Amenorrhea / Anovulation

Introduction

• 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