Amenorrhea – an approach to diagnosis and management

amenorrhea diagnosis and management


  1. Ovulation
    1. If present, indicates unresponsive endometrium.
    2. Suggested by the presence of cyclic events (e.g., mittelschmerz, premenstrual complaints).
    3. Diagnosed by basal body temperature charts, progesterone level, or endometrial biopsy.
  2. Estrogenic status
    1. Hypoestrogenic states are associated with osteoporosis regardless of cause.
    2. Suggested by hot flushes and vaginal dryness.
    3. Lack of Provera withdrawal suggests hypoestrogenic state but 10% to 15% of hypoestrogenic females will have some bleeding.
    4. Estradiol is useful only when the estradiol level is high (estrogen tumor).
    5. Vaginal cytology is helpful.
  3. Androgen excess
    1. Suggested by oily skin or hair, hirsutism, clitoromegaly, and defeminization
    2. Testosterone (50% ovarian, 50% adrenal), androstenedione (50% ovarian, 50% adrenal), dehydroepiandrosterone (DHEAS) (90% adrenal)
    3. 17-hydroxyprogesterone levels as necessary
  4. Pituitary status
    1. Suggested by galactorrhea, visual field defects.

FSH, LH, TSH, and prolactin: necessary for evaluation.

  1. Most patients require blood for FSH, LH, TSH, and prolactin.
    • A progesterone withdrawal confirms outflow tract integrity and suggests normal endogenous estrogen.
    • Absence of bleeding to even sequential estrogen and progester’ one necessitates a hysteroscopy or hysterosalpingogram.
  2. Testosterone and DHEAS levels are useful when androgenic fea­tures are present.
  3. GnRH stimulation test will be diagnostic for pituitary failure.
  4. CT scans and MRI are necessary with hyperprolactinemia.

Counseling is imperative with eating or weight disorders.

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