Amenorrhoea
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Important points on history taking
Primary amenorrhoea is no menstruation by the age of 14 years in the absence of secondary sexual characteristics, or by the age of 16 years if they are present. Constitutionally delayed puberty is frequent in South Africa. If a specialist Endocrine clinic is available, refer cases (except outflow abnormalities) after basic investigations have been ordered. Take care to approach these patients with care and consideration, as they and their families may be extremely concerned.
Secondary amenorrhoea is cessation of menstruation for 6 months after it has been present. Beyond excluding pregnancy, do not investigate a woman with amenorrhoea of < 6 months.
Amenorrhoea is best considered in terms of anatomy. Some details here apply more to 10, some to 20, some to both. Always exclude pregnancy first.
- Outlow tract: imperforate hymen, transverse vaginal septum, absent uterus, Asherman’s syndrome
- Ovaries: anovulation, Turner’s syndrome, menopause
- Adrenals: congenital adrenal hyperplasia (v rare), Cushing’s (rare)
- Thyroid: amenorrhoea usually occurs with hyperthyroidism
- Pituitary: hyperprolactinaemia, contraceptive agents, psychotropic drugs, Sheehan’s syndrome, Cushing’s (rare)
- Hypothalamus: anorexia nervosa, athletes, severe stress, Kallman’s syndrome, injury, prior infection
Important points on history taking
- Duration of amenorrhoea
- Pattern of menstruation before onset of secondary amenorrhoea
- Sexual activity and contraception
- Headache, visual disturbance, galactorrhoea (hyperprolactinaemia)
- Weight gain or loss
- Lifestyle: stress, exercise and diet
- Hot flushes
- Evidence of hirsutism or virilism
- History of pregnancies and lactation, massive haemorrhage in pregnancy
- Uterine surgery or curettage
- Use of psychotropic drugs
- Medical history – head injury, meningitis, previous radiotherapy, TB
Physical examination
- Complete general examination
- Height & weight (height <150cm makes a syndrome more likely)
- Secondary sexual characteristics (breasts, hair distribution etc)
- Stigmata of chromosomal abnormalities (e.g. Turner’s syndrome)
- Abdominal/pelvic masses (pregnancy, hormone-producing tumors or hematocolpos associated with imperforate hymen/transverse septum)
- Vaginal examination: imperforate hymen or a septum, & presence of a cervix & uterus
Investigations
- Pregnancy test
- Pelvic ultrasound – haematocolpos, haematometra, polycystic ovaries, presence or absence of uterus
- Progestogen challenge test (below)
- Blood tests which may be done, depending on findings, include:
- Prolactin; if raised or if symptoms of hyperthyroidism - TSH
- Estradiol
- FSH/LH
- Testosterone, SHBG, DHEAS, 17-hydroxyprogesterone
- Karyotype
Progestogen challenge test
Give medroxyprogesterone acetate (MPA, Provera) 10 mg orally twice daily for 10 days. A positive test (bleeding after completion of Provera) suggests anovulation as the cause of amenorrhoea, & demonstrates a patent oestrogenized outflow tract. A negative test necessitates blood tests for ovarian & hypothalamic amenorrhoea. Do not use norethisterone (Primolut) instead of MPA, as it is more androgenic, resulting in unfavourable side-effects in women with polycystic ovarian syndrome.
Treatment of Amenorrhoea
- All patients with primary amenorrhoea must be discussed with a consultant
- Some patients with secondary amenorrhoea may be managed quite routinely (with a consultant) others e.g. with thyroid disorders, or Cushing’s syndrome, require specialist physicians