AMENORRHEA

  Primary Amenorrhea? absence of menses by age 15 OR Secondary Amenorrhea? absence of menses for >6 months ...

 

Primary Amenorrhea?

• absence of menses by age 15
  OR

Secondary Amenorrhea?

• absence of menses for >6 months after documented menarche

History and Physical Ex

1. Tanner staging?
2. breasts present?
3. uterus present?
4. possibility of pregnancy

Causes of Primary and Secondary Amenorrhea

Anatomic

1. pregnancy
2. adhesion
3. gonadal dysgenesis (absent uterus, ovarie present)
4. imperforate hymen
5. vaginal septum
6. GTN

Ovarian Failure

1. 
   menopause
2. surgery, radiation, chemotherapy
3. chromosomal
4. Turner Syndrome (XO)
5. Androgen Insensitivity Syndrome (XY)
6. Resistant Ovary Syndrome

Endocrine

1. hypothalamic/pituitary tumours
2. hyperprolactinemia
3. isolated gonadotropin deficiency
4. hyperandrogenism
   
   • PCOD
   • Ovarian/adrenal tumour
   • Testosterone injections
5. hypothyroidism
6. Cushing Disease

Other

1. stress
2. anorexia
3. post OCP
4. illness
5. exercise

Investigations

1. progesterone challenge to assess estrogen status
   
   • medroxyprogesterone acetate (Provera) 10 mg OD for 10 days
   • if withdrawal bleeding occurs ---> adequate estrogen
   • if no bleeding occurs ---> hypoestrogenism
2. karyotype if indicated
3. U/S to rule out cyst, polycystic ovarian disease

Treatment

Hypothalamic dysfunction

1. stop drugs, reduce stress, adequate nutrition, and decrease excessive exercise
2. clomiphene citrate (Clomid) if pregnancy desired
3. otherwise BCP to induce menstruation

Hyperprolactinemia

1. bromocriptine
2. surgery for macroadenoma

Premature ovarian failure

1. treat associated autoimmune disorders
2. HRT to prevent osteoporosis and other manifestations of hypoestrogenic state

Hypoestrogenism

1. karyotype
2. removal of gonadal tissue if Y chromosome present

Polycystic ovarian disease

see Polycystic Ovarian Disease section