1. Laboratory evaluation of amenorrhoea
Modified by Dr R de Villiers (2007)
Dr N Oosthuizen (2006)
Dept of Chemical Pathology - UP
Block 11
Laboratory evaluation of amenorrhoea

2. Amenorrhoea Primary (1º) Secondary (2º)
no menarche by 16y
Secondary (2º)
cessation of established menstruation >3-6 months
Trend of earlier onset of menarche – workup for amenorrhoea at 15y

3. 2º Amenorrhoea Case 1
32y ♀
LNM 3m ago

4. 2º Amenorrhoea: Causes Cause Lab investigations Other Pregnancy
Clues
Lab investigations
Other
Pregnancy
 β-hCG
Hypothalamic
35%
Weight
 Exercise
Stress; illness
Clomiphene test
Ovarian
Hot flashes; Surgery/ Trauma/ Inf/ Infiltration
Para-/Thyroid/ Adrenal
Estradiol,  FSH
+ Auto Ab
PCOS
= DM of bearded women with anovulation
30%
Hyperandrogenism
Hirsutism
Weight
Acne
 DHEAS; Testosterone
LH:FSH
Insulin Resistance (QUICKY)
Sonar
Pituitary
19%
 LH, FSH; GnRH test
10%
Drugs, Hypothyroidism
 prolactin
MRI
Uterine 5%
History of processes that may  endometrial scar (Asherman syndrome)
Progestin challenge
Progestin + EE challenge
Hystero-scopy 1%
Thyroid disorders
Hyperthyroidism Sx
TSH
Adrenal (CAH)
ACTH test
(17OH Progesterone)
Iatrogenic
Contraception

5. 1º Amenorrhoea Case
16y ♀
No menarche

6. 1º Amenorrhoea: Causes Cause Lab investigations Other
Clues
Lab investigations
Other
Chromosomal
Turner Syndrome
Gonadal dysgenesis
Mullerian dysgenesis
50%
15%
Turner phenotype
No 2º sexual
Karyotype
45 X FSH
46 XX N ♀ Testosterone
Sonar
No uterus
Hypothalamic
20%
Weight
 Exercise
Stress; illness
Vaginal
Transverse septum
Imperforate hymen 5%
Cyclic pelvic pain
Pituitary
Short stature;
Visual field
 FSH, LH,  Prolactin
MRI
Adrenal (CAH)
Virilization
17OH Progesterone;
 DHEAS  Testosterone; FSH
PCOS
Hyperandrogenism
Hirsutism; Weight;
Acne
 DHEAS; Testosterone
LH:FSH
Insulin Resistance (QUICKY)
Thyroid
Hypothyroidism Sx
TSH
Androgen Insensitivity (Testicular Feminization)
46 XY ♂ Testosterone

7. Prolactin/TSH/LH/FSH
Hx and physical exam
Rule out pregnancy
Prolactin/TSH/LH/FSH
TSH
Prolactin
LH/FSH /
FSH (>40)
Hypothyroidism
Hyperthyroidism
Evaluate hyperprolactin-aemia
Progestin challenge
Evaluate ovarian failure
Withdrawal menses +
Withdrawal menses -
Anovulation – E2 present
Oestrogen-Progestin challenge
Withdrawal menses +
Withdrawal menses -
Anovulation – E2 absent
Anatomic defect
Hypothalamic/pituitary disease

8. Evaluate ovarian failure Anatomic defect
Karyotype if <30y
Uterine US
Uterus absent
Uterus present
XO, XO mosaic XX
Karyotype
Premature ovarian failure if <40y XY XX
Galactosaemia
17-OH-ase deficiency
Autoimmune disorder
Infection
Trauma/surgery
Resistant ovary
LH/FSH defects
Testosterone
AIS (T)
Testicular
regression T
17-OH-ase deficiency
Mullerian
agenesis
Asherman Outflow obstruction

9. Abbreviations β-hCG β-subunit of human chorionic gonadotropin
CAH Congenital Adrenal Hyperplasia
DHEAS Dehydroepiandrosterone Sulphate
E2 Estradiol
FSH Follicle Stimulating Hormone
LH Luteinizing Hormone
PCOS Polycystic Ovarian Syndrome