CAUSES OF REAL AMENORRHOEA :
1. PHYSIOLOGICAL
* BEFORE PUBERTY
* AFTER MENOPAUSE
* DURING PREGNANCY
* DURING LACTATION
2. PATHOLOGICAL
A. GENITAL SYSTEM :
* CONGENITAL ABSENCE OF UTERUS
* CONGENITAL ABSENCE OF OVARIES
* UTERINE HYPOPLASIA
* OVARIAN AGENESIS
* GONADAL DYSGENESIS ( TURNER SYNDROME )
* DESTRUCTION OF BOTH OVARIES BY DOUBLE OVARIAN GROWTH, PELVIC INFLAMMATION, OPERATION, RADIATION
* HYSTERECTOMY
B. CIRCULATORY SYSTEM :
* ANEMIA
* LEUKEMIA
* HODGKINS DISEASE
C. WASTING CONDITIONS :
* MALIGNANT GROWTH
* TUBERCULOSIS
* PROLONGED SUPPURATION
* DIABETES
* LATE STAGES OF NEPHRITIS
* LATE STAGE OF SOME FORM OF HEART DISEASE
* LATE STAGE OF LIVER CIRRHOSIS
D . NERVOUS SYSTEM :
* CRETINISM
* VARIOUS FORMS OF INSANITY
* ANOREXIA NERVOSA OR LOSS OF WT.
* SUGGESTION-FEAR OF PREGNANCY
E . ALTERED INTERNAL SECRETIONS :
* PRIMARY HYPOTHALAMIC PITUTARY FAILURE
* ORAL CONTRACEPTIVES
* ANT. PITUTARY FAILURE ( SIMMOND DISEASE )
* ABSENCE OF OVARIAN HORMONES
* CERTAIN RATE FUNCTIONING TUMORS OF OVARY LIKE ARRHENOBLASTOMA, GRANULOSA CELL TUMOR
* STEIN-LEVENTHAL SYNDROME
* MYXOEDEMA
* ADDISONS DISEASE
* THYROTOXICOSIS
* ADRENAL HYPERPLASIA
* ADRENAL CORTICAL TUMORS
* ACROMEGALY
* OBESITY
* DYSTROPHIA ADIPOSE-GENITALIS
* EMOTIONAL STRAIN
* CLIMATIC CHANGE
* DIETETIC DEFICIENCIES
F . TOXIC
* DURING & AFTER SPECIFIC FEVERS
* CHRONIC POISONING BY LEAD, MERCURY, ALCOHOL & MORPHINE
CAUSES OF APPARENT AMENORRHOEA
* IMPERFORATE VAGINA, HYMEN, CERVIX
* ABSENCE OF VAGINA
* DOUBLE UTERUS WITH RETENTION
* HAEMATOCOLPOS
* HAEMATOMETRA
* HAEMATOSALPINX
OTHER TESTS :
* 200 MG PROGESTERONE IN OIL ( A PROGESTATIONAL AGENT WHICH HAS NO OESTROGEN ACTIVITY) SHOULD BE GIVEN I.M. , OR 10 MG MEDROXYPROGESTERONE ACETATE BY MOUTH FOR 5 DAYS, IF BLEEDING OCCURS WITH 2-7 DAYS OF STOPPING TREATMENT, IT SHOWS THAT THERE IS FUNCTIONAL UTERUS WITH REACTIVE ENDOMETRIUM. IF THERE IS NO GALACTORRHOEA & SERUM PROLACTIN IS NORMAL, NO FURTHER TESTS ARE REQUIRED.
* IF SERUM PROLACTIN IS RAISED WITH GALACTORRHOEA, CT SCAN OF HEAD IS DONE TO SEE SELLA TURSICA FOR EVIDENCE OF PROLACTINOMA.
* IF BLEEDING DOESNT OCCUR AFTER PROGESTERONE INJ. THERE MAY BE ABNORMALITY OF UTERUS OR VAGINA LIKE CONGENITAL ABSENCE , VAGINAL ATRESIA , TESTICULAR FEMINIZATION , ASHERMAN SYNDROME. CONFIRMATION OF THESE CONDITIONS IS OBTAINED BY PRIMING THE ENDOMETRIUM WITH OESTROGEN ( 20 MCG ETHINYL OESTRADIOL DAILY FOR 20 DAYS ) BEFORE ADDING PROGESTERON & NO BLEEDING WILL OCCUR. IF BLEEDING OCCURS WITH EOSTROGEN + PROGESTERONE COMBINATION & NOT WITH PROGESTERONE ALONE, THE FAULT LIES IN THE OVARIES, PITUITARY OR HYPOTHALAMUS.
* SERUM GONADOTROPHINS SHOULD BE MEASURED - A RAISED FSH & LH LEVELS INDICATE OVARIAN FAILURE WITH ABSENT FOLLICLES FROM A PREMATURE MENOPAUSE, TURNER SYNDROME , OTHER FORMA OF OVARIAN DYSGENESIS , OVARIAN AGENESIS ( VERY RARE ) , RESISTANT OVARY SYNDROME
* IF PELVIC ORGANS, PROLACTIN LEVELS , CT SKULL & GONADOTROPHINS ARE NORMAL, THE AMENORRHOEA THEN BEING HYPOTHALAMIC IN ORIGIN WHICH MOST COMMONLY FOLLOWS WEIGHT LOSS OR CONTRACEPTIVE PILLS.