Amenorrhea

Amenorrhea (absence of menses) can be transient, intermittent, or permanent. It may result from dysfunction of the hypothalamus, pituitary, ovaries, uterus, or vagina. Primary amenorrhea is the absence of menarche by age 16; secondary amenorrhea is the absence of menses in women previously menstruating for at least three cycles or 6 months. Differentiate amenorrhea from oligomenorrhea, in which menses are less frequent than normal.

Differential Diagnosis

Secondary amenorrhea

• More common than primary
• Hypothyroidism
• Pregnancy
• Polycystic ovarian syndrome
  –Peripubertal onset of menstrual irregularities with hyperandrogenism (hirsutism) and obesity
• Functional hypothalamic amenorrhea due to stress, eating disorders, weight loss, or excessive exercise
• Hyperprolactinemia
  –Galactorrhea
  –Secondary to medications (e.g., OCP, phenothiazines) or primary due to pituitary adenoma
  Primary amenorrhea
  • Constitutional delay of puberty
    –Family history of late puberty
    –Normal development at later age
  • Outflow tract disorders
    –Transverse vaginal septum
    –Imperforate hymen
    –Pelvic or lower abdominal pain are common presenting symptoms
  • Complete androgen insensitivity syndrome
    –X-linked recessive disorder (46,XY)
    –Resistance to testosterone due to a defect in the androgen receptor
    –Testes may be palpable in labia or inguinal area
  • Müllerian agenesis (Mayer-Rokitansky-Hauser syndrome)
    –Agenesis of fallopian tubes, uterus, vagina
    –Normally functioning ovaries
    Less common etiologies
    • Turner's syndrome
      –45,X gonadal dysgenesis
      –Ovaries replaced with fibrous tissue
    • Ovarian failure (autoimmune oophoritis or secondary to chemotherapy or radiation injury)
    • 5-αreductase deficiency
    • 17-αhydroxylase deficiency
    • Craniopharyngioma
    • Hypopituitarism
    • Congenital GnRH deficiency (Kallman's syndrome if associated with anosmia)
    • Cushing's syndrome

    Workup and Diagnosis

    • Complete history, physical, and pelvic examination
    • All patients require an initial pregnancy test—any woman with amenorrhea is considered pregnant until proven otherwise
    • Anatomic abnormalities should be excluded before performing an endocrine evaluation
      –Pelvic ultrasound will evaluate for the presence or absence of müllerian structures
  • Endocrine evaluation may include LH, FSH, estradiol, testosterone, prolactin, TSH, 17-hydroxyprogesterone, and DHEA-S levels
    –Elevated gonadotropins suggest ovarian failure
    –Elevated FSH indicates primary ovarian failure
    –Low FSH suggests functional hypothalamic amenorrhea or congenital GnRH deficiency
    –Elevated DHEA-S suggests adrenal insufficiency or tumor
    • Diagnostic administration of medroxyprogesterone acetate (“progesterone challenge test”) may be used; if estrogen levels are adequate, menstrual bleeding should occur within a week and diagnosis is chronic anovulation
    • Head MRI (or CT) is indicated if primary hypogonadotropic hypogonadism, elevated prolactin, visual field defects, or headaches are present
    • Karyotype analysis is diagnostic in some cases (e.g., Turner's syndrome)

    Treatment

    • Imperforate hymen requires surgical correction
    • Androgen insensitivity syndrome: Excise testes after puberty because of increased risk of testicular cancer
    • Absent müllerian structure or presence of Y chromosome: Psychological counseling
    • Ovarian failure: Consider hormone replacement therapy
    • Polycystic ovarian syndrome
      –Oral contraceptives decrease ovarian androgen secretion
      –Weight reduction decreases peripheral estrogen
      –Clomiphene to enhance fertility
      –Cyclic progesterone prevents endometrial hyperplasia
    • Functional hypothalamic amenorrhea
      –Weight gain and reduction in intensity of exercise
      –Consider oral contraceptives to prevent osteoporosis
      –Exogenous gonadotropins or pulsatile GnRH may be necessary

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Amenorrhea

Read excerpts from these other book chapters related to Amenorrhea:

Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Amenorrhea

• Back to symptom: Amenorrhea: Introduction (review 279 causes)
• Next Book Extract About Amenorrhea: Amenorrhea – Secondary (In A Page: Pediatric Signs and Symptoms)
• All Book Extracts: All Online Book Extracts for Amenorrhea

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: Amenorrhea – Secondary (In A Page: Pediatric Signs and Symptoms)

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