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

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

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

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

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

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

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

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