AMENORRHEA

Ask the following questions:

1. Is there galactorrhea? Of course, the most common cause of galactorrhea would be the galactorrhea following pregnancy and delivery. However, if there is galactorrhea, one should consider the possibility that the patient is taking drugs, including contraceptive pills and marijuana. Also, one should consider pituitary tumors and hypothalamic tumors.
2. Are there abnormal or absent secondary sex characteristics? If there is masculinization, then an adrenal or ovarian tumor or polycystic ovaries should be considered. If there is simply absence of female secondary sex characteristics, one should consider Turner's syndrome or Simmonds' disease and other pituitary disorders.
3. Are there abnormal findings on the vaginal examination? The amenorrhea may be due to an imperforate hymen, an imperforate vagina, absence of the vagina, a cervical stenosis with hematometra, and absence of a uterus, as in testicular dysgenesis. If there are normal female secondary sex characteristics and a normal vaginal examination and no galactorrhea, then some systemic disease such as anemia, leukemia, or Hodgkin's disease must be considered as well as psychogenic causes. Perhaps the amenorrhea is secondary to a neurologic disorder.

DIAGNOSTIC WORKUP

The first thing to do is a pregnancy test, as pregnancy is the most common cause of secondary amenorrhea. If the pregnancy test is negative, referral to a gynecologist may be done at this time. If a specialist is not handy, one may proceed with the workup. A trial of medroxyprogesterone acetate (Provera®) may be done by intermuscular injection or by mouth. If bleeding occurs on withdrawal of the progesterone, then it is established that the uterus is functional. It also establishes that the cervix and vagina are patent. If bleeding does not occur, uterine pathology is likely, and referral to a gynecologist is necessary.

If there is no galactorrhea, a normal response to progesterone, and the patient is a teenager, one may simply discontinue studies at this point and observe for the normal onset of the menstrual cycle.

If the patient with primary amenorrhea has already reached her twenties or if there is definite secondary amenorrhea, then further diagnostic studies should be done. If there is galactorrhea, a serum for prolactin should be done. If that is elevated, a CT scan of the brain should be done to look for a pituitary tumor or hypothalamic tumor. If there is no galactorrhea, one should still order a prolactin, but also order tests for follicle-stimulating hormone (FSH), luteinizing hormone (LH), and serum estradiol. If the FSH and LH are elevated and the estradiol is decreased, primary ovarian failure must be considered. A buccal smear for sex chromogens should be done to rule out Turner's syndrome. Other causes of primary ovarian failure are ovarian agenesis and polycystic ovary syndrome. An elevated free testosterone will support the diagnosis of polycystic ovary syndrome (Stein-Leventhal syndrome).

If the FSH, LH, and estradiol are all decreased, then hypopituitarism should be considered, as well as hypothalamic disorders. Referral to an endocrinologist is wise at this point. When an adrenocortical tumor is suspected, a serum cortisol and cortisol suppression test should be done.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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