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Dr.Aliya Waheed
Senior Registrar
Department of Obstetrics and Gynaecology
Ziauddin University & Hospitals

Complete absence or cessation of menstrual

bleeding for greater than 6 months (not due
to pregnancy)


It is the time when one becomes

functionally able to reproduce.

Physiology of puberty
Onset: 10-16 years
Hypothalamus matures pulsatile release
Gonadotrophin releasing hormone
(GnRH) Pituitary gland FSH & LH
release Ovaries Oestradiol
Secondary sexual characteristics

Signs Of Puberty
Breast development
Pubic & axillary hair
Growth spurt
Onset of menstruation

Physiology of menstruation and

GnRH FSH & LH one or more follicles
mature estrogen negative feedback on
pituitary and hypothalamus FSH large LH
and small FSH surgeovulationcollapsed
follicle luteinized secretes progesterone and
estrogentheca lutein cells degenerate
progesterone and estrogen negative feedback
FSH endometrial shed menstruation

Physiological amenorrhea
Before menarche
After menopause


Secondary Amenorrhea

Primary Amenorrhea

Primary Amenorrhea
Failure of spontaneous onset of menstruation
by the age of 16 years.

Primary Amenorrhea

If menarche delayed beyond 16 years then

it should be investigated

With normal secondary sexual

Without secondary sexual characteristics

Secondary sexual characteristics

Imperforate hymen
Transverse vaginal septum
Absent vagina and functioning uterus
Absent vagina and non-functioning uterus
XY female
Resistant ovarian syndrome
Constitutional delay

Secondary sexual characteristics

absent (normal stature)
GnRH deficiency
Weight loss/Anorexia
Excessive exercise
Gonadal agenesis/dysgenesis
Ovarian failure (rare)

Secondary sexual characteristics

absent (short stature)
Congenital or neonatal infections
damaging hypothalamus
Empty Sella syndrome
Turner syndrome(45XO)

Case 1:
17 years old brought by her mother for
complaints of failure to start menstrual

Withdrawl bleed, cyclical pain, urinary
Past medical and surgical history (cranial,
thyroid, genital tract, chemotherapy,
Family history (mother and other sisters)
Personal history: athlete, vigorous exercise

Height and weight (BMI)
Secondary sexual characteristics, breast and
hair distribution (axillary and pubic)
Systemic examination (perabdominal mass)
Genital tract inspection

Normal secondary sexual

N o rm a l s e c o n d a ry s e x u a l c h a ra c te ris ti c s
U ltra s o u n d

U te ru s a b s e n t

U te ru s p re s e n t

K a ry o ty p e

O u t flo w o b s tu c tio n



A b s e n t u te ru s a n d v a g in a

X Y fe m a le

N o rm a l a n a to m y

F S H /L H
P ro la c tin

N o rm a l

L H /F S H

F S H /L H

P ro la c tin

H Y p o th a lm ic


R e s is ta n t o v a ry

P ro la c tin o m a

No secondary sexual
N o s e c o n d a r y s e x u a l c h a r a c t e r is t ic s
H e ig h t

N o rm a l

S h o rt

F S H /L H

F S H /L H


H ig h


H ig h

H y p o g o n a d o t r o p h ic
h y p o g o n a d is m

K a ry o ty p e

I n t r a c r a n ia l le s io n

K a r y o t y p in g

* P r e m a t u r e o v a r ia n fa ilu r e
* R e s is t a n t o v a r y
* G o n a d a l a g e n e s is

* X Y a g e n e s is
* X Y e n z y m a t ic fa ilu r e

X O o r v a r ia n t s

Normal secondary sexual characteristics

Imperforate Hymen

Early childhood--bulging hymen (mucocele)

--hymenectomy, no subsequent problem.

At puberty cyclical intermittent abdominal pain,

haematocolpos, haematometra, difficulty with
micturation and defecation.

On exam: abdominal swelling, tense bulging

bluish membrane which is hymen ------cruciate
incision in the hymen allows drainage of retained
menstrual blood.

Normal secondary sexual characteristics

Transverse Vaginal septum
Vagina fails to cannulate, the upper and lower part of the
vagina are separate.
Septum occurs at three levels lower, middle or upper third
Cyclical abdominal pain (haematocolpos)
Palpable abdominal mass
On inspection blind ending vagina, bulging but pink.
Separate hymenal remnants.
No introital swelling and mass on rectal examination
Special reconstruction to create a vagina

Normal secondary sexual characteristics

Absent vagina and functioning uterus
Embriologically the uterine body has
developed normally, but there is failure of
development of the cervix and upper vagina
Cyclical abdominal pain but no pelvic mass
Small haematometra, retrograde
menstruation ------ endometriosis and pelvic

Normal secondary sexual characteristics

Absent vagina and non-functioning uterus
(Meyer-Rokitansky-kuster-Hauser syndrome)
Second most common cause of primary amenorrhoea
(second only to Turner syndrome)
Ovarian function is unaffected
Normal female external genitalia but blind ending vaginal
dimple 1.5 cm in depth and uterine development is usually
very rudimentary.
Small uterine remnants found on the lateral pelvic walls
40% renal anomalies, 15% major e.g. absent kidney

Normal secondary sexual characteristics


Female phenotype
Failure of testicular development, enzymatic failure of the
testis to produce androgens (testosterone), and androgen
receptor absence or failure of function.
Androgen insensitivity ---- structural abnormality with
androgen receptors, due to abnormalities of androgen
receptor genes---non-functional receptors.
Peripheral conversion of androgen to estrogen and
subsequent stimulation of breast growth

Scanty pubic hairs

Normal vulva but short vagina
Absent uterus ovaries and fallopian tubes
Testes --- lower abdomen or hernial sac

Normal secondary sexual characteristics

Rare condition
Elevated gonadotrophins, appearently
normal ovarian tissues
Absence or malfunction of FSH receptors in
the ovarian follicles and are unable to
respond properly to FSH

Normal secondary sexual characteristics

Constitutional delay
No anatomical anomaly
Normal endocrine levels
Immature pulsatile release of GnRH
Spontaneous menstruation

No secondary sexual characteristics

(normal height)
Isolated GnRH deficiency (Kallman syndrome)
Hypothalamus lacks the ability to produce GnRH
(Hypogonadotrophic state)
Pituitary gland is normal and stimulation with
GnRH leads to normal release of gonnadotrophins
Maldevelopment of neurons in the arcuate nucleus
of hypothalamus (derived embriologically from
olfactory bulb and some have anosmia)

Case 2:
35 years old para 3+0 complaint of absent
menstrual cycles for 6 months.


Previous menstrual cycles, L.M.P

Previous obstetrical history
Hot flushes, insomnia
Last delivery (PPH)
Weight gain or loss (exercise)
Headache, galactorrhoea, vision
Drug history (contraception, radiotherapy
Surgery (diagnostic D&C)

General (BMI, thyroid, Galactorrhoea,
hirsuitism, galactorrhoea)
Systemic (mass)
Local examination

Secondary Amenorrhea

Absence of menstruation for at least 6 consecutive

months or longer if the patient has previous
regular periods and for 12 months or more when a
patient has oligomenorrhea.

Classification of Secondary
Uterine causes:

Ashermans syndrome
Cervical stenosis

Ovarian causes:

Premature ovarian failure (genetic, autoimmune,
infective, radio and chemotherapy)

Hypothalamic causes
(hypogonadotrophic hypogonadism):

Weight loss
Chronic illness
Psychological distress

Pituitary causes

Hypopituitarism (Sheehan syndrome)

Causes of hypothalamic/pituitary damage


Tumors (craniopharyngioma, gliomas


Cranial irradiations

Head injuries


Systemic causes:

Chronic illness
Weight loss
Endocrine disorders
(thyroid disease, cushings disease)

Investigations and treatment

I n v e s t ig a t io n s

P r o la c t in


H ig h

N o rm a l / L o w

A s s e s s R x ta k e n
C T s c a n o f p it u it a r y fo s s a

A b n o rm a l

N o rm a l

N e u r o lo g ic a l
o p in io n

C heck TS H
le v e l

N o rm a l o r

H ig h

E s tr o g e n le v e l
I f p r e g n a n c y r e q u ir e d , e v a lu a t e p r o g e s t e r o n e
s t im u la t io n t e s t

H ig h

R e fr a c t o r y
o v a ry
b le e d in g + v e

H ig h

N o rm a l

T h y r o x in e

B r o m o c r ip t in e

C lo m ip h e n e

I f fa ilu r e

b le e d in g - v e

F o llit r o p in /
hC G or G nR H


O v a r ia n
fa liu r e

Is the commonest endocrine disorder in
women (prevalence15-20%)
PCO runs in families and affects 50% of
first-degree relatives.

Oligo- and/or anovulation
Hyperandrogenism(clinical and/or
Polycystic Ovaries (ovary with 12 or more
follicles measuring 2-9 mmin diameter and
increased volume(>10cm3 )on TVS.

Menstrual disturbances
Asymptomatic with PCO on U/S

Serum Endocrinology
Fasting Insulin
Leutinizing hormone,normal FSH
Sex hormone binding globulin(SHBG)

Late Sequele of PCOs

Diabetes Mellitus
Hypertension,Cardiovascular disease
Endometrial cancer
Breast cancer

34 years old female married since 5 yrs
para 0+2,presented in OPD with secondary
a.Differential diagnosis.
b.What additional information will you obtain
about her complaint?
c.Briefly outline the investigation you will
undertake on her?

Wt loss,stress anrexia
Feature of hyperandrogenismacne,hirsutism,wt gain voice change
Exclude Ashermans syndrome, infection
Symptoms of thyroid dysfunction
Premature menopause-hot flushes,mood

Exclude pregnancy
Hormonal profile
U/S of pelvis
C.T of brain to rule out prolactinoma