Amenorrhea

Amenorrhea is the abnormal absence or suppression of menstruation. Primary amenorrhea is the absence of menarche in an adolescent (by age 18). Secondary amenorrhea is the failure of menstruation for at least 3 months after normal onset of menarche.

Causes and incidence

Amenorrhea is normal before puberty, after menopause, or during pregnancy and lactation; it’s pathologic at any other time. It usually results from anovulation due to hormonal abnormalities, such as decreased secretion of estrogen, gonadotropins, luteinizing hormone, and follicle-stimulating hormone; lack of ovarian response to gonadotropins; or constant presence of progesterone or other endocrine abnormalities.

Amenorrhea may also result from the absence of a uterus, endometrial damage, or from ovarian, adrenal, or pituitary tumors. It’s also linked to emotional disorders and is common in patients with severe disorders, such as depression and anorexia nervosa. Mild emotional disturbances tend merely to distort the ovulatory cycle, while severe psychic trauma may abruptly change the bleeding pattern or may completely suppress one or more full ovulatory cycles. Amenorrhea may also result from malnutrition, intense exercise, and prolonged hormonal contraceptive use. The incidence of primary amenorrhea in the United States is less than 1%. The incidence of secondary amenorrhea (due to some other cause than pregnancy) is about 4%.

Diagnosis

Confirming diagnosis  A history of failure to menstruate in a female older than age 18 confirms primary amenorrhea.

Secondary amenorrhea can be diagnosed when a change is noted in a previously established menstrual pattern (absence of menstruation for 3 months). A thorough physical and pelvic examination rules out pregnancy, as well as anatomic abnormalities such as cervical stenosis that may cause false amenorrhea (cryptomenorrhea), in which menstruation occurs without external bleeding.

Onset of menstruation within 1 week after administration of pure progestational agents, such as medroxyprogesterone and progesterone, indicates a functioning uterus. If menstruation doesn’t occur, special diagnostic studies are appropriate.

Blood and urine studies may reveal hormonal imbalances, such as lack of ovarian response to gonadotropins (elevated pituitary gonadotropins), failure of gonadotropin secretion (low pituitary gonadotropin levels), and abnormal thyroid levels. Tests for identification of dominant or missing hormones include cervical mucus ferning, vaginal cytologic examinations, basal body temperature, endometrial biopsy (during dilatation and curettage), urinary 17-ketosteroids, and plasma progesterone, testosterone, and androgen levels. A complete medical workup, including appropriate X-rays, laparoscopy, and a biopsy, may detect ovarian, adrenal, and pituitary tumors. (See Diagnosing amenorrhea.)

Treatment

Appropriate hormone replacement re-establishes menstruation. Treatment of amenorrhea not related to hormone deficiency depends on the cause. For example, amenorrhea that results from a tumor usually requires surgery.

Special considerations

❑ Explain all diagnostic procedures.

❑ Provide reassurance and emotional support. Psychiatric counseling may be necessary if amenorrhea results from emotional disturbances.

❑ After treatment, teach the patient how to keep an accurate record of her menstrual cycles to aid early detection of recurrent amenorrhea.

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Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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