Amennorhea

• Girls have experienced menarche at increasingly younger ages during the past century. To continue to represent two standard deviations above the mean age for development of secondary sexual characteristics and menses, respectively, the age limitations defining primary amenorrhea have been lowered. Primary amenorrhea is now defined as absence of menses at age 13 years when there is no visible secondary sexual characteristic development or age 15 years in the presence of normal secondary sexual characteristics. A woman who has previously menstruated can develop secondary amenorrhea, which is defined as absence of menstruation for three normal menstrual cycles or 6 months.
• When premature gonadal failure occurs in conjunction with primary amenorrhea, it is associated with a relatively high incidence of genetic abnormalities (30%).
• The anatomic causes of amenorrhea are relatively few, and the majority may be diagnosed by history and physical examination.
• The most important elements in the diagnosis of amenorrhea include physical examination for secondary sexual characteristics and anatomic abnormalities, measurement of human chorionic gonadotropin (hCG) to rule out pregnancy, and assessment of follicle-stimulating hormone (FSH) levels to differentiate between hypergonadotropic and hypogonadotropic forms of hypogonadism.
• Therapeutic measures may include specific therapies (medical or surgical) aimed at correcting the primary cause of amenorrhea, hormone replacement to initiate and maintain secondary sexual characteristics and provide symptomatic relief, treatments aimed at maintenance of bone mass (bisphosphonates), and ovulation induction for patients desiring pregnancy.
  
  

  

  
  

  
  
  Amenorrhea without Secondary Sexual Characteristics
          Abnormal physical examination
          Hypergonadotropic hypogonadism
          Hypogonadotropic hypogonadism
          
  Amenorrhea with Secondary Sexual Characteristics and Anatomic Abnormalities
          Mullerian anomalies
  
          Androgen insensitivity
          true hermaphrodites(자웅동체)
  
          absent endometrium
          Asherman's syndrome(자궁내강유착증)
          IUD
  
  
  Amenorrhea with Secondary Sexual Characteristics and Nonanatomic Causes
      Ovarian failure
          Chromosomal etiology
          Iatrogenic causes
          Infections
          Autoimmune
          Galactosemia
          Savage syndrome(Gonadotropin-resistant ovary syndrome)
          Cigarette smoking
  
  
      Pituitary and hypothalamic lesions
  
          Pituitary and hypothalamic
  
              Craniopharyngioma

  Craniopharyngioma

  Germinoma

  Tubercular granuloma

  Sarcoid granuloma

  Dermoid cyst

  
  
          Pituitary
  
              Nonfunctioning adenomas

  Hormone-secreting adenomas

  Prolactinoma

  Cushing's disease

  Acromegaly

  Primary hyperthyroidism

  Infarction

  Lymphocytic hypophysitis

  Surgical or radiologic ablations

  Sheehan's syndrome

  Diabetic vasculitis

  
  
  
  
      Abnormalities Affecting Release of Gonadotropin-releasing Hormone
  
          Variable estrogen status
  
              Anorexia nervosa
              Exercise induced
              Pseudocyesis
              Malnutrition
              Chronic disease
              Hyperprolactinemia
              Thyroid dysfunction
  

  
  

          Euestrogen status
  
            Obesity
            Hyperandrogenism
              Cushing's syndrome
              Congenital adrenal hyperplasia
              Androgen secreting adrenal tumors
              Androgen secreting ovarian tumors
            Granulosa cell tumor
  
  
  

  Obesity

  Hyperandrogenism

  Polycystic ovary syndrome

  Cushing's syndrome

  Congenital adrenal hyperplasia

  Androgen-secreting adrenal tumors

  Androgen-secreting ovarian tumors

  Granulosa cell tumor

  Idiopathic

  
  
  
  
  
  
  
  
  *무월경의 work up

1. urine hCG

2. serum PRL, TSH

3. Progesterone challenge test

4. Estrogerone challenge test

5. FSH