Amenorrhea / Anovulation

Introduction

Anovulation

May be primary or secondary
- primary
  - absence of menses by age 16
- secondary
  - the absence of menses for three months
  - in a woman with previous normal cycle
  - most commonly due to unexpected pregnancy
Causes
- hypothalamic dysfunction
  - situational stress
  - anorexia
  - obesity
  - serious illness
  - excessive exercise
  - excess cortisol, androgens, and prolactin
  - malignancy
- pituitary dysfunction
  - pituitary neoplasm
    - prolactinoma
  - hyperprolactinemia
  - pituitary infarct
    - Sheehan’s syndrome
- ovarian failure
  - menopause
  - polycystic ovarian syndrome
  - premature ovarian failure
    - autoimmune destruction
    - radiation
    - chemotherapy
    - endometriosis
  - Turner syndrome
- end-organ
  - imperforate hymen (primary amenorrhea)
  - Rokitansky-Kuster-Hauser syndrome (primary amenorrhea)
  - endometrial scarring (secondary amenorrhea)
    - Asherman syndrome
      - arises from intrauterine scarring following dilation and curettage
most common anatomic cause

Evaluation

Hypothalamic/pituitary
- ↓ FSH and LH
  - hypogonadotropic hypogonadism
- no menstrual bleeding when given progesterone
Ovarian
- ↑ FSH and LH
  - hypergonadotropic hypogonadism
- no menstrual bleeding when given progesterone
End-organ
- normal FSH and LH
normal estrogen and progesterone

Treatment

Hypothalamic/pituitary
- reverse underlying cause
- induce ovulation with gonadotropins
- excision if caused by tumor
- bromocriptine for prolactinoma
Ovarian
- exogenous estrogen replacement
End-organ
- surgery