Amenorrhea

A minimum bodyweight of 48kg, and a fat content of 16-24% are required for menstruation to ocurr. For this reason it is common for women suffering from anorexia nervosa, chronic disease with convalescence, mal nutrition, and long distance runners to experience amenorrhea.

Primary Amenorrhea

Primary amenorrhea refers to young women who have never had menarche by the expected age. Its causes include:

• Chromosomal
  • Turner’s
  • Androgen insufficiency syndrome
  • Congenital adrenal hyperplasia
• Vaginal agenisis
• Neuroendocrine disturbance
  • Stress
  • LOW
  • Excessive excercize
  • Chronic illness
  • Post OCP

Secondary Amenorrhea

Characterized by the absence of menses for 6 months or for longer. It can be differentiated via FSH levels.

• FSH low: neuroendocrine stress: eg female athlete triad, prolactinoma
• FSH normal: comorbid endocrine disease: eg PCOS, hypothyroidism
• FSH high; premature ovarian insufficiency/failure, menopause

Causes:

• Physiological
  • Pregnancy/lactation
  • Menopause
• Endocrine
  • Hyperprolactinemia
  • Thyroid disturbance
  • Premature ovarian syndrome
• Neruoendocrine
  • Female Athlete Triad
  • Starvation

Female Athlete Triad

• Amenorrhea
• Low bone mass (osteopenia, psteoporosis)
• Eating behavior disorders (low body weight, high excercize levels)

Excessive excercize is a form of chronic stress that the HPA axis then responds by reducing thyroid hormone levels, vitamin D, and increasing ACTRH and GnRH.

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The defining symptom is the absence of menstrual periods. Depending on the underlying cause, this may be accompanied by features such as hot flushes and vaginal dryness in estrogen deficiency, galactorrhea with hyperprolactinemia, excess hair growth and acne in PCOS, or the low body weight and reduced bone density seen in the female athlete triad.

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Prolonged amenorrhea reduces bone density, increasing the risk of osteopenia and osteoporosis. Acyclic estrogen exposure causes hyperplasia of the endometrium, and amenorrhea often occurs alongside concurrent and severe premenstrual syndrome.

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• Pregnancy test (beta HCG)

• Computerized tomography (CT) scan or magnetic resonance imaging (MRI) of pituitary area

• Thyroid stimulating hormone

• Plasma hormone levels of FSH & LH

• Estradiol

• Prolactin

• Testosterone

• Progesterone withdrawal test: give a progestogen for 5 days. If the woman bleeds afterwards, she has estrogen in her circulation and a uterus.

• Ultrasound assessment of:

  • uterine size;
  • pregnancy;
  • ovarian size and morphology
  • follicular function.

• Examination under anesthesia if congenital abnormality:

  • assess the pelvic organs;
  • perform a laparoscopy to inspect the pelvic organs and to take a biopsy of the ovaries

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