Failure to Menstruate

Amenorrhoea is defined as the failure to menstruate. It can be classified as primary (Menstruation fails to start) or secondary, which is defined as the cessation of periods for greater than 6 months in a woman who previously menstruated . Amenorrhoea may be due to the absence of the uterus as in an XY female , blockage of the outflow tract owing to an imperforate hymen, Mulleria agenesis like Major-Rokitanky

Primary menstrual failure: Absence of menstruation by the age of 16 years Any girl over 16 years who hasn’t started menstruating needs investigations.

Secondary menstrual failure: The most common causes of secondary amenorrhoea are hypothalamic suppression or polycystic ovarian syndrome. Other causes include thyroid disease, adrenal disease, premature ovarian failure and Sheehan syndrome. Sheehan syndrome is a form of hypopituitarism causes by post partum ischaemic necrosis of the anterior pituitary. The hyperplastic pituitary gland at pregnancy is more susceptible to hypotension and severe post partum haemorrhage may precipitate Sheehan syndrome.

Asherman syndrome should be suspected in women who have amenorrhoea and have normal hormonal profiles with evidence of ovulation, Particularly in women who have had some form of uterine surgery , for example termination of pregnancy or dilatation and curettage (D&C) which could precipitate the formation of intrauterine adhesions. Pregnancy and natural menopause are physiological courses of amenorrhoea. When a woman presents with secondary amenorrhoea pregnancy and natural menopause should always be considered.

ALL OPTIONS IN THE MANAGEMENT OF AMENORRHOEA AND PROGNOSIS THEREOF SHOULD BE DISCUSSED WITH THE PATIENT BEFORE EMBARKING ON INVESTIGATION AND TREATMENT.