Etiologies of amenorrhea are categorized by where in the hormone cascade the lesion is.

Absence of menses for 3 to 6 months is defined as oligomenorrhea.

When diagnosing amenorrhea, always rule out pregnancy first.

Hypothalamic Causes of Amenorrhea

All hypothalamic causes result in X FSH/LH levels:

■ Kallman's syndrome: Congenital lack of GnRH

■ Pituitary stalk compression: Tumors, granulomas, irradiation

■ X GnRH release: Stress, anorexia, hyperprolactinemia, severe weight loss, extreme exercise

Pituitary Causes of Amenorrhea

All pituitary causes result in X FSH/LH levels:

■ Sheehan's syndrome: Pituitary infarction resulting from hypotension during delivery, usually resulting from hemorrhage

■ Tumors: Either compress stalk (as above) or are prolactin-secreting tumors

■ Hemosiderosis: Iron deposition in pituitary that impairs its function

Ovarian Causes of Amenorrhea

All ovarian causes result in T FSH/LH levels:

■ Premature ovarian failure: Menopause before age 35

■ Savage's syndrome: Ovarian resistance to FSH/LH

■ Enzyme defects: Most commonly 17a-hydroxylase deficiency

■ Turner's syndrome (XO karyotype): Ovarian dysgenesis

■ Polycystic ovary disease (PCOD): T Estrogen levels cause which cause abnormal follicular growth and androgen secretion.

Uterine Causes of Amenorrhea

■ Imperforate hymen

■ Uterine causes have normal levels of FSH/LH

■ Congenital absence of uterus

■ Asherman's syndrome: Uterine scarring and adhesions following dilation and curettage (D&C)

Progestin challenge test:

Give progestin for 5 days and then stop. This stimulates progesterone withdrawal. If ovaries are secreting estrogen, sloughing will occur and menses results. No menses indicates no ovaries, no estrogen, or blood flow obstruction.

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