Amenorrhea

1. Primary amenorrhea
2. Secondary amenorrhea

Primary amenorrhea

never seen menses by 14 with no secondary sexual characteristics (or)

no menses by age 16 who has developed secondary sexual characteristics

The evaluation for primary amenorrhea with normal breast development should start at age 15.

If no breast development or menses has occured by the age of 13, evaluation is warranted.

1st step is to check uterus (by ultrasound)

If uterus is absent; it could be

1. Mullerian agenesis (XX)
   • upper part - ovaries and tubes are present -> estrogen >> secondary sexual characteristics
   • Tx - create vagina
2. Androgen insensitivity (XY)
   • grow up like girls; have secondary sexual characteristics
   • testes secrete estrogen too
   • Tx - remove testes; estrogen

2nd step -  check breast (thelarche) means, no estrogen

1. Turner's syndrome (XO)
   • streak gonards --> no estrogen --> increased FSH
2. HPA
   • low FSH --> no follicles --> no estrogen
   • P° cause - Kallman's syndrome
   • 2° cause - anorexia, exercise, stress, craniopharyngioma

Breast/Uterus +, then could be anatomical

1. Vaginal agenesis/ septa
2. imperforate hymen