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Chapter 4 • Amenorrhea 51
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of amenorrheic adolescents with intact female genitalia and developed breasts have an inappropriate LH
feedback, anovulatory cycles, or high levels of androgenic hormones. They will bleed after a PCT and
should be monitored for continued menses to avoid
endometrial hyperplasia.
Menstrual History
Absence of a menstrual period for the past 3 months
in females with established normal menstruation or
9 months in females with previous oligomenorrhea
(menstrual periods occurring at intervals of greater
than 35 days, with only four to nine periods in a year)
is considered secondary amenorrhea. Sudden cessation
of menstruation is more likely to indicate pregnancy or
stress as a cause, whereas a gradual cessation suggests
polycystic ovarian syndrome (PCOS) or premature
ovarian failure.
Are there any constitutional delays causing
the amenorrhea?
Key Questions
n Has there been a change in weight, percentage of
body fat, or athletic training intensity?
n Are you under unusual stress at school, home, or
work?
n Do you or anyone in your family have any congenital
disorders or chronic diseases?
Change in Weight, Percentage Body Fat, and
Athletic Training Intensity
Underweight persons typically have a low body fat–
to–lean muscle ratio. Body fat can be assessed by
measuring the body mass index (BMI). The severe
stress of anorexia nervosa can produce prolonged
amenorrhea. Exercise from various sports—jogging,
middle and long distance running, ballet dancing,
gymnastics, and track and eld events—can lower
body fat sufciently to cause menstrual aberrations.
Long distance runners and ballerinas are more apt to
be amenorrheic than are swimmers; however, even
moderate exercise can cause one or two missed periods a year. The mechanism of action on the HPO axis
is unknown but is expressed by delayed puberty,
shortened luteal phase, anovulation, and amenorrhea.
Obesity can be the cause of amenorrhea or be a sign
of PCOS. PCOS causes ovarian dysfunction—
elevated androgens, hirsutism, low sex steroid
binding globulin (SSBG), and an elevated LH/FSH
ratio.
Emotional State
The stress of athletic competition, family situations,
school performance, peer relations, and work can disrupt normal cyclic menses. The HPO axis of a teenager
is more sensitive to physical and psychological stress
than that of an adult female.
Congenital or Chronic Diseases
Turner syndrome stigmata (see the discussion on
performing a head and neck examination later in this
chapter) or similar physical ndings suggest the
probability of an abnormality of one or all components (CNS, structural anomalies, or HPO axis) necessary for menstruation. Most structural anomalies
that would prevent outow of the menstrual blood
are detectable on physical examination. Chronic diseases, such as anorexia nervosa, diabetes mellitus,
Crohn disease, systemic lupus erythematosus, glomerulonephritis, cystic brosis, pituitary adenoma,
adrenal diseases, and thyroid dysfunction, can cause
amenorrhea.
Could this be thyroid dysfunction?
Key Questions
n Have you noticed changes in the texture of your hair
or skin?
n Are you bothered by hot or cold temperatures?
n Have you had any changes in your energy level?
n Have you had any changes in your bowel function?
Hair and Skin Changes and Temperature
Intolerance
Hypothyroidism and hyperthyroidism are expressed by
changes in hair and skin texture. Hyperthyroidism
often makes women intolerant of the heat, and this is
sometimes confused with menopausal syndrome symptoms. Cold intolerance is frequently exhibited by persons with low-functioning thyroids.
Energy and Bowel Changes
Increased functioning of the thyroid causes restlessness and diarrhea, whereas decreased functioning
results in constipation and fatigue. Even mild thyroid
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dysfunction can cause menstrual irregularities; therefore a thyroid function test is needed to assess the
thyroid status.
Could this be caused by hyperprolactinemia?
Key Questions
n Are you able to express a discharge or liquid from
your nipples?
n Is there increased stimulation to your nipples?
n Have you had any surgery or disease of the breasts
or chest wall?
Galactorrhea
Women notice breast nipple discharge that is not
associated with breastfeeding or medications. Offensive medications are listed in Box 4-1 and include primarily the dopamine antagonist agents and
estrogens.
Nipple Stimulation and Chest Wall Stimulation
Nipple stimulation from clothing irritation during jogging or nipple manipulation during sexual activity may
cause galactorrhea. Surgical interventions, such as
lymph node dissection, or disease processes, such as
herpes zoster, can also lead to galactorrhea, triggered
by peripheral neural stimulation.
Could the hyperprolactinemia be caused
by medications?
Key Questions
n What prescription medicines are you taking?
n Have you used any street drugs? What kind of drugs
have you used?
Box 4-1
Drugs That May Cause
Amenorrhea
Prolactin Increase
Antipsychotics: Phenothiazines, haloperidol, pimozide,
clozapine
Antidepressants: Tricyclic antidepressants, monoamine
oxidase inhibitors
Antihypertensives: Calcium channel blockers, methyl-
dopa, reserpine
Estrogenic Effect
Digitalis, marijuana, flavonoids, oral contraceptives
Ovarian Toxicity
Busulfan, chlorambucil, cisplatin, cyclophosphamide,
fluorouracil
Modified from Kiningham RB, Apgar BS, Schwenk TL: Evaluation of
amenorrhea, Am Fam Physician 53:1186, 1996.
Visual Changes and Headaches
A pituitary tumor could be responsible for the hyperprolactin state. Enlarging pituitary tumors cause headaches. As the tumor grows out of the sella turcica, it
compresses the optic chiasm and nerves. The common
visual defect is bitemporal hemianopia, although other
defects can occur. Changes in visual elds are often
self-diagnosed when the patient recognizes vision
problems while reading or driving an automobile.
Clinical changes in vision warrant a referral to an
ophthalmologist and computed tomography (CT) or
magnetic resonance imaging (MRI) work-up for a
tumor of the sella turcica. A high prolactin level indicates a pituitary adenoma that presents with or without
galactorrhea.
Medication History
Some medications, such as phenothiazines or contraceptives, can cause amenorrhea. These drugs increase
prolactin levels, induce an estrogenic effect, or are
toxic to the ovaries (see Box 4-1). Illicit drugs, such
as heroin and methadone, also lead to menstrual
abnormalities.
Is a pituitary tumor causing the amenorrhea?
Key Questions
n Have you experienced any visual changes?
n Are you having an increased number of headaches?
Is this a problem of the HPO axis?
Key Questions
n Have you experienced any problems with infertility?
n Do you have excess hair on your face or chest?
n Are you having any menopausal symptoms (e.g., hot
ashes, vaginal dryness)?
n Did you hemorrhage during childbirth?
Infertility
Many cases of infertility are caused by failure of
ovulation. PCOS affects women between the ages of
15 and 30 years. Basal body temperature charts and
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endometrial biopsies can reveal anovulatory cycles.
Vaginal ultrasound shows enlarged ovaries with multiple small, uid-lled cysts. Infertility can be caused
by low or high estrogen levels. Measurement of gonadotropins, vaginal maturation index (MI), and progesterone levels provide insight into the functioning
of the HPO axis.
Androgen Excess
About 50% of women diagnosed with PCOS are hirsute, obese, and have difculty conceiving. Few other
signs of masculinization are present. LH is elevated
with PCOS. Truncal obesity, acne, and male pattern
baldness can signify androgen excess.
Estrogen Deficiency
Hot ashes or ushes, changes in mood, and difculty sleeping are common menopausal symptoms
that women with low estradiol levels can experience.
A dry vagina is often accompanied by dyspareunia
and sometimes dysuria. The dysuria can be secondary to the hypoestrogenic state of the urethra and not
be the result of a urinary tract infection. Prolonged
hypoestrogenic status leads to osteopenia, regardless
of age.
Hemorrhage at Childbirth
Amenorrhea can occur subsequent to a pregnancy
and delivery if, at the time of delivery, there was severe hemorrhage. Obstetric hemorrhage causes pituitary ischemia and infarction and results in pituitary
insufciency. This pathological process is known as
Sheehan syndrome. In this instance, refer the patient
to an endocrinologist.
Is this a problem of the uterus?
be made by performing weekly serum progesterone tests
to determine if any value is within the ovulatory range
(.3 ng/mL) yet there are no periods. The diagnosis can
also be made by the gynecologist via hysteroscopy, hysterosalpingography, or measuring endometrial thickness
by ultrasonography.
What symptoms support a structural outow
problem?
Key Questions
n Do you have cyclic abdominal bloating or cramping?
n Have you been amenorrheic since you had a cervi-
cal procedure?
Presence of Premenstrual Symptoms or
Dysmenorrhea
Cyclic symptomatology of dysmenorrhea in the absence of menses can be caused by an incomplete outow tract. Physical examination validates a vaginal
opening, imperforate hymen, intact uterus, or congenital imperforate cervical os. If there is no indication of
a uterus by examination or lower abdominal ultrasound, a karyotype is needed to determine the congenital disorder. A referral to an endocrinologist or
gynecological surgeon could be indicated for removal
of any abdominal male gonads, which would be a risk
for cancerous degeneration.
Amenorrhea Since Cervical Procedure
Stenosis of the cervical os can occur after gynecological ofce surgeries, such as cervical biopsies and cryotherapy. However, it is more common after cone biopsies of the cervix, such as the loop electrosurgical
excision procedure (LEEP), or carbon dioxide laser
treatment.
Key Question
n Have you had a miscarriage or abortion, uterine in-
fection, or any surgery or procedure involving your
uterus?
Gynecological Problem
Endometritis, incomplete abortion, or aggressive curettage of the uterus can lead to denuding of the endometrial layer, scarring, and Asherman syndrome. The patient with Asherman syndrome will not bleed after the
PCT, nor will she bleed after the uterus is primed with
estrogen and challenged with DMPA. The diagnosis can
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Note General Appearance
The body morphology of the patient can provide
clues to the cause of amenorrhea; often diseases can
be diagnosed secondary to short stature, underweight, or overweight. A height less than 5 feet
(short stature) in a girl who is 14 years old or older
could indicate a congenital chromosomal problem.
Assess the woman’s general state of health to determine if there are signs of systemic, chronic, or congenital disease.
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Assess Nutritional Status and Plot
Measurements on Growth Chart
in Adolescents
Assess nutritional status, looking for signs of undernutrition or overnutrition. Measure the height, weight,
and arm span of the adolescent. Plot on a growth chart
if delayed puberty is a consideration. Anorexia nervosa
is often found while evaluating an adolescent who has
short stature and is underweight.
Assess Sexual Maturity
Use the Tanner SMR scales to assess and rate the stage
of breast and PH development. An SMR can be calculated by averaging the girl’s stage of PH and breast
development. The stage of breast and PH development
in the adolescent girl is related to her chronological
age, age at menarche, and evidence of growth spurt.
The breasts often develop at different rates, so some
asymmetry is common. Menarche generally occurs at
SMR 4 or breast stage 3 to 4. Plot these physiological
events on the growth curve.
Screen for Eating Disorders
If you suspect anorexia nervosa or bulimia, administer
a screening instrument to help determine the diagnosis.
Refer to the DSM-IV-TR for diagnostic criteria. About
half of the females with eating disorders will have
short stature.
Calculate the Body Mass Index
Seventeen percent body fat is needed for most females
to be menarchal, and about 22% body fat is necessary
for ovulation. Calculate the BMI (Box 4-2; also see
Appendix C). A BMI of 19 kg/m2 usually indicates
about 17% body fat, which can cause amenorrhea.
Obesity causes amenorrhea secondary to ovarian
dysfunction. A BMI of greater than 27 kg/m2 corresponds to being more than 20% overweight. Adipose
cell stroma convert androstenedione to estrogen (estrone) as the body fat increases. Obesity also increases
sex hormone binding globulin, thereby increasing free
steroid levels. Both processes can cause an imbalance
in the HPO axis and lead to amenorrhea.
Box 4-2
BMI is helpful in assessing the nutritional status and total
body fat of the patient. You can use the BMI chart, Appendix C, to determine the BMI. You can also calculate
the BMI by using the following formula:
Multiply the patient’s weight in pounds by 704. Take
that number (product) and divide by the height in inches.
Once again, divide by the height in inches.
Example: Weight 5 75 pounds; height 5 4 feet 2 inches
or 50 inches
Body Mass Index (BMI)
75 3 704 5 52,800
52,800 4 50 5 1056
1056 4 50 5 21.12
BMI 5 21
brittle nails. Hyperthyroidism is characterized by
ne, warm skin that is hyperpigmented at pressure
points. Nails will often separate from the nail plate
(onycholysis), and hair will be ne, thin, and limp.
Cushingoid features include truncal obesity, striae,
and moon face. Observe for other signs of androgen
excess, which include hirsutism, acne, and male
pattern baldness.
Perform a Head and Neck Examination
During the head and neck examination, note any visual
changes, including visual eld defects, that might indicate a pituitary tumor. Anosmia might denote a congenital absence of GnRH, resulting in no secretion
of LH or FSH from the pituitary. Without LH or
FSH production, there is no ovulation; anovulatory
cycles are amenorrheic. Also look for Turner syndrome
stigmata—webbed neck and low-set ears (other signs
are shieldlike chest and short fourth metacarpal).
Palpate the Thyroid Gland
and Lymph Nodes
Palpate the thyroid gland for diffuse enlargement, asymmetry, and nodules. Auscultate for thyroid bruits and
count the pulse rate. Assess for supraclavicular and infraclavicular lymphadenopathy or carcinogenic masses of
the sternal notch and abdomen, which could arise from a
tumor of germ cell, adrenal, or pituitary origin.
Examine the Skin and Hair
Observe for signs of thyroid dysfunction or adrenal
excess. Features of hypothyroidism include dry, coarse,
aky skin; coarse hair that tends to break; and thick,
Perform Clinical Breast Examination
Physical examination veries sexual maturation level.
The growth spurt occurs before breast development
(thelarche), which is followed by the appearance of
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axillary hair. Perform a breast examination and assess
breast maturity level using Tanner SMR scales. More
than 95% of adolescents are menarchal 1 year after
they reach a breast maturity rating of 4. Check for
galactorrhea (see Chapter 5).
Perform a Pelvic Examination
Observe for maturation of the female genitalia and
secondary sex characteristics. Assign a Tanner SMR
scale for PH development. A congenital problem
might manifest as vaginal or uterine agenesis and is
identied by the absence of a vagina, cervix, or
uterus. There could be a small invagination of the
perineum below the urinary meatus. It can be explored using a cotton-tipped applicator and otoscope
with a large ear speculum or nasal speculum to determine the dimensions of the vault and presence of a
cervix. A clitoris larger than 1 cm is suggestive of
androgen excess.
Assess for other outlet problems, including an imperforate hymen (painful, bluish bulging of the
perineum), stenotic cervix (bulging os or inability to
pass a cotton-tipped applicator through the os), or a
transverse vaginal septum. The development of hematocolpos, hematometra, or hematoperitoneum from
menses behind an obstructed outow tract needs immediate intervention to prevent inammatory changes
and endometriosis. Needle aspiration is not recommended because it might potentiate infection. Refer to
a reconstructive gynecological surgeon for MRI and,
often, extensive surgery.
If the introitus is small, use a pediatric Pedersen,
Huffman-Graves, or Graves’ speculum (which measures approximately 1/2 inch wide and 33/4 inches
long), or a Huffman vaginoscope. Vaginal walls that
are pale and dry, have few rugations, and are friable
are estrogen decient. Low estrogen levels cause scant
cervical mucus. Vaginal cytology reports for women
exhibiting such symptoms show an MI lacking or low
in estrogen.
The bimanual examination can be performed with
only an index nger in the vagina if the vaginal vestibule is small. If the hymen is rigid, a rectal bimanual
examination can be completed instead of the usual
vaginal bimanual examination. On pelvic bimanual
examination, enlarged ovaries are palpated about half
the time in patients with PCOS. Assess for position,
size, shape, and consistency of the cervix, uterus, and
ovaries.
LABORATORY AND DIAGNOSTIC
STUDIES
Pregnancy Test
Immunoassay testing for the beta subunit of the human
chorionic gonadotropin (ß-hCG) is used to identify
or rule out pregnancy and is an essential test on all
females presenting with amenorrhea.
Thyroid-Stimulating Hormone
A serum TSH test identies hypothyroidism. When
hormonal supplementation is provided, menses usually
resumes for these patients. If the amenorrhea is associated with galactorrhea and hyperprolactinemia, the
prolactin level must be measured again after the thyroid
function levels become normal.
Prolactin Levels
The prolactin level is most reliable when it is a fasting measurement. When the patient’s fasting prolactin level is normal (,50 ng/mL), a PCT is indicated.
If the patient’s level is high (.50 ng/mL) or if
she has galactorrhea, a cone-down view of the sella
turcica is taken to rule out a pituitary adenoma. A
level .200 ng/mL is highly suggestive of a prolactinoma. A prolactin elevation less than 100 ng/mL but
higher than normal is most frequently caused by prescribed or illicit drugs. The hyperprolactinemia
usually subsides a few weeks after stopping the offending drug. Microscopic examination of breast
discharge will reveal fat globules and no red blood
cells (see Chapter 5).
Serum Follicle-Stimulating
Hormone Levels
Ovarian failure, which causes a low estradiol secretion,
will raise the FSH level higher than 40 mIU/mL. If
both the FSH and LH levels are greater than 50 mIU/
mL, then primary ovarian failure is established. If the
patient is older than 30 years, menopause is diagnosed;
if she is younger than 30 years, a karyotype should be
done. An FSH measurement of less than 40 mIU/mL
denotes a hypothalamic-pituitary dysfunction and
secondary ovarian failure.
Serum Luteinizing Hormone Levels
A serum LH level greater than 35 milliunits/mL is
frequently seen in patients with PCOS. An LH:FSH
ratio higher than 2:1 is suggestive of PCOS, whereas
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a ratio higher than 3:1 is considered diagnostic
of PCOS.
Dehydroepiandrosterone Sulfate
Mildly elevated levels of dehydroepiandrosterone sulfate
(DHEA-S) are seen in women with PCOS. Signicantly
elevated DHEA-S levels (.700 mg dl21) indicate congenital adrenal hyperplasia.
Central Nervous System Imaging
If both FSH and LH levels are low, indicating a problem of the pituitary, imaging of the CNS is warranted.
Either contrast-enhanced CT or MRI of the sella turcica can determine whether there is an abnormality. If
the prolactin level is greater than 100 ng/mL or the
cone-down view of the sella turcica is abnormal,
CT or MRI with contrast enhancement should be
obtained.
Pelvic Ultrasound and Vaginal
Ultrasound
Pelvic and vaginal ultrasound studies are used to
determine the presence of a uterus; the anatomical
size and endometrial thickness of a uterus; and
whether broids or other tumors exist. Ultrasound is
used to measure ovarian size, to identify cysts, and to
evaluate follicular development. In primary amenorrhea, ultrasound is helpful in assessing müllerian
agenesis and gonadal dysgenesis because there could
be internal organs and no conduit to the perineum.
One third of these patients also have urinary tract
abnormalities; therefore an abdominal ultrasound
can be obtained at the same time to evaluate that
system.
Progesterone Challenge Test
Also called the progesterone withdrawal test, the
PCT consists of the administration of oral DMPA
10 mg daily for 7-10 days or parenteral progesterone
in oil 200 mg intramuscularly. The patient should
respond to the medication within 2 to 7 days. If there
is a positive PCT response, the patient bleeds. This
demonstrates that there are sufcient endogenous
estrogens to prepare the endometrium and conrms
that there is a functioning outow tract. It substantiates an intact HPO axis. Other forms of progesterone
can be used: micronized progesterone 400 mg PO
daily for 7-10 days or norethindrone 5 mg PO daily
for 7-10 days.
Estrogen/Progesterone Challenge Test
The estrogen/progesterone challenge test (E/PCT)
consists of the administration of conjugated estrogens 1.25 mg daily or estradiol 2 mg daily for
21 days followed by progesterone as given in the
PCT. If there is no menstrual ow, administer the
regimen a second time. If there is no ow after both
courses of therapy, the cause is either the outow
tract or the uterine endometrium. The E/PCT is positive if there is menstrual ow within 2 to 7 days. A
positive test denotes that there is inadequate estrogen
production either from inadequate functional ovarian
follicles or from inadequate pituitary gonadotropic
stimulation.
Chromosome Analysis (Karyotyping)
A buccal smear or vaginal smear of epithelial cells is
stained with cresyl violet and examined microscopically. Karyotyping is done to delineate probable chromosomal abnormalities. It is used in the work-up for
ambiguous genitalia, primary amenorrhea, oligomenorrhea, delayed puberty, or abnormal development at
puberty.
Endometrial Biopsy
Endometrial biopsy can be used to show the hormonal
response of the uterine endometrium.
Basal Body Temperature Charting
A woman can take her awakening body temperature
each day and chart it to determine if ovulation is occurring. This test is based on the fact that progesterone
increases the body temperature by 0.5º F to 0.8º F for
11 days during the luteal phase. If this increase in temperature occurs, ovulation has occurred and a positive
estrogen component is inferred. Digital read-out thermometers are quick and easy to use.
Maturation Index
A vaginal cytological smear (Papanicolaou smear) for
evaluation of ovarian function can determine the hormonal status of the vagina. The index is read from left to
right and refers to the percentage of parabasal, intermediate, and supercial squamous cells appearing on a smear,
with the total of all three values equaling 100%. For example, an MI of 0/40/60 represents 0% parabasal cells,
40% intermediate cells, and 60% supercial cells. Lack
of estrogen effect is demonstrated by predominance of
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parabasal cells. Low estrogen effect is demonstrated by
predominance of intermediate cells. Increased estrogen
effect is demonstrated by predominance of intermediate
cells. Both increased and decreased estrogen effects can
be reective of a hormonal imbalance of the HPO axis.
Progesterone Levels
Serum progesterone levels collected at weekly intervals can establish whether ovulation has occurred. A
value greater than 3 ng/mL is found with ovulation.
DIFFERENTIAL DIAGNOSIS
Pregnancy
Pregnancy is the most common reason for amenorrhea
in women of childbearing age. Determining the pregnancy status of the patient is the rst step in the amenorrhea work-up.
Constitutional Problems
Delayed Puberty
A pituitary adenoma must be ruled out for all patients
with delayed puberty. Yearly prolactin levels should be
performed for those with delayed puberty because of
the possibility of occult pituitary adenomas.
Anorexia Nervosa and Bulimia
Anorexia nervosa and bulimia are disorders that are
psychiatric in origin. Affected women have such a fear
of being fat that they do not eat or they purge after eating. Often these women are overachievers and have
low self-esteem. The majority are adolescents, with a
mean age of 13 to 14. Amenorrhea is caused by extreme weight loss and/or cachectic state.
Exercise-Induced Amenorrhea
This amenorrhea is common in competitive athletes,
but exercise can also cause skipped menses in the casual trainer. Gymnasts, ballerinas, and long distance
runners are at high risk, especially if they started their
training at a very early age. Body fat of 17% is needed
for menarche, whereas 22% body fat is necessary for
ovulation. BMI estimates the woman’s body fat level.
Congenital or Chronic Disorders
Turner Syndrome
Turner syndrome causes primary amenorrhea because
of ovarian agenesis. The typical features are short stature, webbed neck, shieldlike chest, and delayed secondary sex characteristics.
Cushing Syndrome
Cushing syndrome is caused by an excess secretion of
adrenocorticotropic hormone (ACTH) from a pituitary
or adrenal adenoma. Classically, patients present with
a “moon face,” acne, hirsutism, kyphosis, purplish
striae of the abdomen, and hypertension. CT can reveal
pituitary or adrenal adenoma.
Thyroid Dysfunction
Amenorrhea from thyroid dysfunction subsides as soon
as serum thyroid levels return to normal. Hypothyroidism frequently causes amenorrhea and is characterized
by fatigue, constipation, cold intolerance, and dry skin.
Polycystic Ovary Syndrome
PCOS typically causes infertility in women ages 15 to
30 years. Half of these women exhibit hirsutism and
obesity. The ovaries are often large and contain multiple uid-lled cysts. The diagnosis is established by
ultrasonography.
Uterine and Outflow Tract Problems
Imperforate Hymen
The woman with an imperforate hymen could present with a painful, bulging perineum. There is lack of
an intact outow tract, which causes the primary
amenorrhea.
Cervical Os Stenosis
Stenosis of the cervical os can be the cause for either
primary or secondary amenorrhea. Stenosis is often
caused by therapeutic procedures of the cervix such as
cryotherapy or cone biopsies. These procedures cause
scarring and stenosis of the os, obstructing the outow
tract.
Asherman Syndrome
Asherman syndrome occurs when the uterine endometrial lining is denuded or scarred, usually by infection
or curettage. The patient does not respond to either a
PCT or an E/PCT.
Hypothalamic-Pituitary-Ovarian Axis
Problem
Ovarian Failure
Menopause occurs when the ovaries fail secondary to depletion of ova. The average age of menopause in the
United States is 51 years. It is a state of hypoestrogenemia.
The gonadotropin levels rise (FSH .40 milliunits/mL),
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and the estradiol levels fall (,15 pg/mL). Clinical symp-
toms are hot ashes, night sweats, insomnia, mood
changes, and amenorrhea for 12 months. If this occurs
before age 40 years, it is considered premature. Common
causes of premature ovarian failure include genetic and
Chest Wall or Nipple Stimulation
Prolactin inhibits the pulsatile secretion of GnRH, unbalancing the HPO axis and possibly causing amenorrhea. The higher the prolactin level, the greater the
chance is that the patient will be amenorrheic.
enzyme disorders, immune disturbances, and chemotherapy.
Pituitary Adenoma
Pituitary macroadenomas and microadenomas should be
Sheehan Syndrome
Sheehan syndrome is activated by severe obstetrical
hemorrhage, which causes pituitary ischemia and infarction. The pituitary gland becomes dysfunctional.
suspected if the prolactin level is greater than 100 ng/mL
or if there are any abnormalities of the cone-down view
of the sella turcica. Patients with pituitary adenomas
should be referred to an endocrinologist. Patients with
prolactin levels exceeding 1000 ng/mL probably have
Medications
an invasive tumor.
Prescription and illicit drugs can increase prolactin
levels, which in turn promote galactorrhea. Offending
drugs are primarily dopamine antagonist agents, estrogens, and marijuana.
DIFFERENTIAL DIAGNOSIS OF Common Causes of Amenorrhea
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Pregnancy
Pregnancy Breast tenderness, morning
sickness, urinary frequency
Constitutional Problems
Delayed puberty No menstruation at age beyond
16 years; more than 5 years
between initiation of breast
growth and menarche
Anorexia nervosa/
bulimia
Exercise-induced
amenorrhea
Mean age 13-14; fear of being
fat; low self-esteem; depression; isolation; overachiever;
food is parental battleground;
preoccupation; hair loss;
abdominal bloating, pain,
constipation
Began athletic training at young
age; more common with long
distance runners, ballerinas,
gymnasts
Globular, enlarged uterus; soft,
bluish color cervix
Breast stage 1 persists beyond
age 13.4; PH stage 1 persists
beyond age 14.1
Amenorrhea before or after
weight loss; cachexia; low
body fat; short stature; yellow,
dry, cold skin; acrocyanosis:
increased lanugo hair;
hypotension, systolic
murmurs, often mitral valve
prolapse
BMI ,17% body fat TSH normal; prolactin
b-hCG pregnancy test
positive; ultrasonography positive
Prolactin normal; TSH,
T4 normal; CBC, U/A
normal; chemistry
profile normal; bone age
normal; skull radiograph
normal
TSH normal; prolactin
normal; FSH and LH
usually low; glucose normal; ECG: bradycardia,
low-voltage changes,
T wave inversions, and
occasional ST segment
depression
normal
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Amenorrhea—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Congenital or Chronic Disorders
Turner syndrome Congenital; short stature;
infantile sexual development
Cushing
syndrome
Thyroid
dysfunction
Polycystic ovary
syndrome
Uterine and Outflow Tract Problems
Imperforate
hymen/stenotic
cervical os
Asherman
syndrome
Hypothalamic-Pituitary-Ovarian Axis Problem
Ovarian failure Hot flashes, night sweats,
Sheehan
syndrome
Medications/
chest wall or
nipple
stimulation
Pituitary adenoma Delayed puberty; history of visual
BMI, body mass index; CBC, complete blood cell count; CT, computed tomography; DHEA-S, dehydroepiandrosterone sulfate; ECG, electrocardiogram; E/PCT, estrogen/progesterone challenge test; FSH, follicle-stimulating hormone; LH, luteinizing hormone; MRI, magnetic resonance
imaging; PCT, progesterone challenge test; PH, pubic hair; RBCs, red blood cells; T3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating
hormone; U/A, urinalysis.
Weight gain; weakness; back
pain
Hypothyroid: delayed growth,
weight gain, fatigue, constipation, cold intolerance; hyperthyroid: weight loss, nervousness, heat intolerance
Infertility Hirsutism; obesity; enlarged
Monthly bloating, cramping, and
pelvic pressure; no menses;
cryotherapy or other procedure
to cervix
History of uterine infection;
tuberculosis, schistosomiasis;
uterine iatrogenic scarring;
curettage, irradiation
insomnia, mood changes
Recent history of postpartum
hemorrhage and shock during
delivery
Breast nipple discharge; his-
tory of dopamine antagonists,
estrogens, or illicit drugs;
stimulation to nipples: exercise
or sexual; history of chest wall
surgery or herpes zoster
changes, increasing headaches
Characteristics: webbed neck,
low-set ears, shield-like chest,
short fourth metacarpal
Moon face, acne, hirsutism,
purple striae of abdomen
Hypothyroid: dry skin, fine hair,
galactorrhea; hyperthyroid:
moist skin, hyperpigmentation
over bones, thin hair, goiter
ovaries
Fibrotic hymen without patent
opening; stenotic cervical os
Pelvic examination normal PCT negative; E/PCT
Pale, dry vaginal mucosa;
few rugae
Hair loss; depigmentation of
skin; mammary and genital
atrophy
Nipple discharge: bilateral;
multiduct; milky, clear, or
yellowish discharge
Visual field defects;
galactorrhea
Karyotype (45,X)
Cortisol increased;
17-ketosteroids
increased; CT adenoma
Hypothyroid: TSH high;
hyperthyroid: TSH low;
T3 high; T4 high
Ultrasonography: enlarged
ovaries with multiple
fluid-filled cysts;
testosterone high;
DHEA-S may be
elevated
Clinical diagnosis by
history and findings
negative; hysteroscopy
adhesions
FSH and LH high;
estradiol low
Pituitary and end-organ
hormones low;
hemoglobin low
Wet mount or hemoccult
of nipple discharge:
negative for RBCs; prolactin high; cone-down
view of sella turcica; MRI
or CT with contrast
Prolactin high; cone-down
view of sella turcica
positive; MRI or CT with
contrast positive
60 Chapter 4 • Amenorrhea
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REFERENCES AND READINGS
American Academy of Pediatrics, Committee on Sports Medicine
and Fitness: Medical concerns in the female athlete, Pediatrics
106:610, 2000.
Bielak KS, Harris S: Amenorrhea, e-Medicine (website): http://
emedicinemedscape.com/article/953850-overview. Updated April 8,
2010. Accessed September 21, 2010.
Deligeoroglou E, Tsimaris P: Menstrual disturbances in puberty,
Best Pract Res Clin Obstet Gynaecol 24:157, 2010.
Goodman LR, Warren MP: The female athlete and menstrual func-
tion, Curr Opin Obstet Gynecol 17:466, 2005.
Goswami D, Conway GS: Premature ovarian failure, Hum Reprod
Update 11:391, 2005.
Heiman D: Amenorrhea, Prim Care 36:1, 2009.
Hunter MH, Sterrett JJ: Polycystic ovary syndrome: it’s not just
infertility, Am Fam Physician 62:1079, 2000.
Master-Hunter T, Heiman DL: Amenorrhea: evaluation and treatment,
Am Fam Physician 73:1374, 2006.
Pletcher JR, Slap GB: Menstrual disorders: amenorrhea, Pediatr
Clin North Am 46:505, 1999.
Sabatini S: The female athlete triad, Am J Med Sci 322:193, 2001.
Wilson GR, Haddad JE, Haddad CJ: Amenorrhea: common causes
and evaluation, Compr Ther 31:270, 2005.
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