Amenorrhea


Article Author:
Gul Nawaz


Article Editor:
Alan Rogol


Editors In Chief:
Rhonda Coffman
Lindsay Iverson
Heather Templin


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
11/22/2018 1:12:02 PM

Introduction

Female menstrual cycle normally comprises a 28 to 30-day cycle, which contains 2 phases, the proliferative phase, and secretory phase. At the end of the cycle, the uterine lining starts shedding off which is a normal phenomenon of female menstruation.[1][2][3]

The absence of menstruation during the female during the reproductive ages of approximately 12 to 49 years is known as amenorrhea.

Etiology

Primarily amenorrhea is classified into 2 types determined by pathogenesis.[4]Primary amenorrhea is the absence of initiation of menses, and secondary amenorrhea is an absence of menses in a previously normal menstruating female. There are many other types of classification of amenorrhea based on the anatomy of female reproductive organs, but this is the most accepted form of classifying the causes of amenorrhea.

Epidemiology

Amenorrhea is not life-threatening, but the loss of the menstrual cycle has been associated with a high risk of hip and wrist fractures.

Pathophysiology

The absence of menses in a female of reproductive age is related to the disturbance of normal hormonal, physiological mechanism or female anatomic abnormalities. The normal physiological mechanism works by balancing hormones and providing feedback between the hypothalamus, pituitary, ovaries, and uterus.

During normal female menstruation cycle, gonadotropin-releasing hormone (GnRH) is released from hypothalamus, and it works on pituitary to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH) and these 2 hormones from pituitary act on ovaries and ovaries finally make estrogen and progesterone to work on the uterus to carry out the follicular and secretory phase of menstrual cycle. Any defect at any level of this normal physiology of female can cause amenorrhea.

On other hand, deviation from the normal anatomy of reproductive organs of a female can also cause amenorrhea.

History and Physical

During history and physical examination, clinicians first need to ask about the age of a patient and at what age the patient started menses at puberty (menarche). This information is important to determine and differentiate between primary and secondary amenorrhea. If the patient was not menstruating at all, then it must be primary amenorrhea. All other cases will be secondary amenorrhea.[5][6]

After chronological age, the most important thing to determine is the psychosocial age of the patient, as well as their intelligence quotient (IQ) to rule out any chromosomal cause of primary amenorrhea. After that, clinicians should inquire about the other aspects of growth like breast bud development, because an absence of breast bud by the age of 13 to 14 years indicates estradiol deficiency, and there is a need for further investigation.

To rule out secondary amenorrhea, physicians need to determine the time frame of the absence of menses in the previously normal menstruating female. The most important cause of secondary amenorrhea is pregnancy, so it should be ruled out first. They should then ask about previous surgeries for Asherman syndrome.

A history of night sweats, sleep disturbance, and hot flushes for premature ovarian failure, history of chemotherapy, and radiation therapy for neoplasm should be obtained because these can also cause ovarian failure in young females. Polycystic ovary syndrome (PCOS) should be ruled out in accordance with Rotterdam criteria.

Vision test and sense of smell should be performed to for pituitary adenoma and Kallman syndrome. A history of medication is very important because antipsychotics are one of the most common causes of high prolactin levels which lead to the amenorrhea. The use of contraception, cocaine, opioids, antiepileptics can cause failure of menstruation to occur, dieting, strenuous exercise, history of weight loss, and anorexia nervosa can be determined by proper history taking to ascertain the cause of amenorrhea.

History of neurosarcoidosis, hemochromatosis, and presence of any chronic illness should be detected to determine the exact reason as these diseases greatly effect the hypothalamic-pituitary axis which plays a vital role in controlling of the female menstrual cycle.

Physical examination includes the general physical examination which can be used to determine causes like malnutrition or hepatomegaly. The examination also should include:

  • Measuring height, weight, and fat index of the patient to look for the presence of any chronic illness
  • Checking body mass index (BMI) to rule out anorexia nervosa and malnutrition, 
  • Checking for dental erosion, 
  • Looking for metacarpophalangeal calluses or bruises
  • Checking the skin for hirsutism, hair loss, or acne to investigate possible hyperandrogenemia

Acanthosis nigricans (skin condition) can also provide the clue for PCOS. Examing the breasts, pubic hair, and the clitoral index is also an important part of the physical examination in the female with amenorrhea. Turner syndrome can be ruled out through a normal chest examination. Clinicians should also perform a fundal examination to rule out pregnancy and a vaginal examination to check for hematocolpos in an imperforate hymen.

Evaluation

The evaluation should include:

  • Beta hCG to rule out pregnancy, because pregnancy is most common cause of amenorrhea
  • Prolactin level to rule out prolactinoma
  • Testosterone and DHEAS to rule out hyperandrogenism
  • FSH and LH for hypothalamic amenorrhea, BMI (to look for malnutrition, anorexia nervosa, and excessive strenuous exercise)
  • Pelvic ultrasound and adrenal CT for androgen-secreting tumors and other anatomical defects like Mayor-Rokitansky-Kauser-Hauser syndrome
  • Progesterone challenge test: This test is performed to differentiate between the anovulation, anatomic and estradiol deficiency as causes of amenorrhea. Progesterone is administrated to the patient in the form of intramuscular injection, and after progesterone is withdrawn. If bleeding takes place within 2 to 7 days, the cause must be the anovulation, but if no bleeding takes place after progesterone withdrawal, the causes are other than anovulation or premature ovarian failure. These other causes can include estradiol deficiency or anatomic defects like cervical stenosis and Asherman syndrome.
  • Karyotyping is sometimes important test for Turner and androgen insensitivity syndromes.

Treatment / Management

Treatment mainly depends on the cause of amenorrhea. If the cause of amenorrhea is estrogen deficiency, estrogen can be administered. If amenorrhea is due to malnutrition, proper diet plan can cure the patient successfully. For anorexia nervosa and stress-induced amenorrhea, cognitive-behavioral therapy and SSRIs can help. Dopamine agonist drugs like cabergoline can treat prolactinoma, and if large, surgery can provide a full cure. The appropriate surgical procedure can treat anatomical causes of amenorrhea. PCOS can be handled by combined oral contraceptives and metformin. SSRI can treat Stress-induced hypothalamic amenorrhea.[7][8][9]

Pearls and Other Issues

The causes of amenorrhea are diverse, and a multidisciplinary approach is required. Patients must be followed up for several years to ensure that the menstrual cycle has returned.

Enhancing Healthcare Team Outcomes

Amenorrhea is a common problem at some point in the life of most females. After ruling out pregnancy, however, determining the cause can be a challenge. Asides from the gynecologist, the disorder is best managed by a multidisciplinary team of healthcare workers that includes an endocrinologist, dietitian, internist, mental health worker, and a fertility expert. The outcomes in women with amenorrhea depend on the cause. Some women with PCOS need lifelong treatment as they are at a high risk for adverse cardiac events and the metabolic syndrome. Patient education is vital and the patient should be encouraged to pay attention to factors that affect bone density. In addition, these women need to eat a healthy diet fortified with calcium and participate in regular exercise. [2][10](Level V)

 


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Amenorrhea - Questions

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Which of the following is not a cause of amenorrhea?



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What is amenorrhea?



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What is the most common cause of amenorrhea?



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What is the next step in determining the cause of primary amenorrhea in a patient of child bearing age with normal puberty, hirsutism and acne, otherwise normal anatomy, and a negative pregnancy test?



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Which is false in regards to the workup for amenorrhea?



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Which statement is true regarding exercise-induced amenorrhea?



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A 17-year-old female reports she has not had a menstrual period in 4 months and that she is not sexually active. Which of the following is the most appropriate next step?



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What is not part of the workup for amenorrhea?



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What is not true regarding amenorrhea?



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Which medications are not associated with amenorrhea?



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Which is not a cause of amenorrhea?



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Which cause of amenorrhea is not related to basal metabolic index changes?



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Which is the most common endocrinopathy causing amenorrhea?



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Which is not correct regarding treatment of amenorrhea?



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What is the definition of amenorrhea?



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Which of the following can cause primary amenorrhea in a 16-year-old female?



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Which of the following is a common cause of secondary amenorrhea in adolescent girls?



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The absence of menses of what duration should prompt evaluation for secondary amenorrhea?



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A young female is seen in the gynecology clinic and reports that she has not had a period for the past 6 months. Which of the following may be the reason for her condition? Select all that apply.



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A 13-year-old female presents because she has not had a menstrual cycle for the past three months. She reached menarche 14 months ago and previously menstruated every 30 to 40 days with 5 to 7 days of bleeding. She has never been sexually active. She enjoys running and swimming in her spare time. Height and weight are within normal limits for her age. Her mother recently had a total abdominal hysterectomy because of excessive bleeding. The urine pregnancy test is negative. Which of the following is the most appropriate next step in managing this patient?



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Amenorrhea - References

References

Bain J,Bragg S,Ramsetty A,Bradford S, Endocrine Conditions in Older Adults: Menopause. FP essentials. 2018 Nov     [PubMed]
Macut D,Milutinović DV,Rašić-Marković A,Nestorov J,Bjekić-Macut J,Stanojlović O, A decade in female reproduction: an endocrine view of the past and into the future. Hormones (Athens, Greece). 2018 Nov 12     [PubMed]
Daily JP,Stumbo JR, Female Athlete Triad. Primary care. 2018 Dec     [PubMed]
Rundell K,Panchal B, Being Reproductive. Primary care. 2018 Dec     [PubMed]
Maciejewska-Jeske M,Szeliga A,Męczekalski B, Consequences of premature ovarian insufficiency on women's sexual health. Przeglad menopauzalny = Menopause review. 2018 Sep     [PubMed]
Ackerman KE,Misra M, Amenorrhoea in adolescent female athletes. The Lancet. Child     [PubMed]
Shozu M,Ishikawa H,Horikawa R,Sakakibara H,Izumi SI,Ohba T,Hirota Y,Ogata T,Osuga Y,Kugu K, Nomenclature of primary amenorrhea: A proposal document of the Japan Society of Obstetrics and Gynecology committee for the redefinition of primary amenorrhea. The journal of obstetrics and gynaecology research. 2017 Nov     [PubMed]
Christ JP,Gunning MN,Fauser BCJM, Implications of the 2014 Androgen Excess and Polycystic Ovary Syndrome Society guidelines on polycystic ovarian morphology for polycystic ovary syndrome diagnosis. Reproductive biomedicine online. 2017 Oct     [PubMed]
Chanson P,Raverot G,Castinetti F,Cortet-Rudelli C,Galland F,Salenave S, Management of clinically non-functioning pituitary adenoma. Annales d'endocrinologie. 2015 Jul     [PubMed]
Skiba MA,Islam RM,Bell RJ,Davis SR, Understanding variation in prevalence estimates of polycystic ovary syndrome: a systematic review and meta-analysis. Human reproduction update. 2018 Nov 1     [PubMed]

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