Amenorrhea
L. Allen Dobson, Jr.
Pregnancy is the most common cause of amenorrhea. Evaluation and diagnosis of the other causes of amenorrhea are possible by use of a simple workup scheme (section V).
Approach
Cyclic menstrual bleeding requires an intact hypothalamic-pituitary-ovarian axis, functioning ovaries, a responsive uterine endometrium, and an unobstructed outflow tract. Localizing the specific site of defect is the goal of evaluation.
A. Definitions. Any patient who meets the following definitions of amenorrhea should be evaluated. The differentiation between primary and secondary amenorrhea does not alter the basic evaluation scheme.
1. No bleeding by age 14 years in the absence of growth or development of secondary sexual characteristics.
2. No menstrual periods by age 16 years, regardless of the presence of normal growth and development, with the appearance of secondary sexual characteristics.
3. In a woman who has been menstruating, the absence of periods for a length of time equivalent to a total of at least three of the previous cycles, or 6 months of amenorrhea (1).
B. Considerations. Next to pregnancy, disorders of the hypothalamic-pituitary-ovarian axis are the most common causes of amenorrhea (2). Strict adherence to the aforementioned definitions should not delay evaluation in the presence of obvious characteristics of Turner’s syndrome or abnormal genital anatomy.
History
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).
Testing
A. Clinical laboratory tests. Serum or urine human chorionic gonodotropin, thyroid-stimulating hormone, prolactin, follicle-stimulating hormone, and luteinizing hormone are usually the only tests required to make a diagnosis (section V). Additional tests for premature ovarian failure should include free thyroxine (T4), thyroid antibodies, morning cortisol, calcium, phosphorus and antinuclear antibody, rheumatoid factor, erythrocyte sedimentation rate, and a complete blood count. Further adrenal evaluation of women who exhibit signs of hyperandrogenism with anovulation (“hyperandrogenic chronic anovulation”) includes fasting serum testosterone, dehydroepiandrosterone (DHEA)-S, and 17-hydroxyprogesterone (17-HP).
B. Other laboratory evaluation. Karotyping is indicated in all women with premature ovarian failure prior to age 30 years or with any physical evidence suggestive of Turner’s syndrome (short stature, web neck, shield-shaped chest, lack of secondary sexual characteristics) (3). Endometrial biopsy should be considered in women with prolonged amenorrhea or with evidence of estrogen or androgen excess to exclude endometrial hyperplasia.
C. Provocative tests
1. Progesterone challenge test. Oral progesterone acetate (10 mg daily for 15 days). A positive test is withdrawal bleeding between days 2 and 7 after finishing medication; alternatively, parenteral progesterone (200 mg) in oil or micronized progesterone 200 mg at bedtime.
2. Estrogen-progesterone challenge test. Oral conjugated estrogen (1.25 mg) or 2 mg estadiol qd for days 1 through 21 with oral progesterone acetate (10 mg) on days 17 through 21. A positive test is withdrawal bleeding between days 2 and 7 after finishing medication.
D. Diagnostic imaging. A coned lateral view of the sella turcica is indicated as a screening examination for galactorrhea if the prolactin level is less than 100 ng/ml. A magnetic resonance imaging scan, which is more sensitive, is indicated for elevated prolactin, abnormal screening x-ray film, or diagnosis of hypothalamic amenorrhea (section V).
Diagnostic assessment
Use the approach outlined in Figure 11.1 to guide diagnosis (1–3).
References
1. Speroff L, Glass RH, Kase NG. Clinical gynecologic endocrinology and infertility, 5th ed. Baltimore: Williams & Wilkins, 1994:401–456.
2. Kiningham RB, Apgar BS, Swenk TL. Evaluation of amenorrhea. Am Fam Physician 1996;53:1185–1194.
3. Scott J, DiSaia P, Hammond C, Spellacy W, eds. Danforth’s obstetrics and gynecology, 7th ed. Philadelphia: JB Lippincott, 1994:665–679.
4. Alper MM, Garner PR. Premature ovarian failure: its relationship to autoimmune disease. Obstet Gynecol 1985;66:27–30.
Pictures
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Menstrual irregularities
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