Amenorrhoea

Evaluation and management of a patient with amenorrhea is common in gynecology, and the prevalence of pathologic amenorrhea ranges from 3 to 4 percent in reproductive-aged populations (Bachmann, 1982; Pettersson, 1973). Amenorrhea is diagnosed in a female: (1) who has not menstruated by age 14 years and who lacks other evidence of pubertal development; (2) who has not menstruated by age 16, even in the presence of other pubertal signs; or (3) who has previously menstruated but has been without menses for a time equivalent to a total of three previous cycles or 6 months. Although amenorrhea has classically been defined as primary (no prior menses) or secondary (cessation of menses), this distinction may lead to diagnostic error and should be avoided.

In some circumstances, evaluation reasonably may be initiated despite the absence of these strict criteria. Examples include a patient with the stigmata of Turner syndrome, obvious virilization, or a history of uterine curettage. An evaluation for delayed puberty should also be considered before the ages just listed if the patient or her parents are concerned. Although the list of possible etiologies is extensive, most causes will fall into a limited number of categories. Of course, amenorrhea is a normal state prior to puberty, during pregnancy and lactation, and following the menopause.

Numerous classification systems for the diagnosis of amenorrhea have been developed, and all have their strengths and weaknesses. One useful scheme is outlined in. This is system divides the causes of amenorrhea into anatomic versus hormonal etiologies with further division into inherited versus acquired disorders.

As described earlier, normal menses require adequate ovarian production of steroid hormones. Decreased ovarian function (hypogonadism) may result either from a lack of stimulation by the gonadotropins (hypogonadotropic hypogonadism) or from primary failure of the ovary (hypergonadotropic hypogonadism). A number of disorders are associated with relatively normal LH and FSH levels (eugonadotropic), however, there is loss of appropriate cyclicity.

Anatomic abnormalities that may present as amenorrhea can broadly be viewed as either inherited or acquired disorders of the outflow tract (uterus, cervix, vagina, and introitus).

Amenorrhea will be observed in the presence of an imperforate hymen (1 in 2000 women), a transverse vaginal septum (1 in 70,000 women), or isolated atresia of the vagina (Banerjee, 1999; Parazzini, 1990; Reid, 2000). Patients with these anomalies have a 46,XX karyotype, female secondary sexual characteristics, and normal ovarian function. Therefore, the amount of uterine bleeding is normal, but its normal path for egress is obstructed or absent. Th ese patients may note moliminal symptoms, such as breast tenderness, food cravings, and mood changes, which are attributable to elevated progesterone levels. In addition, accumulation of menstrual blood behind an obstruction frequently results in cyclic abdominal pain. In women with outflow tract obstruction, an increase in retrograde menstruation may lead to development of endometriosis with associated complications such as chronic pain and infertility.

Postoperative scarring and stenosis of the cervix may follow dilatation and curettage (D&C), cervical conization, loop electro surgical excision procedures, infection, and neoplasia. Severe atrophic or radiation changes can also be causative. Stenosis most commonly involves the internal os, and symptoms in menstruating women include amenorrhea, abnormal bleeding, dysmenorrhea, and infertility. Postmenopausal women are usually asymptomatic until fluid, exudates, or blood accumulates. If obstruction is complete, a soft, enlarged uterus is palpable.