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Amenorrhoea is defined as the absence of menstruation (regular periods) in women of reproductive age. It can be primary or secondary. It is distinctly different from oligomenorrhoea – which is the presence of irregular periods.

Physiological amenorrhoea occurs during pregnancy and breastfeeding. It is also often seen with many types of hormonal contraception.


Primary Amenorrhoea

This occurs when the patient has never had a period
This should be investigated in:

  • 14 year old girls with no breast development
  • 15 year old girls

The most common cause is late puberty (which is often familial), and you can reassure parents and patients that this is most likely the case.

When to consider further investigation

  • Are the external genitalia normal?
  • If so, are the internal genitalia normal?
  • Consider genotypic karyotyping for:
    • Turner’s Syndrome
    • Testicular feminization

True primary amenorrhoea is often caused by either congenital absence or underdevelopment of the ovaries or uterus.


Secondary Amenorrhoea

Common causes – the hypothalamic – pituitary – ovarian axis can be easily unbalanced by many things, including:
  • Emotional distress
  • Weight loss / low body weight – a body fat percentage of <17% is associated with amenorrhoea
  • Excessive exercise
  • Systemic disease
  • Hyperthyroidism
  • Drug Induced – commonly by contraceptive agents (particularly progesterone only), anti-psychotics, and women taking long term opiates

Other things to consider

Rare causes include:

  • Pituitary tumours
  • Pituitary necrosis
  • Early menopause occurs in about 1% of patients


Blood Tests
  • FSH – may be very high in premature menopause
  • Testosterone – may be raised in polycystic ovarian syndrome
  • LH – may be raised in polycystic ovarian syndrome
  • TFT’s – amenorrhoea may be due to Hyperthyroidismalso note that hypothyroidism can cause the opposite effect: menorrhagia


This essentially involves treating the underlying cause. In women who do not plan on having any biological children treatment may not be required.


  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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