What is the workup for three months of amenorrhea (absence of menstruation)?

From the Guidelines

The workup for three months of amenorrhea should begin with ruling out pregnancy if clinically indicated, as this is the most straightforward and non-invasive initial step. According to the U.S. Selected Practice Recommendations for Contraceptive Use, 2013, adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use, 2nd edition 1, if a woman’s regular bleeding pattern changes abruptly to amenorrhea, considering ruling out pregnancy is essential.

Key Considerations

• Amenorrhea does not necessarily require medical treatment, and reassurance can be provided to the patient, as stated in the study 1.
• If the amenorrhea persists and the woman finds it unacceptable, counseling on alternative contraceptive methods and offering another method if desired is recommended 1.

Evaluation and Management

The evaluation should focus on identifying potential causes of amenorrhea, including hormonal imbalances, and the patient's medical history and physical examination are crucial in this process.

• Measuring hormone levels such as FSH, LH, estradiol, prolactin, TSH, and testosterone may be necessary to identify potential hormonal imbalances.
• A comprehensive medical history, including weight changes, exercise habits, stress levels, and medication use, is essential.
• Additional testing, such as a progesterone challenge test or pelvic ultrasound, may be warranted based on the patient's presentation and initial evaluation findings.

Treatment

Treatment of amenorrhea depends on the underlying cause and may include lifestyle modifications, hormonal therapy, or specific medications targeting the identified disorder.

• For patients not seeking pregnancy, cyclic hormonal therapy, such as combined oral contraceptives, may be used to prevent endometrial hyperplasia and maintain bone health, although this is not explicitly mentioned in the provided study 1, it is a common practice in clinical medicine. Regular follow-up is important to monitor response to treatment and adjust management as needed.

From the FDA Drug Label

Since pregnancy is often the therapeutic objective in many hyperprolactinemic patients presenting with amenorrhea/galactorrhea and hypogonadism (infertility), a careful assessment of the pituitary is essential to detect the presence of a prolactin-secreting adenoma Patients not seeking pregnancy, or those harboring large adenomas, should be advised to use contraceptive measures, other than oral contraceptives, during treatment with bromocriptine mesylate Since pregnancy may occur prior to reinitiation of menses, a pregnancy test is recommended at least every four weeks during the amenorrheic period, and, once menses are reinitiated, every time a patient misses a menstrual period.

The workup for three months of amenorrhea includes:

• A careful assessment of the pituitary to detect the presence of a prolactin-secreting adenoma
• Pregnancy testing at least every four weeks during the amenorrheic period 2

From the Research

Workup for Three Months of Amenorrhea

The workup for three months of amenorrhea, also known as secondary amenorrhea, involves a systematic evaluation to identify the underlying cause. The following steps are recommended:

• Pregnancy test to rule out pregnancy as the most common cause of amenorrhea 3, 4, 5
• Serum levels of:
  • Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to evaluate ovarian function 3, 4, 5
  • Prolactin to check for hyperprolactinemia 3, 4, 5
  • Thyroid-stimulating hormone (TSH) to evaluate thyroid function 3, 4, 5
• Physical examination to identify anthropometric and pubertal development trends 6, 5
• Medical history to identify potential causes of amenorrhea, such as eating disorders, stress, or vigorous exercise 3, 4, 5
• Additional testing, such as karyotyping, serum androgen evaluation, or pelvic or brain imaging, may be individualized based on the patient's presentation and initial test results 4, 5

Potential Causes of Secondary Amenorrhea

The potential causes of secondary amenorrhea include:

• Polycystic ovary syndrome (PCOS) 3, 5
• Hypothalamic amenorrhea, often associated with eating disorders, stress, or vigorous exercise 3, 4, 5
• Hyperprolactinemia 3, 4, 5
• Primary ovarian insufficiency (POI) 3, 7, 5
• Other endocrine gland disorders, such as thyroid disease 4, 7, 5
• Sequelae of chronic disease or physiologic conditions, such as weight loss or gain 3, 4, 5