There is considerable difficulty in defining the term primary amenorrhoea, other than the obvious statement that it is the failure to establish menstruation. The difficulty of definition relates to the time frame in which this definition is applied. To look at primary amenorrhoea as an isolated event is misleading as it is part of the whole development of puberty. Of the five changes that occur at puberty, menstruation is but one and may normally occur any time between ages 10 and 18 years. However, it occurs in conjunction with the development of other secondary sexual characteristics. It is therefore more useful to look upon secondary sexual development as the criteria for investigation and management in association with primary amenorrhoea. As a general rule, therefore, failure of the development of any secondary sexual characteristic by the age of 14 years should be investigated. In the presence of secondary sexual characteristics, menstruation ought to occur within 2 years of the establishment of this development. Failure to do so would warrant investigation. However, any child brought by its mother at any stage because of concern over the failure to establish either secondary sexual characteristics or menstruation should be investigated at that time. There are usually very good reasons why a mother will bring her daughter for investigation. This often relates to the fact that a sibling completed her pubertal development at an earlier age than the patient. While investigations may not lead to a diagnosis of abnormality, the proof of normality is also extremely important (Figs 38.1 and 38.2). It can be seen therefore that the term primary amenorrhoea is really not very meaningful in terms of definition, and a more useful term would be delayed puberty. This term encompasses the completion of the processes involved in reaching sexual maturity and allows a much more pragmatic approach to the management.
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The first trimester is very important for the mother and the baby. For most women it is common to find out about their pregnancy after they have missed their menstrual cycle. Since, not all women note their menstrual cycle and dates of intercourse, it may cause slight confusion about the exact date of conception. That is why most women find out that they are pregnant only after one month of pregnancy.