].
• Endocrine abnormalities include increased serum
concentrations of testosterone, prolactin, luteinizing
hormone (LH) (with normal follicle-stimulating hormone
[FSH] levels), and insulin resistance with compensatory
hyperinsulinaemia.
 Premature ovarian failure

• Menopause/ovarian failure occurring before the

age of 40 years is considered premature.
• Auto-immune disease is the most common cause;
auto-antibodies to ovarian cells, gonadotrophin
receptors, and oocytes have been reported in 80%
of cases.
• Before puberty or in adolescents, ovarian failure is
usually due to a chromosomal abnormality, e.g.
Turner mosaic, or previous radiotherapy, or
chemotherapy
 Ovarian failure (premature
(menopause
chromosomal
anomalies
If the woman is under 30, a
karyotype should be
performed to rule out any
mosaicism involving a Y
chromosome.
If a Y chromosome is found the
gonads should be surgically
excised.
autoimmune
disease
it is prudent to screen for thyroid,
parathyroid, and adrenal
dysfunction
Laboratory evidence of autoimmune
phenomenon is much more prevalent
than clinically significant disease
autoimmune related dysfunction
 The most common association is with thyroid
disease, but the parathyroids and adrenals can also
be affected.
 Several studies have shown laboratory evidence of
immune problems in about 15-40% of women with
premature ovarian failure.
 In general, ovarian biopsy is not indicated in
patients with premature ovarian failure since no
clinically useful information will be obtained.
 Hyperprolactinaemia
• A prolactinoma is the commonest cause of
hyperprolactinaemia (60% of cases).
• Other causes include non-functioning pituitary adenoma
(disrupting the inhibitory influence of dopamine on prolactin
secretion);
• dopaminergic antagonist drugs (e.g. phenothiazines,
haloperidol, clozapine, metoclopramide, domperidone,
methyldopa, cimetidine); primary hypothyroidism
(thyrotrophin-releasing hormone stimulates the secretion of
prolactin), or it may be idiopathic.
• Prolactin acts directly on the hypothalamus to reduce
the amplitude and frequency of pulses of gonadotrophin-
releasing hormone.
 Weight-related amenorrhoea

• A regular menstrual cycle is unlikely to

occur if the body mass index (BMI) is less
than 19 (normal range 20-25).
• Weight loss may be due to illness, exercise,
or eating disorders, among which anorexia
nervosa lies at the extreme end of the
spectrum.
 Post-pill' amenorrhoea

• This is defined as absence of menstruation

for 6 months following cessation of the
combined oral contraceptive pill.
• It probably results from A transient inhibition
of gonadotrophin-releasing hormone .
 Progestogen-associated amenorrhoea

• Depot medroxyprogesterone acetate inhibits the secretion of

gonadotrophins and thus suppresses ovulation.
• After 1 year of use, 80% of women have amenorrhoea or very scanty,
infrequent vaginal bleeding.
• There is partial oestrogen deficiency in women who use depot
medroxyprogesterone acetate.
• The progestogen-only pill leads to reversible long-term
amenorrhoea in a minority of women, due to complete suppression of
ovulation.
• The levonorgestrel-releasing intra-uterine device commonly
results in amenorrhoea after a few months. This is thought to be
mainly a local effect, but suppression of ovulation can occur in some
women (in some cycles).
ASSESSMENT of primary
amenorrhea
 TSH elevated
hypothyroidism
Normal
If puberty delayed delayed
bone age
constitutional delay
Normal

LH, FSH, and prolactin levels low or within

reference range

elevated head MRI

•pituitary tumor or a
brain lesion
45,XO, the cause is gonadal dysgenesis •drug use, an eating
karyotype. disorder, athleticism,
or psychosocial
46,XX, the primary cause is ovarian failure
stress.
 If the pregnancy test result is negative

If puberty elevated
not delayed TSH and prolactin levels hypothyroidism and
hyperprolactinemia
within reference range

-VE progestin challenge +VE

E2 /progestin challenge consider anovulatory cycles
PCO
- +
outlet obstruction obtain FSH and LH levels.

low or within reference range high

karyotype
head MRI.

exclude chronic disease,

anorexia nervosa, or karyotype is normal (46,XX),
psychosocial stress. Turner synd.
the cause is ovarian failure
genital tract
karyotype
abnormalities

If the karyotype is 46,XY If the karyotype is 46,XX

testosterone levels

müllerian agenesis
(ie, Rokitansky-Kuster-Hauser
syndrome).
male range female range

testicular regression
androgen insensitivity. or gonadal enzyme deficiency.
Breast development, pubertal growth spurt,
and adrenarche are delayed or
absent in persons with

hypothalamic pituitary
failure.
 adrenarche occurs normally, while
estrogen-dependent breast development and the
pubertal growth spurt are absent or delayed.

isolated ovarian insufficiency

or failure
Secondary Amenorrhea
 History

A good history can reveal the etiologic

diagnosis in up to 85% of cases of
amenorrhea.
 If the history and physical
exam are suggestive of a
certain etiology :

 for the sake of efficiency and cost-

effectiveness, the workup can
sometimes be more directed according
to history.
( in 85% of cases)
In patients that will not demonstrate any
obvious etiology for their amenorrhea
on history and physical exam. These
patients can be worked up in a logical
manner using a stepwise approach.
 How do I assess my patient with
secondary amenorrhoea?
History
• Risk of pregnancy
• Associated symptoms, e.g. galactorrhoea, hirsutism, hot flushes, dry
vagina, symptoms of thyroid disease
• Recent change in body weight
• Recent emotional upsets
• Level of exercise
• Previous menstrual and obstetric history
• Previous surgery, e.g. endometrial curettage, oophorectomy
• Previous abdominal, pelvic, or cranial radiotherapy
• Family history, e.g. of early menopause
• Drug history, e.g. progestogens, combined oral contraceptive,
chemotherapy
 How do I assess my patient with
secondary amenorrhoea?
Examination

• Height and weight: calculate body mass index if appropriate.

• Signs of excess androgens, e.g. hirsutism, acne
• Signs of virilization, e.g. deep voice, clitoromegaly in addition to
hirsutism, and acne
• Signs of thyroid disease .
• Acanthosis nigricans: this hyperpigmented thickening of the skin folds
of the axilla and neck is a sign of profound insulin resistance. It is
associated with polycystic ovary syndrome (PCOS) and obesity.
• Breast examination for galactorrhoea.
• Fundoscopy and assessment of visual fields if there is suspicion of
pituitary tumour.
• Pelvic examination .
 -VE Preg.test

TSH ,PROLACTIN’,
Prog.challenge test

withdrawal without withdrawal

bleeding bleeding

hypoestrogenic compromised
outflow tract.
anovulation
+ve.est,progest, +
challenge test -ve.est,progest
challenge test

FSH low FSH>30-40

Normal FSH
Repeat+serum, est.
repeat
level
hypothalamic- HSG OR hysteroscopy
pituitary failure PROF asherman
•Raised testosterone/androgen level. This group includes women with
polycystic ovary syndrome (mildly raised level), and women with
androgen-secreting tumours of the ovary or adrenal gland, late-onset
congenital adrenal hyperplasia, or Cushing's syndrome.
•Raised gonadotrophins (follicle-stimulating hormone [FSH] and
luteinizing hormone [LH]) with a low estradiol level. This group
includes women with premature ovarian failure and resistant ovary
syndrome.
•Hyperprolactinaemia. This group includes women with prolactinomas
and hypothyroidism.
•Low gonadotrophins (FSH and LH) with a low estradiol level. This
group includes women with amenorrhoea secondary to exercise, low
weight, and stress.
•Normal or mildly raised gonadotrophin levels with normal
estradiol levels. This group includes women with polycystic ovary
syndrome (PCOS) or other mild disorders of gonadotrophin regulation or
action.
 Complications and prognosis

• Osteoporosis: women with amenorrhoea associated with oestrogen

deficiency are at significant risk of developing osteoporosis. This increased
risk persists even if normal menses are resumed. Oestrogen deficiency is
of particular concern in younger women as a desirable peak bone mass
may not be attained
• Cardiovascular disease
• Young women with amenorrhoea associated with oestrogen deficiency
may be at increased risk of cardiovascular disease

• Women with polycystic ovary syndrome have an increased risk of

developing cardiovascular disease, hypertension, and type 2 diabetes
[Hopkinson et al, 1998].
 Complications and prognosis
• Endometrial hyperplasia: women with amenorrhoea but
no associated oestrogen deficiency are at increased risk of
endometrial hyperplasia and endometrial carcinoma .
• Infertility: women with amenorrhoea generally do not
ovulate.
• Psychological distress: amenorrhoea often causes
considerable anxiety, Many women have concerns about
loss of fertility, loss of femininity, or worry about an
unwanted pregnancy. The diagnosis of Turner's syndrome,
testicular feminization, or developmental anomaly can be
traumatic for both girls and their parents .
Thank you