Amenorrhoea

Last updated: Wednesday, 27, October, 2010
CausesAppropriate Tests

Initial clinical assessment including whether amenorrhoea is primary or secondary, although many of these disorders may present as either.

Some disorders may be associated with oligomenorrhoea rather than amenorrhoea.

Without androgen excess

Physiological, especially

  • Pregnancy
  • Lactation
  • Menopause

The menopause is defined by amenorrhoea of >1 year duration, in a non-pregnant woman >35 years of age, usually associated with oestrogen deficiency symptoms. A perimenopausal transition period with fluctuating ovarian function may be present over several years. LH, FSH levels are increased, but the assays are only indicated if clinical doubt exists.

Post-oral contraceptive use

A brief period of amenorrhoea may occur.

Intensive exercise

Psychological/Stress

Serious illness

Major weight loss, especially

  • Anorexia nervosa
  • Malnutrition

Endocrine disorders, especially

  • Hyperthyroidism
  • Hypothyroidism
  • Pituitary/hypothalamic disorders
  • Hyperprolactinaemia
See pituitary hormone excess

Chromosomal abnormalities especially

Cytogenetics (constitutional).

  • Turner syndrome
  • Gonadal agenesis
  • 17α-hydroxylase deficiency

Cortisol - plasma.

  • Androgen resistance syndromes

Patients are phenotypically female but genotypically male, with male testosterone levels.

Cytogenetics (constitutional), Testosterone.

    • Complete testicular feminisation
    • Incomplete testicular feminisation
  • Steroid 5α-reductase 2 deficiency

Testosterone/epitestosterone ratio.

Sex cord/stromal tumours especially

  • Granulosa-theca cell tumour

Anatomical abnormalities, especially

  • Post-traumatic uterine adhesions
  • Imperforate hymen
  • Vaginal atresia

Autoimmune ovarian failure

Ovarian antibodies: if positive, further autoimmune endocrinopathies should be sought.

See Thyrogastric cluster.

Cytototoxic drugs/irradiation

With androgen excess

Testosterone, Dehydroepiandrosterone sulphate, Androstenedione, LH, FSH.

Hormone assays are not indicated if it is suspected that androgen excess is due to clandestine anabolic steroid use: see below.

Polycystic ovary syndrome

Sex cord/stromal cell tumour especially

  • Sertoli/Leydig cell tumour
  • Hilar cell (lipoid) tumour

Cushing's syndrome

Congenital adrenal hyperplasia especially

17-Hydroxyprogesterone.

For late onset patients the test may need to be done following Synacthen stimulation.

  • 21-hydroxylase deficiency

Drug-induced, especially

  • Anabolic steroids

Anabolic steroids - urine.