Amenorrhea

Definition —  No period for 3 months (for 6 months if periods always irregular & spaced out)

  • Doesn’t count women using birth control methods which commonly cause amenorrhea
  • Assuming patient is not pregnant (pregnancy test is always first step in diagnosis)

Causes of Amenorrhea

xxxCommon Causes (>90% of cases)xxxxxxUncommon Causes
โ€ข Functional *
โ€ข Polycystic Ovarian Syndrome (PCOS) **
โ€ข Conditions of the Brain (Hypothalamus and xxxxPituitary Gland)
โ€ข Premature Ovarian Failure (Premature xxxxMenopause)
x
โ€ข Hyperthyroidism / Hypothyroidism
โ€ข Celiac Disease
โ€ข Type-1 Diabetes
โ€ข Various Tumors (brain, pituitary gland, ovary)
โ€ข Scars in Uterus (from surgery; or severe xxxxbleeding during childbirth)
โ€ข Congenital Adrenal Hyperplasia (CAH) **

Most Common Causes

*  “Functional” Amenorrhea due to eating disorders, malnutrition, excessive exercise (running, ballet, gymnastics, figure skating), severe physical or psychological stress

** ย Polycystic Ovarian Syndrome (PCOS) excess facial / body hair, scalp hair loss, acne; & obesity.ย  Similar body characteristics also with Congenital Adrenal Hyperplasia (CAH); but PCOS is much more common.

Premature Ovarian Failure Menopause occurs too soon, usually for reasons nobody knows

Diagnostic Work-Up of Amenorrhea

Initially — Pregnancy Test.  If negative, then:

1.  Look for signs of PCOS.  If present, blood test for Testosterone & maybe other male hormones.

2.  Blood TestsTSH (thyroid test), Prolactin, FSH & Estradiol (female hormones).

Diagnosis & other Work-Up

  • Abnormal TSH  โž™ Thyroid Disease (Hyperthyroid or Hypothyroid)
  • Elevated Prolactin (repeat a 2nd time too) โ†’ Pituitary Gland tumor  โ†’ brain MRI
  • Elevated FSH (maybe low Estradiol; hot flushes, vaginal dryness) โ†’ Premature Ovarian Failure [if very young for Premature Menopause, refer to Gynecology to rule out rare causes]
  • All labs normal & symptoms of PCOS  โ†’   diagnose PCOS (esp. if elevated level of Testosterone; if very elevated, refer to Endocrinology to rule out rare tumors)
    • Might order 17-hydroxyprogesterone level (early morning) for CAH
  • All labs normal except maybe low Estradiol   โ†’   test for Diabetes Type-1 and Celiac Disease.  If those tests negative:
    • if no such factors   โ†’   brain MRI to rule out Pituitary Gland Tumor
    • if history of uterine surgery or severe bleeding after childbirth   โ†’   try to induce a period with hormone pills.  If no period, refer to Gynecology to examine for uterine scars (adhesions)

See Amenorrhea โ€” Full Text for more in-depth explanations and discussions.

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