From the Guidelines
Amenorrhea does not require any medical treatment, and the initial step should be to provide reassurance and consider ruling out pregnancy if clinically indicated. The workup for amenorrhea should be guided by the clinical presentation and medical history of the patient. According to 1, if a woman’s regular bleeding pattern changes abruptly to amenorrhea, pregnancy should be ruled out if clinically indicated.
Initial Evaluation
The initial evaluation of amenorrhea should include:
- A thorough medical history to identify any potential causes of amenorrhea
- A physical examination to assess for signs of androgen excess, thyroid abnormalities, and galactorrhea
- Laboratory tests, such as pregnancy test, FSH, LH, prolactin, TSH, and estradiol levels, as indicated by the clinical presentation 1
Further Testing
Further testing may be indicated based on the results of the initial evaluation, and may include:
- Assessment of androgens (DHEAS, testosterone) if hirsutism is present
- Pelvic ultrasound to evaluate for polycystic ovary syndrome or structural abnormalities
- A progesterone challenge test to determine estrogen status
- Brain MRI if prolactin is elevated to rule out pituitary adenoma 1
Treatment
Treatment of amenorrhea should be individualized and based on the underlying cause, ranging from lifestyle modifications for stress or weight-related amenorrhea to hormone replacement for hypogonadism or specific treatments for conditions like PCOS or hyperprolactinemia. According to 1, if amenorrhea persists and the woman finds it unacceptable, counseling on alternative contraceptive methods and offering another method if desired may be appropriate.
From the Research
Amenorrhea Workup
The workup for amenorrhea typically involves a combination of medical history, physical examination, and laboratory tests.
- A thorough history and physical examination can help narrow the differential diagnosis of amenorrhea 2, 3, 4, 5, 6.
- Initial workup of primary and secondary amenorrhea includes a pregnancy test and serum levels of luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone 2, 4, 6.
Primary Amenorrhea
Primary amenorrhea is defined as the absence of menarche by age 15 years 5 or the failure to reach menarche 2.
- The evaluation of primary amenorrhea includes a thorough health history, physical exam, lab evaluation, and, in some cases, imaging 5.
- Primary amenorrhea has three broad causes: genetic, hormonal, and anatomic 5.
Secondary Amenorrhea
Secondary amenorrhea is defined as the cessation of regular menses for three months or the cessation of irregular menses for six months 2 or previously regular menses for three months or previously irregular menses for six months 6.
- Pregnancy should be ruled out in all cases of secondary amenorrhea 2, 3, 4, 6.
- The treatment of secondary amenorrhea is based on the causative factor and may include hormone replacement therapy, contraception, or infertility services 2, 6.
Laboratory Tests
Laboratory tests for amenorrhea may include:
- Serum prolactin and thyroid-stimulating hormone (TSH) levels 4
- Progesterone challenge test to determine outflow tract patency and estrogen status 4
- Serum gonadotropin, follicle-stimulating hormone, and luteinizing hormone levels to determine whether amenorrhea represents ovarian failure or pituitary or hypothalamic dysfunction 4
- Karyotyping, serum androgen evaluation, and pelvic or brain imaging may be individualized 6