Confirming diagnosis A history of failure to menstruate in a female older than age 18 confirms primary amenorrhea.
Secondary amenorrhea can be diagnosed when a change is noted in a previously established menstrual pattern (absence of menstruation for 3 months). A thorough physical and pelvic examination rules out pregnancy, as well as anatomic abnormalities such as cervical stenosis that may cause false amenorrhea (cryptomenorrhea), in which menstruation occurs without external bleeding.
Onset of menstruation within 1 week after administration of pure progestational agents, such as medroxyprogesterone and progesterone, indicates a functioning uterus. If menstruation doesn’t occur, special diagnostic studies are appropriate.
Blood and urine studies may reveal hormonal imbalances, such as lack of ovarian response to gonadotropins (elevated pituitary gonadotropins), failure of gonadotropin secretion (low pituitary gonadotropin levels), and abnormal thyroid levels. Tests for identification of dominant or missing hormones include cervical mucus ferning, vaginal cytologic examinations, basal body temperature, endometrial biopsy (during dilatation and curettage), urinary 17-ketosteroids, and plasma progesterone, testosterone, and androgen levels. A complete medical workup, including appropriate X-rays, laparoscopy, and a biopsy, may detect ovarian, adrenal, and pituitary tumors. (See Diagnosing amenorrhea.)
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Oligomenorrhea:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
After asking the patient’s age, find out when menarche occurred. Has the patient ever experienced normal menstrual cycles? When did she begin having abnormal cycles? Ask her to describe the pattern of bleeding. How many days does the bleeding last, and how frequently does it occur? Are there clots and tissue fragments in her menstrual flow? Note when she last had menstrual bleeding.
Next, determine if she’s having symptoms of ovulatory bleeding. Does she experience mild, cramping abdominal pain 14 days before she bleeds? Is the bleeding accompanied by premenstrual symptoms, such as breast tenderness, irritability, bloating, weight gain, nausea, and diarrhea? Does she have cramping or pain with bleeding? Also, check for a history of infertility. Does the patient have any children? Is she trying to conceive? Ask if she’s currently using hormonal contraceptives or if she’s ever used them in the past. If she has, find out when she stopped taking them.
Then ask about previous gynecologic disorders such as ovarian cysts. If the patient is breast-feeding, has she experienced any problems with milk production? If she hasn’t been breast-feeding recently, has she noticed milk leaking from her breasts? Ask about recent weight gain or loss. Is the patient less than 80% of her ideal weight? If so, does she claim that she’s overweight? Ask if she’s exercising more vigorously than usual.
Screen for metabolic disorders by asking about excessive thirst, frequent urination, or fatigue. Has the patient been jittery or had palpitations? Ask about headache, dizziness, and impaired peripheral vision. Complete the history by finding out what drugs the patient is taking.
Begin the physical examination by taking the patient’s vital signs and weighing her. Inspect for increased facial hair growth, sparse body hair, male distribution of fat and muscle, acne, and clitoral enlargement. Note if the skin is abnormally dry or moist, and check hair texture. Also, be alert for signs of psychological or physical stress. Rule out pregnancy by a blood or urine pregnancy test.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Amenorrhea:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin by determining whether the amenorrhea is primary or secondary. If it’s primary, ask the patient at what age her mother first menstruated because age of menarche is fairly consistent in families. Form an overall impression of the patient’s physical, mental, and emotional development because these factors as well as heredity and climate may delay menarche until after age 16.
If menstruation began at an appropriate age but has since ceased, determine the frequency and duration of the patient’s previous menstrual cycles. Ask her about the onset and nature of any changes in her normal menstrual pattern, and determine the date of her last menses. Find out if she has noticed any related signs, such as breast swelling or weight changes.
Determine when the patient last had a physical examination. Review her health history, noting especially any long-term illnesses, such as anemia, or use of hormonal contraceptives. Ask about exercise habits, especially running, and whether she experiences stress on the job or at home. Probe the patient’s eating habits, including number and size of daily meals and snacks, and ask if she has gained weight recently.
Observe her appearance for secondary sex characteristics or signs of virilization. If you’re responsible for performing a pelvic examination, check for anatomic aberrations of the outflow tract, such as cervical adhesions, fibroids, or an imperforate hymen.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Amenorrhea:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Menstrual and reproductive history. What was the patient’s age at menarche? When was the patient’s last menstrual period and her previous menstrual pattern? Document pregnancy history with attention to any complications. Is there a history of gynecologic or obstetric procedures?
1. A history of postpartum infection or curettage (Asherman’s syndrome) may suggest destruction of the endometrium and subsequent outflow tract problem.
2. A history of severe postpartum bleeding requiring transfusion may suggest pituitary failure (Sheehan’s syndrome).
B. Other history. Were there any significant medical or psychosocial events preceding amenorrhea? Is there any galactorrhea? Does the patient have any endocrine, metabolic, or eating disorders? Is there a history of recent weight gain or loss? Document the medication history. Is there a history of prolonged and intense exercise? Is there a family history of menstrual problems or endocrine or autoimmune disorders (Section 14)?
1. Stressful situations or events are often associated with amenorrhea (3).
2. The incidence of amenorrhea is greatest among competitive endurance athletes and ballet dancers (2).
3. Premature ovarian failure can be caused by autoimmune disease (4).
4. Medications associated with amenorrhea include antipsychotics, tricyclic antidepressants, calcium channel blockers, methyldopa, reserpine, digitalis, and chemotherapeutic drugs.
Physical examination
The purpose of the focused examination is to screen for abnormal anatomy or development and signs of endocrinopathies. A breast examination should document the presence or absence of galactorrhea which, with hair distribution, should provide an evaluation of normal secondary sexual characteristics (Tanner stage). Palpate the thyroid for enlargement or nodules. A careful pelvic examination is essential to detect any structural abnormalities or lesions. Signs of possible androgenic excess are truncal obesity, hirsutism, acne, male pattern baldness, and clitoral enlargement (Chapter 14.3).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Secondary Amenorrhea:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Pregnancy
❑ Menopause
❑ Functional hypothalamic amenorrhea
❑ Drugs
❑ Anorexia nervosa
❑ Post-contraceptive
❑ Endometrial scarring
❑ Endocrinopathy
❑ Hyperprolactinemia
❑ Premature ovarian failure
❑ Polycystic ovary syndrome
❑ Chromophobe adenoma
❑ Ovarian tumors
❑ Panhypopituitarism
❑ Müllerian dysgenesis
Diagnostic Approach
Evaluation should always begin with a history and a urine hCG for pregnancy. On physical examination, attention should be paid to darkening of the areola, and evidence of estrogenization of the vagina.
Estrogen sufficiency can be assessed by observing a fern-like pattern of cervical mucous on a slide or by giving medroxyprogesterone for 5 days and looking for withdrawal bleeding. Bleeding suggests suppression of LH surge as seen in functional amenorrhea or polycystic ovary syndrome.
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Source: Field Guide to Bedside Diagnosis, 2007
Oligomenorrhea:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
After asking the patient’s age, find out when menarche occurred. Has the patient ever experienced normal menstrual cycles? When did she begin having abnormal cycles? Ask her to describe the pattern of bleeding. How many days does the bleeding last, and how frequently does it occur? Are there clots and tissue fragments in her menstrual flow? Note when she last had menstrual bleeding.
Next, determine if she’s having symptoms of ovulatory bleeding. Does she experience mild, cramping abdominal pain 14 days before she bleeds? Is the bleeding accompanied by premenstrual symptoms, such as breast tenderness, irritability, bloating, weight gain, nausea, and diarrhea? Does she have cramping or pain with bleeding? Also, check for a history of infertility. Does the patient have any children? Is she trying to conceive? Ask if she’s currently using hormonal contraceptives or if she has ever used them in the past. If she has, find out when she stopped taking them.
CULTURAL CUE:Be sensitive when you ask questions about sexual activity. In many cultures, women may be reluctant to discuss sexual matters with others.
Then ask about previous gynecologic disorders such as ovarian cysts. If the patient is breast-feeding, has she experienced any problems with milk production? If she hasn’t been breast-feeding recently, has she noticed milk leaking from her breasts? Ask about recent weight gain or loss. Is the patient less than 80% of her ideal weight? If so, does she claim that she’s overweight? Ask if she’s exercising more vigorously than usual.
Screen for metabolic disorders by asking about excessive thirst, frequent urination, or fatigue. Has the patient been jittery or had palpitations? Ask about headache, dizziness, and impaired peripheral vision. Complete the history by finding out what drugs the patient is taking.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Amenorrhea:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin by determining whether the amenorrhea is primary or secondary. If it’s primary, ask the patient at what age her mother first menstruated because age of menarche is fairly consistent in families. Form an overall impression of the patient’s physical, mental, and emotional development because these factors as well as heredity and climate may delay menarche until after age 16.
If menstruation began at an appropriate age but has since ceased, determine the frequency and duration of the patient’s previous menses. Ask her about the onset and nature of any changes in her normal menstrual pattern, and determine the date of her last menses. Find out if she has noticed any related signs, such as breast swelling or weight changes.
Determine when the patient last had a physical examination. Review her health history, noting especially any long-term illnesses such as anemia or use of hormonal contraceptives. Ask about exercise habits, especially running, and whether she experiences stress on the job or at home. Probe the patient’s eating habits, including the number and size of daily meals and snacks, and ask if she has gained weight recently.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Oligomenorrhea:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
After asking the patient's age, find out when menarche occurred. Has the patient ever experienced normal menstrual cycles? When did she begin having abnormal cycles? Ask her to describe the pattern of bleeding. How many days does the bleeding last, and how frequently does it occur? Are there clots and tissue fragments in her menstrual flow? Note when she last had menses.
Next, determine if she's having symptoms of ovulatory bleeding. Does she experience mild, cramping abdominal pain 14 days before she bleeds? Is the bleeding accompanied by premenstrual symptoms, such as breast tenderness, irritability, bloating, weight gain, nausea, and diarrhea? Does she have cramping or pain with bleeding? Also, check for a history of infertility. Does the patient have children? Is she trying to conceive? Ask if she's currently using hormonal contraceptives or if she has ever used them in the past. If she has, find out when she stopped taking them.
Then ask about previous gynecologic disorders such as ovarian cysts. If the patient is breast-feeding, has she experienced problems with milk production? If she hasn't been breast-feeding recently, has she noticed milk leaking from her breasts? Ask about recent weight gain or loss. Is the patient less than 80% of her ideal weight? If so, does she claim that she's overweight? Ask if she's exercising more vigorously than usual.
Screen for metabolic disorders by asking about excessive thirst, frequent urination, or fatigue. Has the patient been jittery or had palpitations? Ask about headaches, dizziness, and impaired peripheral vision. Complete the history by finding out what drugs the patient is taking.
Begin the physical examination by taking the patient's vital signs and weighing her. Inspect for increased facial hair growth, sparse body hair, male distribution of fat and muscle, acne, and clitoral enlargement. Note if the skin is abnormally dry or moist, and check hair texture. Also, be alert for signs of psychological or physical stress. Rule out pregnancy by a blood or urine pregnancy test.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Amenorrhea:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin by determining whether the amenorrhea is primary or secondary. If it's primary, ask the patient at what age her mother first menstruated because age of menarche is fairly consistent in families. Form an overall impression of the patient's physical, mental, and emotional development because these factors as well as heredity and climate may delay menarche until after age 16.
If menstruation began at an appropriate age but has since ceased, determine the frequency and duration of the patient's previous menses. Ask her about the onset and nature of any changes in her normal menstrual pattern, and determine the date of her last menses. Find out if she has noticed any related signs, such as breast swelling or weight changes.
Determine when the patient last had a physical examination. Review her health history, noting especially any long-term illnesses, such as anemia, or use of hormonal contraceptives. Ask about exercise habits, especially running, and whether she experiences stress on the job or at home. Ask about the patient's eating habits, including the number and size of daily meals and snacks, and ask if she has gained or lost weight recently.
Observe her appearance for secondary sex characteristics or signs of virilization. If you're responsible for performing a pelvic examination, check for anatomic aberrations of the outflow tract, such as cervical adhesions, fibroids, or an imperforate hymen.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
HYPOMENORRHEA AND AMENORRHEA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Obviously the first thing to do is rule out pregnancy both by
examination and a pregnancy test, preferably the serum β -subunit human
chorionic gonadotropin (HCG). One must keep an ectopic pregnancy in mind
even if the examination is normal and plan follow-up examinations and
ultrasonography should the situation warrant. Altered secondary sex
characteristics should be noted. If the examination fails to show evidence
of pregnancy, congenital anomalies, or tumors of the ovaries, the physician should order thyroid
function studies, a Wassermann test, CBC, and sedimentation rate. If these
tests are normal, a gynecologist should be consulted. The gynecologist may
give a test dose of intramuscular progesterone to prove that the endometrium
functions well. He or she may do a D & C first. Then serum or urine FSH,
LH, and prolactin levels are done; if the FSH level is high, the ovary is
probably the site of the trouble. If the levels are low, even after
gonadotropin-releasing factor (GRF) is administered, the pituitary is
responsible. X-rays of the skull, CT scans, culdoscopy, and exploratory
laparotomy all share their place in the workup.
CASE PRESENTATION #52
A 34-year-old white mother of three complained of amenorrhea and weight
loss. A pregnancy test was negative. She has been under a lot of emotional
distress for several months and has lost her appetite.
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