Amenorrhoea is defined as
the absence of menses, when
a woman does not see her
menstrual period. This can be
normal in the case of pre-pubertal
girls, pregnancy or following
However, in other women it is a sign of
a gynaecological problem, although the
menstrual cycle can also be affected by
It is divided into two groups:
1. Primary amenorrhoea – this
is when a female has never had
menses. This is considered abnormal
if menses has not started by age 16
or if there has been no development
of breasts or pubic hair by age 14.
It is a problem affecting about
3 percent of younger women.
2. Secondary amenorrhoea – this is
when a woman who had menses
previously, then experiences no
menses for six months or more. This
can affect women of any age. These
women have normal breast and
pubic hair development.
The two types have different causes
and treatments and these will be
discussed in the next section. There
are many potential causes but the
commonest are highlighted in bold.
Secondary amenorrhoea is commoner so it will be discussed first and in more detail.
There are two areas of the brain which influence the menstrual cycle – the hypothalamus and the pituitary. The hypothalamus produces gonadotrophin releasing hormone (GnRH) which stimulates the anterior pituitary to produce luteinising hormone (LH) and follicle stimulating hormone (FSH). The anterior pituitary hormones then affect the ovaries causing release of oestradiol, progesterone and inhibin. These hormones have a intricate link and the timings and amounts affect the menstrual cycle.
The diagram below illustrates the influence of the brain and ovaries on the production of hormones.
Again, the causes can be split into the
Commonly it can be constitutional,
often following a family pattern, which
is the commonest cause. However, it
can also be due to the effect of other
chronic illnesses such as diabetes.
Anorexia nervosa or excessive
exercise can be a cause in teenagers.
Problems with the development of the
pituitary or tumours of the pituitary or
hydrocephalus are much rarer causes.
Problems with the normal functioning
of the ovaries or the absence of ovaries
can also result in no menses. This can
be due to abnormal development,
premature ovarian failure, genetic
problems, autoimmune disease,
infections or following chemotherapy/
Genetic problems can be a rare cause
of amenorrhoea e.g. Turner syndrome
which is when the child only has one
copy of the X chromosome.
Anatomical causes are more common
in primary amenorrhoea:
Your doctor should take a detailed
history from you and examine you. This
should include a breast examination
and a check for other signs of normal
sexual development e.g. axillary and
pubic hair growth, especially in women
who are younger and never had a
The examination may include a check
of your visual fields by the doctor. It
is usual to examine both the external
genitalia and a vaginal examination
both with a speculum and a bimanual
Your height and weight should be
taken and your body mass index
A pregnancy test should be offered
as this is the commonest cause of
A range of hormone tests may be
ordered depending on the symptoms
• Follicle Stimulating Hormone (FSH)
• Luteinising Hormone (LH)
• Sex hormone binding globulin
• Thyroid function
It is usual to have an ultrasound of the
pelvis to assess the uterus and ovaries.
In women who have been sexually
active or have used tampons during
menses, this can be carried out using a
small vaginal probe, which should not
Other investigations which rarely may
be required are:
• CT or MRI to exclude rare tumours
of the hypothalamus, pituitary, or
• Blood tests for chromosomes.
• A hysteroscopy, an investigation
when a small camera is passed into
the uterus through the vagina and
The treatment is dependent on the cause.
For women who are underweight resulting in amenorrhoea, lifestyle and dietary advice is the mainstay. However, if their oestrogen levels are very low they may benefit from hormone therapy to prevent osteoporosis.
For women with polycystic ovarian syndrome there is no cure as the exact cause for it is still not completely known. However, weight loss in women with high BMI can help the return of more regular menses.
Women not wishing to conceive
who are not seeing their menses are
usually advised to start hormonal
treatment. This is especially important
if the menses come less frequently
than three-monthly, as this in the
longer-term increases the chance
of endometrial abnormalities and
over the years can increase the risk
of endometrial cancer. Therefore, the
combined pill or progesterones every
three months can be used to provoke
a bleed to shed the endometrium.
Metformin is a non-hormonal daily
treatment which can sometimes be
considered. It is important to stress that
there are many treatments to help if
you are trying to conceive.
Problems with excess facial or body
hair are experienced by many women
with PCOS. Creams which can be used
to slow the growth of the hair, along
with laser treatment can help with this.
A specific type of the combined pill can
also be helpful for symptoms of excess
hair growth or acne.
High levels of prolactin normally just
requires treatment with medication,
rarely is surgery required. A referral
to a Specialist in this area, an
Endocrinologist, is usual.
Premature ovarian failure is not
normally reversible, and this can cause
women to consider oocyte donation
with fertility treatment if pregnancy
is desired. This can be a very difficult
diagnosis and extra psychological
support may be needed.
Hormone replacement therapy is
normally advised either in the form
of the combined oral contraceptive
pill or hormone replacement therapy
to prevent osteoporosis in the long
term, which has significant morbidity
and mortality compared to the risks of
Surgery may be required for tumours
in the hypothalamus, ovary or adrenal
gland, as well as for intrauterine
adhesions or problems with cervical
If the cause of the amenorrhoea is due
to other disease then optimising the
control of these medical problems is
the key to treatment.
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