GPAtlas🧭 When to suspect
Suspect primary amenorrhoea in females who have not started menstruation by age 13 (if no secondary sexual characteristics are present) or by age 15 (if secondary characteristics are present).
Suspect secondary amenorrhoea if menstruation has stopped for ≥ 3 months (in previously regular cycles) or ≥ 6 months (in previously irregular cycles).
Patients may present with absent periods alongside symptoms such as galactorrhoea, hirsutism, acne, or significant weight changes. The most useful first step is to localise the problem to one of four levels – but in every case, pregnancy is the single most common cause of secondary amenorrhoea and must be excluded first.
| Level | Representative causes |
|---|---|
| Hypothalamic | Functional hypothalamic amenorrhoea (low weight, excessive exercise, stress); Kallmann syndrome (with anosmia). |
| Pituitary | Hyperprolactinaemia / prolactinoma; other pituitary tumours; Sheehan syndrome. |
| Ovarian | PCOS (the commonest cause of oligo/amenorrhoea); premature ovarian insufficiency; Turner syndrome. |
| Outflow / structural | Imperforate hymen; Müllerian agenesis (MRKH); Asherman syndrome; androgen insensitivity syndrome. |
| Other endocrine | Thyroid disease; Cushing's syndrome – and, in all cases, pregnancy. |
Source: NICE
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