• 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


  • 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

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

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

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
  • 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


Defer for gynecology evaluation

Ongoing Care


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

Pearls and Pitfalls

  • Pregnancy is the most relevant etiology of amenorrhea in the emergency department:
    • 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
  • Hyperprolactinemia from use of antipsychotic drugs is a common etiology of amenorrhea in psychiatric patients

Additional Reading

  • Heiman DL. Amenorrhea. Prim Care Clin Office Pract. 2009;36:1–17.
  • Klein DA, Poth MA. Amenorrhea: an approach to diagnosis and management. Am Fam Physician. 2013;87:781–788.
  • Lentz G, Lobo R, Gershenson D, et al. Comprehensive Gynecology, 6th ed. Philadelphia, PA: Mosby; 2012.
  • Patrice Committee of the American Society for Reproductive Medicine. Current evaluation of amenorrhea. Fertil Steril. 2006;86:S148.
  • 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.


Andrew J. French
Jamal J. Taha

© Wolters Kluwer Health Lippincott Williams & Wilkins