Amenorrhoea

Keywords: Oligomenorrhoea

Causes

Appropriate Tests

 

Initial clinical assessment including whether amenorrhoea is primary or secondary, although many of these disorders may present as either.

Some disorders may be associated with oligomenorrhoea rather than amenorrhoea.

Luteinising hormone. Follicle stimulating hormone. Oestradiol. Prolactin.

Without androgen excess

 

Physiological, especially

 

  • Pregnancy

Beta HCG quantitation

  • Lactation

 

  • Menopause

The menopause is defined by amenorrhoea of >1 year duration, in a non-pregnant woman >35 years of age, usually associated with oestrogen deficiency symptoms. A perimenopausal transition period with fluctuating ovarian function may be present over several years. Luteinising hormone, Follicle stimulating hormone levels are increased, but the assays are only indicated if clinical doubt exists.

Post-oral contraceptive use

A brief period of amenorrhoea may occur.

Intensive exercise

 

Psychological/stress

 

Serious illness

 

Major weight loss, especially

 

  • Anorexia nervosa

 

  • Malnutrition

 

Endocrine disorders, especially

 

  • Hyperthyroidism
  • Hypothyroidism
  • Pituitary/hypothalamic disorders

 

  • Hyperprolactinaemia

See Pituitary hormone excess.

Chromosomal abnormalities especially

Cytogenetics - constitutional.

  • Turner syndrome

Cytogenetic studies

  • Gonadal agenesis

 

  • 17α-hydroxylase deficiency

Cortisol.

  • Androgen resistance syndromes

Patients are phenotypically female but genotypically male, with male testosterone levels.

Cytogenetics - constitutional. Testosterone.

  • Complete testicular feminisation

 

  • Incomplete testicular feminisation

 

  • Steroid 5α-reductase 2 deficiency

 

 

 

Sex cord/stromal tumours especially

  • Granulosa-theca cell tumour

 

Anatomical abnormalities, especially

  • Post-traumatic uterine adhesions
  • Imperforate hymen
  • Vaginal atresia

 

Autoimmune ovarian failure

Ovarian Ab, if positive, further autoimmune endocrinopathies should be sought.

See Thyrogastric cluster.

Cytotoxic drugs/irradiation

Specific drug levels as appropriate.

With androgen excess

Testosterone, DHEA sulphate, Androstenedione, Luteinising hormone, Follicle stimulating hormone.

Hormone assays are not indicated if it is suspected that androgen excess is due to clandestine anabolic steroid use: see below.

Polycystic ovary syndrome

 

Sex cord/stromal cell tumour especially

  • Sertoli/Leydig cell tumour
  • Hilar cell (lipoid) tumour

 

Cushing's syndrome

 

Congenital adrenal hyperplasia especially

  • 21-hydroxylase deficiency

17-hydroxyprogesterone.

For late onset patients the test may need to be done following Synacthen stimulation.

Drug-induced, especially

  • Anabolic steroids

Anabolic steroids urine.