Description

• Absence of menstruation
• Primary amenorrhea:
  • No spontaneous uterine bleeding by age 16 yr or within 5 yr of breast development, which should occur by age 13
• Secondary amenorrhea:
  • Absence of uterine bleeding for 3 mo in a woman with prior regular menses or for 9 mo in a woman with prior oligomenorrhea
  • More common than primary amenorrhea
  • Pregnancy is the most common cause

Etiology

• Primary:
  • Gonadal failure
  • Hypothalamic–pituitary disorder
  • Chromosomal abnormalities
  • Imperforate hymen
  • Gonadal dysgenesis (e.g., Turner syndrome)
• Secondary:
  • Pregnancy, breastfeeding, postpartum state
  • Intrauterine adhesions (Asherman syndrome)
  • Hypothalamic–pituitary–ovarian axis dysfunction
  • Polycystic ovarian syndrome (PCOS)
  • Endocrinopathies
  • Obesity, starvation, anorexia nervosa, or intense exercise
  • Drugs:
    • Oral contraceptives
    • Antipsychotics
    • Antidepressants
    • Calcium channel blockers
    • Chemotherapeutic agents
    • Digitalis
    • Marijuana
  • Autoimmune disorders
  • Premature ovarian failure
  • Menopause

Signs and Symptoms

• Menarche and menstrual history
• Sexual activity
• Exercise, weight loss
• Chronic illness
• Medications
• Previous CNS radiation or chemotherapy
• Family history
• Infertility
• Contraception use
• Galactorrhea:
  • Pituitary tumor
• Hirsutism/acne:
  • PCOS
  • Cushing syndrome
  • Hyperandreogenism
• Illicit drug use:
  • Effect on prolactin
• Headaches or vision changes:
  • CNS tumor
• Temperature intolerance, palpitations, skin changes, diarrhea, tremor
  • Thyroid

• Low estrogen:
  • Atrophic vaginal mucosa
  • Mood swings, irritability
• High androgen:
  • Truncal obesity
  • Hirsutism
  • Acne
  • Male-pattern baldness
• Thyroid exam
• Pelvic/genital exam
• Tanner staging

Essential Workup

Urine pregnancy test (UPT)

Diagnostic Tests and Interpretation

• If pregnancy test is negative, no further testing is needed emergently
• May send TSH, LH, FSH, and prolactin for follow-up by gynecology or primary care physician

Differential Diagnosis

• Pregnancy
• Mullerian agenesis:
  • Congenital malformation of the genital tract
  • Normal breast development without menarche
  • Associated with:
    • Fused vertebrae
    • Urinary tract defects
• Transverse vaginal septum
• Imperforate hymen
• Complete androgen insensitivity syndrome
• Asherman syndrome:
  • Intrauterine synechiae
  • Due to gynecologic instrumentation
• Primary ovarian insufficiency
• Hypothalamic/Pituitary
• Prior CNS infection, trauma, or autoimmune destruction of pituitary
• Polycystic ovary syndrome
• Contraceptive use
• Thyroid disease:
  • Hyperthyroid more likely than hypothyroid
• Adrenal disease

Pre Hospital

If amenorrhea is the result of pregnancy, stabilize patient as appropriate for pregnancy

Ed Treatment/Procedures

Reassurance and referral for follow-up

Medication

Defer for gynecology evaluation

Disposition

Admission Criteria
Admit if ectopic pregnancy cannot be ruled out

Discharge Criteria
Discharge with appropriate referral

Issues for Referral
Referral to gynecology

Follow-Up Recommendations

Gynecology follow-up is recommended