• 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
    • 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


Signs and Symptoms

  • 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

  • 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

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



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
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]



  • 256.8 Other ovarian dysfunction
  • 626.0 Absence of menstruation


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


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


Andrew J. French

© Wolters Kluwer Health Lippincott Williams & Wilkins

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