Amenorrhoea is not as common a problem as heavy and painful periods but is often poorly understood and managed. Amenorrhoea is a symptom that requires investigation and not a diagnosis in itself.

AMENORRHOEA

Primary: girl has never experienced a menstrual period

Secondary: periods have been absent for 6 months or more.

Causes of primary amenorrhoea

The causes of primary amenorrhoea are considered differently, depending on whether or not secondary sexual characteristics are present (Figure 6.1). In girls with no secondary sexual characteristics, the cause is usually hormonal, whereas in girls with normal pubertal development the cause is usually anatomical.

As a general rule, girls who have primary amenorrhoea with no secondary sexual characteristics should be investigated by the age of 14 years. Common causes include:

1. • constitutional delay

2. • chronic systemic disease

3. • absence of ovarian function

4. • hypothalamic pituitary dysfunction.

CONSTITUTIONAL DELAY

These girls have delayed maturation of the hypothalamic—pituitary—ovarian axis, with resultant delay in the whole process of puberty. There is frequently a family history of similar symptoms in the mother or older siblings. Examination shows a normal relationship between skeletal growth and sexual maturity. Hormone profile shows low levels of FSH, LH and estradiol. Estimation of bone age, if performed, will show delayed skeletal maturation with the bone age being behind the chronological age. Ultrasound examination of the ovaries may be helpful, as the finding of follicles in the ovaries is reassuring and confirms the presence of gonadotrophin activity.