Amenorrhoea: investigation and treatment

Amenorrhoea and severe oligomenorrhoea are frequently seen in gynaecological practice. Appropriate investigation and treatment are best organised from an anatomical standpoint, with rapid and cost-effective assessment of each level of the hypothalamo–pituitary–ovarian–uterine axis. Investigation should also be tailored to meet the needs of the patient—a young woman with primary amenorrhoea and little secondary sexual development has very different concerns and potential diagnoses from an anovular infertile 30-year-old with secondary amenorrhoea. Whilst the commoner diagnoses of polycystic ovary syndrome (PCOS), premature ovarian failure and prolactinoma are easily made and involve evidence-based treatment, the rarer causes of amenorrhoea may escape diagnosis unless the clinician is sufficiently alert to detect anomalous results of investigations. Treatment of amenorrhoea depends on the cause—key areas are the induction and maintenance of menstruation in young women with amenorrhoea, and induction of ovulation for the infertile amenorrhoeic patient. Premature ovarian failure warrants consideration of hormone replacement therapy up to the age of natural menopause.