From the Guidelines
The workup for amenorrhea should begin with a pregnancy test, and if the patient's regular bleeding pattern changes abruptly to amenorrhea, consider ruling out pregnancy if clinically indicated, as stated in the 2013 U.S. Selected Practice Recommendations for Contraceptive Use 1.
Initial Evaluation
The initial evaluation of a patient with amenorrhea should include a thorough medical history and physical examination to identify any underlying causes.
- The patient's medical history should be reviewed to identify any potential causes of amenorrhea, such as pregnancy, hormonal imbalances, or structural abnormalities.
- A physical examination should be performed to assess for signs of androgen excess, thyroid dysfunction, and estrogen status.
Laboratory Testing
If the patient's regular bleeding pattern changes abruptly to amenorrhea, laboratory testing may be necessary to rule out underlying causes.
- A pregnancy test should be performed to rule out pregnancy as a cause of amenorrhea.
- If the patient has a history of athletic activity or disordered eating, consideration should be given to evaluating for functional hypothalamic amenorrhea, as recommended by the 2014 Female Athlete Triad Coalition Consensus Statement 1.
Treatment
The treatment of amenorrhea should be guided by the underlying cause, and if amenorrhea persists and the woman finds it unacceptable, counsel her on alternative contraceptive methods, and offer another method if it is desired, as stated in the 2013 U.S. Selected Practice Recommendations for Contraceptive Use 1.
- If the patient is found to have a hormonal imbalance, such as polycystic ovary syndrome (PCOS) or hyperprolactinemia, treatment should be targeted at correcting the underlying hormonal imbalance.
- If the patient is found to have a structural abnormality, such as an outflow tract obstruction, treatment should be targeted at correcting the underlying anatomical abnormality.
- Lifestyle modifications, such as changes to diet and exercise, may also be recommended to help manage amenorrhea.
From the Research
Workup for Amenorrhea
The workup for amenorrhea, which is the absence of menstruation, typically involves a systematic evaluation including:
- A detailed history
- Physical examination
- Laboratory assessment of selected serum hormone levels 2, 3, 4, 5, 6 The initial workup of primary and secondary amenorrhea includes:
- A pregnancy test
- Serum levels of luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone 2, 5, 6
Diagnostic Approach
The diagnostic approach to amenorrhea is based on the presence or absence of sexual development and the distinction between primary and secondary amenorrhea 3, 6
- Primary amenorrhea is often the result of chromosomal irregularities leading to primary ovarian insufficiency or anatomic abnormalities 2
- Secondary amenorrhea is defined as the cessation of regular menses for three months or the cessation of irregular menses for six months 2 The most common causes of secondary amenorrhea include:
- Polycystic ovary syndrome
- Hypothalamic amenorrhea
- Hyperprolactinemia
- Primary ovarian insufficiency 2, 6
Laboratory Tests
Laboratory tests that may be ordered as part of the workup for amenorrhea include:
- Follicle-stimulating hormone (FSH)
- Luteinizing hormone (LH)
- Thyroid-stimulating hormone (TSH)
- Prolactin
- Androgen levels (in the presence of acne or hirsutism) 4, 5, 6 Additional testing, such as karyotyping, serum androgen evaluation, and pelvic or brain imaging, may be individualized based on the patient's presentation and initial test results 5