1. AMENORRHEA APPROACH TO AMENORRHEA Primary Amenorrhea?
❏ absence of menses by age 15 OR
Secondary Amenorrhea?
❏ absence of menses for >6 months after documented menarche

2. History and Physical Tanner staging breasts present? uterus present?
r/o possibility of pregnancy

3. Causes of Primary and Secondary Amenorrhea
AnatomicOvarian FailureEndocrineOther•
pregnancy
• menopause
• hypothalamic/pituitary tumours
stress
Adhesion
surgery, radiation, chemotherapy

4. Hyperprolactinemia
Anorexia
gonadal dysgenesis•
chromosomal• isolated gonadotropin deficiency
(absent uterus, ovaries• Turner Syndrome (XO)

5. Hyperandrogenism
illnesspresent)
Androgen Insensitivity
exercise
imperforate hymenSyndrome (XY)
Ovarian/adrenal tumour
vaginal septum
Testosterone injections
Hypothyroidism
Cushing Disease

6. Investigation karyotype if indicated
medroxyprogesterone acetate (Provera) 10 mg for 10 days
if withdrawal bleeding occurs —> adequate estrogen
if no bleeding occurs —> hypoestrogenism
karyotype if indicated
U/S to rule out cyst, polycystic ovarian disease

7. Treatment hypothalamic dysfunction hyperprolactinemia
stop drugs, reduce stress, adequate nutrition, and decrease excessive exercise
clomiphene citrate (Clomid) if pregnancy desired
otherwise BCP to induce menstruation
hyperprolactinemia
bromocriptine
surgery for macroadenoma

8. premature ovarian failure
treat associated autoimmune disorders
HRT to prevent osteoporosis and other manifestations of hypoestrogenic state
hypoestrogenism
karyotype
removal of gonadal tissue if Y chromosome present