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Amenorrhea
Dr Nadia algantary
Associated proffessor
Faculty of medicine
objective
The student be able to understand 
definition of primary &secondary
ammenorrhea.
Be able to know the practical approach to
ammenorrhic patient

Primary Amenorrhea
absence of menarche by age 16 regardless of 
secondary sex changes
–absence of normal menstruation in a patient 
without previously established cycles
–no periods by age 14 with no secondary sex 
changes
-
Secondary amenorrhea
–absence of menses for 3 cycle lengths in
oligomenorrhea, or for 6 months after
having regular menses
–1-5% of the population 

Clinical feature
History 
–milestones, development, diet, exercise, wt 
change
–drug use (antipsychotics, hormones, narcs, 
anti-HTN’s
–systemic disease (hypothyroidism, adrenal 
insuff., GH excess)
–past surgery, glactorrhea, hirsutism 
–gyn/ob hx (hemorrhage, D&C, infection) 
–genetic history 
examination
•
Physical–ht, wt, vitals–signs of thyroid dz 
(protuberant eyes, enlarged gland, puffy
face, heat/cold intolerance)–secondary
sex changes•thelarche (breast devel): avg.
age 10.8 yrs; indication of estrogen
exposure•adrenarche (pubic/axillary hair
development): avg. age 11 and indicates
ovarian and adrenal
causes
Primary amenorrhea–gonadal failure is most
common cause–uterovaginal agenesis is
second most common cause􀁑Anorexia
nervosa is the most common cause of
amenorrhea overall in teens􀁑
causes
CNS or hypothalamic causes•anatomic 
lesions (can appear with or without
secondary sex changes•drugs affecting
prolactin levels (stimulators and
inhibitors)•stress, exercise, and eating
disorders•PCOS•functional hypothalamic
amenorrhea
causes
Pituitary causes􀁑Ovarian causes 
(elevated gonadotropin and low
estrogen)–radiation and chemo; premature
ovarian failure; ovarian resistance sd;
PCOS; infection; vascular injury; 􀁑Uterine
causes (only group in this category who
will show normal endocrine findings
DDx and Tx in Primary Amenorrhea:2nd
sex changes present, cervix present􀁑
Work up–r/o pregnancy–r/o
hyperprolactinemia–if prolactin level
elevated, evaluate thyroid function–
measure FSH and LH–measure 17ahydroxylase progesterone and
progesterone–do a progesterone
challenge test

Treatment–dopamine agonist therapy– 
combination OCP therapy–estrogen
replacement
DDx and Tx in Primary Amenorrhea: 
2nd sex changes present, cervix absent

􀁑androgen insensitivity (testicular feminization sd) 
􀁑mullerian anomalies or agenesis 
􀁑work up 
–karyotype and testosterone level 
–if nl body hair and female testosterone levels, uterine
agenesis is present and pt is sterile

karyotype is to r/o male pseudohermaphrodism 
•IVP should be done to r/o renal anomalies 
•may need reconstructive surgery 
–pts with AI are usually raised as girls (XY) 
•remove gonads after breast development and 
epiphyseal closure
•replace estrogen 
DDx and Tx in Primary Amenorrhea: 
2nd sex changes absent, cervix absent 
􀁑<1% of primary amenorrhea 
–pts are 46XY, but have abnormality in 
testosterone synthesis
–mullerian inhibiting factor causes internal 
female organs to regress
DDx 
–17a-hydroxylase deficiency 
–17,20 desmolase deficiency 
–agonadism 
􀁑Lab: elevated gonadotropins and low-normal 
female testosterone levels
􀁑Tx: remove testicles and replace estrogen; no 
need for progesterone
Secondary amenorrhea
􀁑Differential 
–similar to that of primary amenorrhea with cervix and
secondary sex changes present
􀁑Work up 
–r/o pregnancy 
–r/o hyperprolactinemia 
–if prolactin level elevated, evaluate thyroid function 
–measure FSH and LH 
–measure 17a-hydroxylase progesterone and 
progesterone
–do a progesterone challenge test 

pregnancy is most common cause–
49-62% have hypothalamic
disorders, including PCO–7-16%
have pituitary disorders–10% have
ovarian disorders–7% have
Ashermans syndrome
Secondary amenorrhea
Treatment 
–dopamine agonist therapy 
–combination OCP therapy 
–estrogen replacement 
conclusion
Ammenorrhea is not uncommon problem. 
Pregnancy is the most common causes. 
Ultrasound and hormonal assay is the 
..keys to differentiate between the most
causes of ammenorrhea.