Basics

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
    • Turner syndrome
  • Secondary:
    • Pregnancy, breast-feeding, or postpartum
    • Asherman syndrome (intrauterine adhesions)
    • Dysfunction of the hypothalamic-pituitary-ovarian axis
    • 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
    • Ovarian failure
    • Menopause

Diagnosis

Signs and Symptoms

History
  • Menarche and menstrual history
  • Sexual activity
  • Exercise, weight loss
  • Chronic illness
  • Medications
  • Previous CNS radiation or chemotherapy
  • Family history
  • Infertility

Physical Exam
  • 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

Pregnancy test

Diagnostic Tests and Interpretation

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

Imaging
None needed emergently unless concern for ectopic pregnancy or other emergency as directed by patient's presentation

Diagnostic Procedures/Other
None needed emergently

Differential Diagnosis

Pregnancy

Treatment

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.

Ongoing Care

Disposition

Admission Criteria
No need for admission unless concern for ectopic pregnancy

Discharge Criteria
Discharge with appropriate referral.

Issues for Referral
Referral to gynecology

Follow-Up Recommendations

Gynecology follow-up is recommended.

Pearls and Pitfalls

  • Pregnancy is the most relevant etiology of amenorrhea in the emergency department.
    • Urine pregnancy test (UPT) may give false negative with low urine specific gravity.
    • UPT sensitivity for β-HCG level may vary depending on type/manufacturer. High concern for amenorrhea due to pregnancy, specifically an ectopic, may warrant a qualitative serum pregnancy test
  • Anorexia nervosa is an important consideration in patients with amenorrhea, particularly in adolescents.

Additional Reading

  • Heiman DL. Amenorrhea. Prim Care Clin Office Pract. 2009;36:1–17.
  • Lentz G, Lobo R, Gershenson D, et al. Comprehensive Gynecology, 6th ed. Philadelphia, PA: Mosby; 2012.
  • Rosenberg HK. Sonography of the pelvis in patients with primary amenorrhea. Endocrinol Metab Clin N Am. 2009;38:739–760.
  • Santoro N. Update in hyper- and hypogonadotropic amenorrhea. J Clin Endocrinol Metab. 2011;96:3281–3288.  [PMID:22058375]

Codes

ICD-9

  • 256.8 Other ovarian dysfunction
  • 626.0 Absence of menstruation

ICD-10

  • Primary amenorrhea
  • Secondary amenorrhea
  • Amenorrhea, unspecified
  • Other ovarian dysfunction

SNOMED

  • 14302001 Amenorrhea (finding)
  • 8913004 Primary physiologic amenorrhea (finding)
  • 86030004 Secondary physiologic amenorrhea (finding)
  • 444769001 anovulatory amenorrhea (finding)

Authors

Andrew J. French


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