Classify amenorrhoea:

A. Primary amenorrhoea

• Before puberty

B. Secondary amenorrhoea 

• . During pregnancy
• . During lactation
• . Following menopause

Causes of amonerrhea : 

Physiological cause of amenorrhea : 

Before puberty : The pituitary gonadotrophins are not adequate enough to stimulate the ovarian follicles for effective steroidogenesis – oestrogen levels are not sufficient enough to cause bleeding from the endometrium.

During adolescence : Initial menstrual cycle are often anovulatory and therefore irregular. Periods of amenorrhoea lasting 2- 12 months during the first 1-2 years after the menarche are so common that they should be regarded as normal. They occur in 20% of girls without subsequent ill effect on their fertility .

During Pregnancy :  Large amount of Oestrogen and chorionic gonadotrophins secreted from the trophoblasts suppress the pituitary gonadotrophins – on maturation of the ovarian follicles.

Following menopause : No more reponsive follicles are available in the ovaries for the gonadotrophins to act, As a result, there is cessation of oestrogen production from the ovaries with elevation of pituitary gonadotrophins.

Common Pathological causes of amenorrhea: 

• Congenital absence or gross hypoplasia of uterus

1. Abnormal chromosomal pattern
2. Imperforate hymen
3. Pituitary infantilism
4. Hysterectomy
5. Disorder of adrenal gland
6. Pituitary disorders
7. Disorders of the ovary.

 Define primary amenorrhea : Primary amenorrhoea is the absence of menstruation by 16 years of age in the presence of normal secondary sexual characteristics, or by 14 years of age if secondary sexual characteristics have not been developed.

Cause of primary amenorrhea : 

= Hypogonadotrophic hypogonadism : 

1. Delayed puberty
2. Hypothalamic and pituitary dysfunction : Gonadotrophin deficiency due to –

• .Stress
• . Weight loss.
• Excessive exercise
• .Anorexia nervosa
• . Chronic disease (tuberculosis).

3. Kallamann’s syndrome.

4. Cntral nervous system tumours : Craniopharyngioma

== Hypergonadotrophic hypogonadism : 

1. Primary ovarian failure
2. Resistant ovarian syndrome 
3. Galactosaemia
4. Enzyme deficiency 
5. Others – Gonadotrophin receptor multations

=Abnormal chromosomal Pattern : 

1. Turner’s syndrome (45x)
2. Various mosaic states (45x / 46xx)
3. Pure gonadal dysgenesis (46xx / 46xy)
4. Androgen insensitivity syndrome, 46 XY
5. Partial deletions of the X chromosome (46XX).

=Developmental defect of genital tract : 

1. Imperforate hymen
2. Transverse vaginal septum
3. Atresia of upper third of vagina and cervix
4. Complete absence of vagina
5. Absence of uterus
6. MRKH syndrome

=Dysfunction of thyroid and adrenal cortex : 

1. Adrenogenital syndrom
2. Certinism

=Metabolic disorders : Juvenile diabetes.

=Systemic illness : 

1. Malnutrition
2. Anaemia
3. Weight loss.
4. Tuberculosis.

=Unresponsive endometrium : Congenital : Uterine synechiae.

General Advice of amenorrhea .: 

1. Improvement of general health by proper diet.
2. Reassurance.
3. Psychotherapy
4. Weight reduction by correction of errors in diet
5. Correction of home environment and working environment