Updated: 6/11/2019

Amenorrhea / Anovulation

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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
 

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