AMENORRHEA

Question 1

Amenorrhea

Answer 1

• Primary amenorrhea
  o Failure to menstruate by age 14 in girls with no secondary sex characteristics or by age 16 in girls with secondary sex characteristics
• Secondary amenorrhea
  o Absence of menstruation for 3 or more consecutive months in women who have achieved menarche

Question 2

Amenorrhea: Causes

Answer 2

• Primary amenorrhea
  o Congenital defects of gonadotropin production
  o Genetic disorders (Turner’s syndrome)
  o Congenital CNS defects
  o Congenital anatomical malformations
• Secondary amenorrhea
  o Pregnancy
  o Anovulation caused by neuroendocrine dysfunction
  o Disruption in hypothalamus, pituitary gland, and ovary or outflow tract
  o Stress, weight changes, nutrition, strenuous exercise

Question 3

Amenorrhea: Clinical Presentation

Answer 3

• Menstrual, obstetrical, nutritional, and family history
• Pregnancy history and outcomes
• Presence or absence of secondary sex characteristics (ddx Turner’s)
• Medications being taken
• Neurological exam
• Thyroid exam
• Pelvic and rectal exams (ovarian masses)

Question 4

Amenorrhea: Diagnostic Testing

Answer 4

• Urine pregnancy test***
• Baseline blood chemistry profiles (liver?)
• Thyroid function tests (TSH, T4)
• Vaginal smears
• FSH, LH, and prolactin levels
• Androgen studies
• Progesterone challenge test
  o Indirectly provides information regarding outflow tract patency

Question 5

Amenorrhea: Differential Diagnosis

Answer 5

• Pregnancy
• Menopause
• Premature ovarian failure
• Hyperprolactinemia relating to a tumor
• Stress
• Thyroid dysfunction
• Genetic or chromosomal-related problems
• PCOS

Question 6

Amenorrhea: Management

Answer 6

Goal is to initiate or restore menses while determining the cause
Primary amenorrhea
* Estrogen therapy to develop secondary sex characteristics and prevent osteoporosis
Secondary amenorrhea
* Oral contraceptives
* Periodic or cyclic progesterone 10 mg PO daily/10 days
PCOS (polycystic ovarian syndrome)
* Exercise, diet control of weight
* Metformin to treat underlying metabolic disorder
* Provera to start cycle and try for contraception
* Contraceptive therapy to prevent pregnancy, restart cycles

Question 7

Amenorrhea: Patient Education

Answer 7

• Reassurance and watchful waiting may be all that is needed
• Educate on medication regimen
• Stress importance of notifying health-care provider should new medications be taken because they can adversely affect the action of other meds