Close
11th April 2024
Amenorrhoea
Physiology
The International Federation of Gynaecology and Obstetrics (FIGO) defines the parameters for normal uterine bleeding.
| Frequency: Days between cycles | ≥24 to ≤38 days |
| Duration: Duration of menses | ≤8 days |
| Regularity: Cycle variation dependent on age | ≤7 to 9 days |
| Flow Volume | Normal as determined by the patient |
Primary Amenorrhoea
Primary Amenorrhoea is defined as the failure of the onset of menses by the age of 15 in the presence of secondary sexual characteristics or by the age of 13 in the absence of secondary sexual characteristics.
| Causes of primary amenorrhoea | Features |
|---|---|
| Anatomical abnormalities in Mullerian development | Normal secondary sexual characteristics
Examples include: imperforate hymen; Mayer-Rokitansky-Kuster-Hauser syndrome; |
| 5-alpha reductase deficiency | Genetically male with female-appearing genitalia or genital ambiguity |
| 17-hydroxylase deficiency | In females, this is a non-virilising congenital adrenal hyperplasia (CAH) |
| Partial 21-hyrdroxylase deficiency | The most common cause of CAH and results in virilisation. |
| Flow Volume | Normal as determined by the patient |
| Genetic primary hypogonadism | Distinguished by the absence of or poorly defined secondary sexual characteristics
Turner syndrome, Klinefelter syndrome (XY, distinguished by anosmia), Kallman syndrome |
| Type 1 autoimmune polyglandular syndrome (APS-1) | Rare, recessively inherited auto-immune condition characterised by the triad of chronic mucocutaneous moniliasis, hypoparathyroidism, and Addison’s disease.
Sequelae include ovarian failure, which may present as primary amenorrhoea or infertility. |
| Complete androgen insensitivity syndrome | XY, phenotypically female
Usually diagnosed after puberty, though may be diagnosed in those with prepubescent bilateral inguinal hernias (due to testes in the inguinal canal) |
| Non-classic congenital adrenal hyperplasia | Clitoromegaly and clinical hyperandrogenism |
Secondary Amenorrhoea
Secondary Amenorrhoea is defined as the absence of menstruation for 3-6 months in a patient with previous regular menses or 6-12 months in patients with oligomenorrhoea.
| Causes of secondary amenorrhoea | Features |
|---|---|
| Pregnancy | Physiological androgen levels, confirmed with β-hCG test |
| Premature ovarian insufficiency (POI) | Females under 40 years old with premature menopausal symptoms (such as amenorrhoea or oligomenorrhoea) with elevated FSH levels on two samples 4-6 weeks apart |
| Functional hypothalamic cause | Physiological androgen levels
Leads to suppression of the hypothalamic-pituitary-ovarian axis and suppression of gonadotrophin-releasing hormone Risk factors include stress and over-exercise |
| Cushing’s syndrome and exogenous androgen-producing tumours | Secondary amenorrhoea results from hypercortisolism. Negative feedback to the hypothalamus leads to decreased GnRH release. |
| Prolactinoma | Presents with galactorrhoea due to prolactin’s suppressive effect on GnRH production from the hypothalamus. Microprolactinomas are more common than macroprolactinomas. The latter may be suspected if clinical signs of raised intracranial pressure are present. Diagnosis is confirmed with an MRI pituitary. |
| Hyperprolactinaemia secondary to medication | Presents with galactorrhoea due to prolactin’s suppressive effect on GnRH production from the hypothalamus. First-generation antipsychotics are the most common cause, though second-generation antipsychotics may also cause hyperprolactinaemia. Other causes include oral contraceptives, metoclopramide, verapamil, and opiates. |
| Asherman’s syndrome | Characterised by scar tissue in the uterine cavity and may present as oligomenorrhoea or amenorrhoea and infertility
History of dilatation and curettage and normal gonadotrophins |
Investigations
After excluding pregnancy, initial biochemical tests include FSH, LH, TSH and prolactin. If there are systemic features of androgen excess, total testosterone levels could be considered. A pelvic ultrasound should be considered if an anatomical abnormality of the genital tract is suspected. Diagnosis of POI in women <40 years is based on clinical features such as oligomenorrhoea/amenorrhoea >4 months and biochemical confirmation of hypergonadotropic hypogonadism (two raised FSH (>30) levels taken at a 4–6-week interval). Hysteroscopy is the gold standard for diagnosing Asherman’s syndrome.
Management
Management is specific to the underlying condition and includes specialist referral to a gynaecologist and/or an endocrinologist as appropriate. The main aims for treatment are to restore fertility if desired, treat the underlying pathology and prevent complications of hormone deficiency. In POI, either HRT or a combined hormonal contraceptive) reduces the risk of chronic diseases, including cardiovascular disease and osteoporosis. For symptomatic prolactinoma, cabergoline is the first-line treatment. If pregnant, it is important to review medications as many are contraindicated, such as lithium, which is teratogenic and may cause hypothyroidism.
References
- Management of spontaneous primary ovarian insufficiency (premature ovarian failure) – UpToDate, https://www.uptodate.com/contents/management-of-spontaneous-primary-ovarian-insufficiency-premature-ovarian-failure?search=hypogonadism women&source=search_result&selectedTitle=8~150&usage_type=default&display_rank=8 (accessed 20 July 2022).
- Munro MG, Critchley HOD, Fraser IS, et al. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynecol Obstet 2018; 143: 393–408.
- Amenorrhoea | Health topics A to Z | CKS | NICE, https://cks.nice.org.uk/topics/amenorrhoea/
- Evaluation and management of primary amenorrhea – UpToDate, https://www.uptodate.com/contents/evaluation-and-management-of-primary-amenorrhea?search=hypogonadotropic hypogonadism female&source=search_result&selectedTitle=4~95&usage_type=default&display_rank=4 (accessed 20 July 2022).
- Evaluation and management of secondary amenorrhea – UpToDate, https://www.uptodate.com/contents/evaluation-and-management-of-secondary-amenorrhea?search=hypogonadotropic hypogonadism female&source=search_result&selectedTitle=1~95&usage_type=default&display_rank=1#H180195634.
- Diagnosis of premature ovarian insufficiency | Diagnosis | Menopause | CKS | NICE, https://cks.nice.org.uk/topics/menopause/diagnosis/diagnosis-of-premature-ovarian-insufficiency/ (accessed 21 June 2022).
- Polycystic ovary syndrome – NICE CKS, https://cks.nice.org.uk/topics/polycystic-ovary-syndrome/background-information/prevalence/ (accessed 28 July 2022).
Complete Guide to Clinical Genetics ST3 Application and Recruitment (2027)
Written by Medibuddy. Last updated: October 2026. Clinical Genetics is
Complete Guide to Clinical Radiology ST3 Application and Recruitment (2027)
Recruitment paused: NHS England is not running Clinical Radiology ST3+ recru
Complete Guide to Paediatric Surgery ST3 Application and Recruitment in United Kingdom (2026)
Written by Medibuddy. Last updated: October 2026. If you’re planning
Take your subscriptions with you
Our mobile app allows you to access your interview and exam question banks wherever you are.
