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Amenorrhoea  is the absence of a menstrual period in a woman of reproductive age. Physiological states of amenorrhoea are seen during pregnancy and lactation (breastfeeding), the latter also forming the basis of a form of contraception known as the lactational amenorrhea method. Outside of the reproductive years there is absence of menses during childhood and after menopause.
Amenorrhoea is a symptom with many potential causes. Primary amenorrhoea (menstruation cycles never starting) may be caused by developmental problems such as the congenital absence of the uterus, or failure of the ovary to receive or maintain egg cells. Also, delay in pubertal development will lead to primary amenorrhoea. It is defined as an absence of secondary sexual characteristics by age 14 with no menarche or normal secondary sexual characteristics but no menarche by 16 years of age. Secondary amenorrhoea (menstruation cycles ceasing) is often caused by hormonal disturbances from the hypothalamus and the pituitary gland or from premature menopause, or intrauterine scar formation. It is defined as the absence of menses for three months in a woman with previously normal menstruation or nine months for women with a history of oligomenorrhea.

Classification of amenorrhoea
Types of amenorrhoea is diagnosed based on several factors which include the age of onset, and level of hormonal involvement.

Age of onset
There are two types of amenorrhea: primary and secondary amenorrhea. Primary amenorrhoea is the absence of menstruation in a woman by the age of 16. As pubertal changes precede the first period, or menarche, women by the age of 14 who still have not reached menarche, plus having no sign of secondary sexual characteristics such as thelarche or pubarche -thus are without evidence of initiation of puberty- are also considered as having primary amenorrhoea.
Secondary amenorrhoea is where an established menstruation has ceased - for three months in a woman with a history of regular cyclic bleeding, or nine months in a woman with a history of irregular periods. This usually happens to women aged 40–55. Amenorrhoea may cause serious pain in the back near the pelvis and spine. This pain has no cure but can be relieved by a short course of progesterone to trigger menstrual bleeding.

1.Primary amenorrhoea:
1. Gonadal dysgenesis, including Turner Syndrome.
2. Mullerian agenesis (Mayer-von-Rokitansky-Küster-Hauser syndrome (MRKH)).
3. Androgen insensitivity syndrome.
4. Delay in hypothalamic-pituitary maturation.
5. Olfacto-genital dysplasia, Kallmann syndrome.
6. Vaginal obstruction, cryptomenorrhea, imperforate hymen.
7. Receptor abnormalities for hormones FSH and LH.
8. Specific forms of congenital adrenal hyperplasia
9. Swyer syndrome
10. Galactosemia
11. Aromatase deficiency
12. Prader-Willi syndrome
13. Male pseudo-hermaphroditism (about 1 in every 150,000 births)
14. Other intersexed conditions
2.Secondary amenorrhoea:
1. Pregnancy
2. Anovulation
3. Menopause
4. Premature menopause
5. Hypothalamic-pituitary dysfunction, including
6. Exercise amenorrhoea, related to physical exercise
7. Stress amenorrhoea,
8. Eating disorders and weight loss (obesity, anorexia nervosa, or bulimia)
9. Hyperprolactinemia (elevated prolactin levels)
10. Polycystic ovary syndrome (PCO-S)
11. Androgen producing tumor (i.e arrhenoblastoma)
12. Intrauterine adhesions (Asherman's Syndrome)
13. Thyroid dysfunction
14. Hemochromatosis
15. Drug-induced

Hormonal involvement

Hypogonadotropic amenorrhoea refers to conditions where there are very low levels of serum FSH and LH. Generally, inadequate levels of these hormones lead to inadequately stimulated ovaries who then fail to produce enough estrogen to stimulate the endometrium (uterine lining), hence amenorrhoea. This is typical for conditions of pubertal delay, hypothalamic or pituitary dysfunction. In general, women with hypogonadotropic amenorrhoea are potentially fertile.

Hypergonadotropic amenorrhoea refers to conditions with high levels of FSH (and LH). FSH levels are typically in the menopausal range. This implies that the ovary or gonad does not respond to pituitary stimulation. Gonadal dysgenesis or premature menopause are possible causes. Chromosome testing is usually indicated in younger individuals with hypergonadotropic amenorrhoea.

In normogonadotropic amenorrhoea, FSH levels are in the normal range. This would suggest that the hypothalamic-pituitary-ovarian axis is functional. Amenorrhoea may be due to outflow obstruction, or abnormal ovarian regulation or excess androgens as seen in polycystic ovary syndrome.
Cushing's Disease/Syndrome can also cause amenorrhoea due to excessive amounts of cortisol in the blood stream.

Specific types of amenorrhoea
Exercise amenorrhoea
Female athletes or women who perform considerable amounts of exercise on a regular basis are at risk of developing 'athletic' amenorrhoea. It was thought for many years that low body fat levels and exercise related chemicals (such as beta endorphins and catecholamines) disrupt the interplay of the sex hormones estrogen and progesterone. However recent studies have shown that there are no differences in the body composition, or hormonal levels in amenorrheic athletes. Instead, amenorrhea has been shown to be directly attributable to a low energy availability. Many women who exercise at a high level do not take in enough calories to expend on their exercise as well as to maintain their normal menstrual cycles.A second serious risk factor of amenorrhea is severe bone loss sometimes resulting in osteoporosis and osteopenia. It is the third component of an increasingly common disease known as female athlete triad syndrome. The other two components of this syndrome are osteoporosis and disordered eating. Awareness and intervention can usually prevent this occurrence in most female athletes.

Drug-induced amenorrha
Certain medications, particularly contraceptive medications, can induce amenorrhoea in a healthy woman. The lack of menstruation usually begins shortly after beginning the medication and can take up to a year to resume after stopping a medication. Hormonal contraceptives that contain only progestogen like the oral contraceptive Micronor, and especially higher-dose formulations like the injectable Depo Provera commonly induce this side-effect. Extended cycle use of combined hormonal contraceptives also allow suppression of menstruation.

Symptoms of Amenorrhoea :

  • Previously had one or more menstrual periods
  • No menstrual period for 6 months or longer

Other symptoms associated with secondary amenorrhea depend on the cause. They may include:

    Hair falling
  • Galactorrhea
  • Considerable weight gain or weight loss
  • Vaginal dryness
  • Increased hair growth in a "male" pattern (hirsutism)
  • Breast size changes
    • Voice changes

If amenorrhea is caused by a pituitary tumor, other symptoms related to the tumor such as visual loss, may be present.

Exams and Tests:
A physical exam and pelvic exam must be done to rule out pregnancy. A pregnancy test will be done.
Blood tests may be done to check hormone levels. Tests may include:

Other tests that may be performed include:


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