Amenorrhoea is the transient or permanent absence of menstrual flow. There is no consensus on the definition of amenorrhoea, but it may be subdivided into primary and secondary presentations relative to menarche as follows:
Primary amenorrhoea: lack of menses by age 15 years in a patient with appropriate development of secondary sexual characteristics, or absent menses by age 13 years and no other pubertal maturation
Secondary amenorrhoea: lack of menses in a non-pregnant female for at least 3 cycles of her previous interval, or lack of menses for 6 months in a patient who was previously menstruating.
Although attributes overlap between the two groups, the diagnostic approaches vary significantly.
Evidence of the current prevalence of amenorrhoea is scarce. Data from the 1990s suggest that about 3% in women who have previously had regular menstrual periods had amenorrhoea. The prevalence appears to be higher in college students (3% to 5%), competitive endurance athletes (5% to 60%), and ballet dancers (19% to 44%). The prevalence of primary amenorrhoea in the US is <0.1%, compared with 3% to 4% for secondary amenorrhoea.
The most common causes include polycystic ovary syndrome, hypothalamic dysfunction, premature ovarian failure, and hyperprolactinaemia.
Although there are many causes of secondary amenorrhoea, the incidence of each aetiology is low. In general, amenorrhoea accounts for a relatively small percentage of patient visits, even at highly specialised centres.
Despite the low prevalence of secondary amenorrhoea, a prompt, comprehensive assessment is warranted unless the patient is pregnant, lactating, or using hormonal contraceptives, as amenorrhoea is often the presenting sign of an underlying reproductive disorder. A delay in diagnosis and treatment may adversely impact the future of such patients. For example, in polycystic ovary syndrome and hyperinsulinaemia, behavioural and dietary modifications may prevent subsequent cardiovascular disease.
- Eating disorders or female athlete triad
- Emotional or physical stress
- Post-contraception with depot medroxyprogesterone
- Polycystic ovary syndrome (PCOS)
- Idiopathic premature ovarian failure
- Post-chemoradiation ovarian failure
- Chromosomal abnormality (Fragile X carrier, Turner's syndrome mosaic)
- Non-classic congenital adrenal hyperplasia
- Malnutrition or chronic disease state
- Empty sella syndrome
- Sheehan's syndrome (postpartum pituitary necrosis)
- Androgen-producing ovarian tumour
- Autoimmune premature ovarian failure
- Androgen-producing adrenal tumour
- Cushing's syndrome
- Asherman's syndrome
Meir Jonathon Solnik, MD
Associate Professor of Obstetrics and Gynaecology
University of Toronto Faculty of Medicine
Head of Gynaecology and Minimally Invasive Surgery
Sinai Health System
Site Chief of Gynaecology
Women’s College Hospital
MJS is a consultant for Medtronic, Olympus, Hologic, and AbbVie. He holds stock in Field Trip Health Ltd, and Felix Health, Canada.
Joseph S. Sanfilippo, MD, MBA
Department of Obstetrics, Gynecology, and Reproductive Sciences
Division of Reproductive Endocrinology and Infertility
University of Pittsburgh
JSS declares that he has no competing interests.
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