Treatment of Amenorrhea
The treatment of amenorrhea should be directed at the underlying cause, with most cases not requiring medical treatment unless the patient finds the condition unacceptable or there are associated health concerns. 1
Diagnostic Approach
Before initiating treatment, it's essential to determine the cause of amenorrhea:
- Rule out pregnancy - Always the first step for secondary amenorrhea
- Laboratory assessment:
- Luteinizing hormone (LH)
- Follicle-stimulating hormone (FSH)
- Prolactin
- Thyroid-stimulating hormone (TSH)
- Categorize the type of amenorrhea:
- Primary (never had menses by age 15 or 3 years post-thelarche)
- Secondary (cessation of regular menses for 3 months or irregular menses for 6 months)
Treatment Algorithm Based on Etiology
1. Contraceptive-Related Amenorrhea (e.g., LNG-IUD)
- No treatment required - Provide reassurance that this is an expected effect 1
- If amenorrhea persists and the woman finds it unacceptable, counsel on alternative contraceptive methods 1
2. Hyperprolactinemia-Associated Amenorrhea
- Bromocriptine is FDA-indicated for treatment of amenorrhea associated with hyperprolactinemia 2
- Bromocriptine therapy suppresses galactorrhea and reinitiates normal ovulatory menstrual cycles in about 75% of cases 2
- Typical response time is 6-8 weeks, though some patients respond within days while others may take up to 8 months 2
- Monitor for side effects including nausea, headache, dizziness, and hypotension 2
3. Hypothalamic Amenorrhea
- Address underlying causes (stress, excessive exercise, eating disorders)
- Hormone replacement therapy to prevent bone density loss and other complications of hypoestrogenism 3
- For patients desiring pregnancy, ovulation induction with pulsatile gonadotropin-releasing hormone (GnRH) may be effective 3
4. Primary Ovarian Insufficiency
- Hormone replacement therapy to prevent osteoporosis and cardiovascular disease 3
- Patients should not be presumed infertile as unpredictable ovarian function can occur 4, 5
5. Polycystic Ovary Syndrome (PCOS)
- Cyclic progestogen or combined hormonal contraceptives to regulate menstrual cycles 3
- Screen for and address metabolic complications (glucose intolerance, dyslipidemia) 4, 5
- For hirsutism and acne, oral contraceptives with or without antiandrogens 3
6. Anatomical Abnormalities
- Surgical correction for outflow tract obstructions (e.g., imperforate hymen, transverse vaginal septum) 6
Special Considerations
Contraceptive Effectiveness
If contraception is a concern while treating amenorrhea, consider the following effectiveness rates:
- LARCs (IUDs and implants): <1% failure rate 7
- Progestin-only pills: 5-9% failure rate 7
- Combined hormonal contraceptives: 5-9% failure rate 7
Bone Health
Patients with hypothalamic amenorrhea and hypoestrogenic states are at risk for decreased bone density and should be monitored and treated accordingly 4, 5
Fertility Preservation
For patients with amenorrhea who desire future fertility:
- Those with hyperprolactinemia may respond to bromocriptine 2
- Those with PCOS may require ovulation induction 3
- Those with primary ovarian insufficiency should be counseled about fertility preservation options 5
Pitfalls to Avoid
Assuming all amenorrhea requires treatment - Amenorrhea associated with contraceptives like LNG-IUD is expected and generally harmless 1
Missing pregnancy - Always rule out pregnancy before initiating any treatment for secondary amenorrhea 4, 5
Overlooking eating disorders - Patients with hypothalamic amenorrhea should be evaluated for disordered eating 4, 5
Assuming infertility in primary ovarian insufficiency - These patients can maintain unpredictable ovarian function 4, 5
Neglecting metabolic screening in PCOS - These patients need monitoring for glucose intolerance and dyslipidemia 4, 5
By following this structured approach to the treatment of amenorrhea, clinicians can address the underlying cause while minimizing complications and preserving fertility when desired.