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Amenorrhoea

Amenorrhoea is lack of menstruation by age 16 in the presence of sexual characteristics or 14 in their absence

or

Amenorrhoea is an absence of menstruation for 6 months.

History

Emphasis on:

  • Sexual activity, risk of pregnancy, and type of contraceptive used.
  • Galactorrhoea or androgenic symptoms (weight gain, acne, hirsutism).
  • Menopausal symptoms (night sweats, hot fl ushes).
  • Previous genital tract surgery (intrauterine instrumentation or LLETZ).
  • Issues with eating or excessive exercise.
  • Drug use (especially dopamine antagonists for psychiatric conditions).

 

Examination

  • BMI <17/>30, hirsutism, 2° sexual characteristics (Tanner staging).
  • Stigmata of endocrinopathies (including thyroid) or Turner’s syndrome.
  • Evidence of virilization (deep voice, male pattern balding,
    cliteromegaly).
  • Abdominal: may show masses due to tumours or genital tract
    obstruction.
  • Pelvic: imperforate hymen, blind ending vaginal septum, absence of
    cervix and uterus.

Management

Must be guided by the diagnosis and fertility wishes. Options include:

  • Treat any underlying causes including attaining normal BMI.
  • Cabergoline or surgery for hyperprolactinaemia.
  • Cyclical withdrawal bleeds (COCP for PCOS).
  • HRT for POF.
  • Relief of genital tract obstruction: cervical dilation, hysteroscopic resection, incision of hymen.
  • Specific treatment for endocrinopathies and tumours.

Major congenital abnormalities, AIS, etc. should be managed by multidisciplinary teams in specialist centres.

 

Common causes of Amenorrhoea

Physiological causes

  • Pregnancy must always be excluded.
  • Lactation.
  • Menopause.

Iatrogenic causes

  • Progestagenic contraceptives: Depo-Provera® , Mirena IUS ®, Nexplanon ® , POP.
  • Therapeutic progestagens, continuous COCP use, GnRH analogues,
    rarely danazol.

 

Investigations for amenorrhoea

  • Pregnancy test.
  • FSH/LH: in premature ovarian failure (POF), hypothalamic causes (not useful in PCOS).
  • Testosterone and sex hormone-binding globulin (SHBG) are most
    useful for PCOS.
  • Prolactin should always be tested.
  • TFTs.
  • Pelvic ultrasound: Can define anatomical structures, congenital abnormalities, Asherman’s syndrome, haematometra, and PCOS morphology also can indicate physiological activity or endometrial atrophy in POF.
  • Karyotype if uterus absent or suspicion of Turner’s syndrome.
  • Specific tests for endocrinopathies where there is clinical suspicion.

Pathological causes of amenorrhoea

1. Hypothalamic:

  • Functional—stress, anorexia, excessive exercise, pseudocyesis
  • Non-functional— space-occupying lesion (SOL), surgery, radiotherapy, Kallman’s syndrome (1° GnRH defi ciency).

2. Anterior pituitary:

  • Micro- or macroadenoma (prolactinoma) or other SOL
  • Surgery
  • Sheehan’s syndrome (post-partum pituitary failure).

3. Ovarian:

  • PCOS
  • POF
  • Resistant ovary syndrome
  • Ovarian dysgenesis, especially due to Turner’s syndrome (45XO).

4. Genital tract outflow obstruction:

  • Imperforate hymen
  • Ttransverse vaginal septum
  • Cervical stenosis
  • Asherman’s syndrome (iatrogenic intrauterine adhesions).
  • Agenesis of uterus and müllerian duct structures: sporadic or
    associated with AIS.

5. Endocrinopathies:

  • Hyperprolactinaemia
  • Cushing’s syndrome
  • Severe hypo/hyperthyroidism
  • CAH.
  • Oestrogen—or androgen—secreting tumours: usually ovarian or adrenal,

    e.g. granulosa-thecal cell tumours and gynandroblastoma.

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