Amenorrhoea is lack of menstruation by age 16 in the presence of sexual characteristics or 14 in their absence
Amenorrhoea is an absence of menstruation for 6 months.
- 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).
- 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,
- Abdominal: may show masses due to tumours or genital tract
- Pelvic: imperforate hymen, blind ending vaginal septum, absence of
cervix and uterus.
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
- Pregnancy must always be excluded.
- Progestagenic contraceptives: Depo-Provera® , Mirena IUS ®, Nexplanon ® , POP.
- Therapeutic progestagens, continuous COCP use, GnRH analogues,
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.
- 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
- 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
- Sheehan’s syndrome (post-partum pituitary failure).
- 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.
- Cushing’s syndrome
- Severe hypo/hyperthyroidism
- Oestrogen—or androgen—secreting tumours: usually ovarian or adrenal,
e.g. granulosa-thecal cell tumours and gynandroblastoma.