Definitions

Amenorrhoea is the absence of menstruation.

There are two classifications:

Primary amenorrhoea - failure to begin menstruation. (0.3% of girls)

Secondary amenorrhoea - the cessation of periods for 6 months or more after previously having had regular menstruation (3% of women)

Causes

PRIMARY AMENORRHOEA:

  • Turner's syndrome
  • Constitutional delay
  • Pregnancy
  • hypothalamic Disorders (anxiety, anorexia, excessive exercise)
  • Primary ovarian failure
  • Androgen insensitivity syndrome
  • Hypothyroidism
  • Anatomical causes (uterine malformation, vaginal septum, imperforate hymen)
  • Drugs (chemotherapeutic agents, dopamine antagonists)

SECONDARY AMENORRHOEA:

  • Physiological (pregnancy, contraceptives, breastfeeding)
  • Polycystic ovaries
  • Premature ovarian failure
  • Hyperprolactinaemia

Amenorrhoea Causes

Amenorrhoea in Relation to the Endocrine System

Investigations

Investigations of Primary and Secondary Amenorrhoea

Hormone Profile Indications

Management

The management of amenorrhoea depends, of course, on the cause.

 

PRIMARY AMENORRHOEA:

  • Reassurance for those with constitutional delay
  • Thyroxine for hypothyroidism
  • Hymenal division for imperforate hymen
  • Bromocryptine for prolactinaemia
  • Limited exercise + weight gain for girls who have a BMI less than 19
  • Counselling for those with Turner's, androgen insensitivity and premature ovarian failure

 

    *the combined oral contraceptive pill should be given long term to prevent osteoporosis*

     

    SECONDARY AMENORRHOEA:

    PCOS: Combined oral contraceptive pill restores periods, and co-cyprindiol is an anti-androgen and therefore improves symptoms associated with increased testosterone (hirsutism and acne). However, this must be used with caution and after counselling as it can cause an increased risk of thrombosis

     

    Premature ovarian failure: Hormone replacement therapy and counselling. Ovum donation and IVF in patients who want to become pregnant

     

    Prolactinaemia: Bromocryptine or carbergoline. In cases where neither of these treatments work, surgery is indicated

     

    Asherman's Syndrome: Removal of adhesions hysteroscopically followed by insertion of IUD and a 3 month course of systemic oestrogen to prevent more adhesions forming. The patient may also need counselling as pregnancy is unlikely even if periods return

     

    Contraceptive induced: Stop contraception if this is what the patient wants. Discuss how long it will take for periods to return, and discuss other methods of contraception with them if they do not want to become pregnant.

    Further Reading

    • Kumar & Clark: Pocket Essentials of Obstetrics and Gynaecology. 2005. O'Reilly, Bottomley and Rymer. Chapter 5
    • Gynaecology in Focus. 2005.  Rymer and Fish. Chapter 4
    • Master-Hunter, Tarannum "Amenorrhoea: Evaluation and Treatment" American Family Physician, 2009
    • Speroff L, Fritz MA. "Clinical Gynocologic Endocrinology and Infertility" Lippencott, Williams and Wilkins. 2005
    • Dawood A, Al-Talib A, Tulandi T. "Predisposing Factors and treatment outcome of different stages of intrauterine adhesions" Journal of Obstetrics and Gynaecology Canada. 2010. 32(8) 767-70
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