Approach to Patient With Amenorrhoea

It is common in general practice that patients may come with amenorrhoea and it needs a proper diagnostic approach.

Primary Amenorrhoea
Defined as when a girl have never started menstruation and sexual characteristics have not developed by the age of 14 years OR no menstruation by age 16 years when growth and sexual development is normal.

Causes
1. Outflow Abnormalities: Mullerian agenesis, transverse vaginal septum, androgen insensitivity, imperforate hymen.

2. Ovarian Disorders: Gonadal dysgenesis due to chromosomal abnormalities e.g Turner’s syndrome

3. Pitutary Disorders: Prolactinoma

4. Hypothalamic disorders: Kallman’s syndrome.

Secondary Amenorrhoea
Defined as absence of menses for more than 6 months in a previously menstruating woman.

Causes

1. Always consider the possibility of pregnancy.

2. Stress

3. Starvation , anorexia or excessive exercise.

4. Hypo/ Hyperthyroidism

5. Hyperprolactinaemia

6. Polycystic ovarian syndrome

7. Premature menopause.

History And Physical Examination.

Rule out the possibility of pregnancy.

Ask for:

• Any recent changes in weight or life style.
• Life crisis or upset e.g exams or any bereavement.
• Intensity of exercise.
• Family history of premature menopause or late menarche.
• Drug history particularly contraceptives e.g injectable contraceptives.
• Past history of chemo or radiotherapy or gynaecological surgery.

Examine and monitor for

• Weight and height
• Do a pelvic examination as needed.
• Look for secondary sexual characteristics.
• Hirsutism
• Visual field and retinal examination

Investigations

• Serum prolactin
• Thyroid function tests
• FSH/LH
• Karyotyping if phenotypical abnormality.
• Serum testosterone if LH high, hirsutism or virilism
• Ultrasound pelvis if structural abnormality or PCOS suspected.

Management
Treatment is according to the cause identified.