What is the workup for Amenorrhea (Absence of Menstruation)?

From the Guidelines

Amenorrhea does not require any medical treatment, and the initial approach should be to provide reassurance, with consideration of ruling out pregnancy if clinically indicated. The workup for amenorrhea should be guided by the clinical presentation and patient preferences. According to the U.S. selected practice recommendations for contraceptive use, 2013 1, if a woman’s regular bleeding pattern changes abruptly to amenorrhea, pregnancy should be ruled out if clinically indicated.

Key Considerations

• If amenorrhea persists and the woman finds it unacceptable, counseling on alternative contraceptive methods should be offered, and another method provided if desired 1.
• The focus should be on addressing the patient's concerns and providing guidance on contraceptive options rather than immediately pursuing extensive medical testing.

Approach to Amenorrhea

• The initial step is to assess the patient's overall health and determine if there are any underlying conditions that may be contributing to the amenorrhea.
• A pregnancy test should be considered if there is a possibility of pregnancy, as this is a common cause of missed periods.
• Further evaluation and testing should be tailored to the individual patient's needs and preferences, rather than following a standardized protocol.

Patient-Centered Care

• It is essential to prioritize patient-centered care and address the patient's concerns and preferences when managing amenorrhea.
• Providing reassurance and counseling on contraceptive options can help alleviate anxiety and improve patient satisfaction.
• By taking a patient-centered approach, healthcare providers can deliver high-quality care that meets the unique needs of each individual.

From the FDA Drug Label

The workup and treatment of candidates for clomiphene citrate therapy should be supervised by physicians experienced in management of gynecologic or endocrine disorders. Patients should be chosen for therapy with clomiphene citrate only after careful diagnostic evaluation Impediments to achieving the goal of therapy must be excluded or adequately treated before beginning clomiphene citrate. Patients selected for clomiphene citrate therapy should be evaluated in regard to the following:

• Estrogen Levels
• Primary Pituitary or Ovarian Failure
• Endometriosis and Endometrial Carcinoma
• Other Impediments to Pregnancy Pelvic examination is necessary prior to the first and each subsequent course of clomiphene citrate treatment. Endometrial biopsy should always be performed prior to clomiphene citrate therapy in this population.

The workup for Amenorrhea includes:

• Careful diagnostic evaluation
• Excluding impediments to achieving pregnancy
• Evaluating Estrogen Levels
• Ruling out Primary Pituitary or Ovarian Failure
• Checking for Endometriosis and Endometrial Carcinoma
• Identifying Other Impediments to Pregnancy
• Performing a Pelvic examination
• Conducting an Endometrial biopsy in certain populations 2 2

From the Research

Workup for Amenorrhea

The workup for amenorrhea involves a systematic evaluation to identify the underlying cause. This includes:

• A detailed history to identify menstrual onset and patterns, eating and exercise habits, presence of psychosocial stressors, body weight changes, medication use, galactorrhea, and chronic illness 3
• A physical examination to identify anthropometric and pubertal development trends 3
• Laboratory assessment of selected serum hormone levels, including:
  • Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to evaluate ovarian function 4, 5, 6, 3
  • Prolactin to evaluate for hyperprolactinemia 4, 5, 6, 3
  • Thyroid-stimulating hormone (TSH) to evaluate for thyroid dysfunction 4, 5, 6, 3
• A pregnancy test to rule out pregnancy as a cause of secondary amenorrhea 4, 5, 6, 3

Additional Testing

Additional testing may be individualized based on the patient's presentation and initial laboratory results. This may include:

• Karyotyping to evaluate for chromosomal abnormalities 6, 3
• Serum androgen evaluation to evaluate for hyperandrogenism 5, 3
• Pelvic or brain imaging to evaluate for anatomical abnormalities 5, 6, 3

Diagnosis and Treatment

The diagnosis and treatment of amenorrhea depend on the underlying cause. Treatment goals include:

• Prevention of complications such as osteoporosis, endometrial hyperplasia, and heart disease 4, 6, 3
• Preservation of fertility 4, 5, 6, 3
• Progression of normal pubertal development in patients with primary amenorrhea 6
• Addressing the underlying cause of amenorrhea, such as polycystic ovary syndrome (PCOS), hypothalamic amenorrhea, or primary ovarian insufficiency 4, 5, 6, 3