What are the management options for amenorrhea (absence of menstruation)?

Management of Amenorrhea

Amenorrhea does not require medical treatment in most cases and reassurance is the primary management approach, though underlying causes should be identified and addressed when clinically indicated. 1

Diagnostic Approach

• First, rule out pregnancy in all cases of amenorrhea, as this is the most common cause in women of reproductive age 2, 3
• Determine if amenorrhea is primary (absence of menarche by age 16) or secondary (cessation of previously established menses for ≥3 months if regular cycles or ≥6 months if irregular cycles) 2, 4
• Assess for underlying causes through targeted history, physical examination, and laboratory testing 4
  • Measure serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and thyroid-stimulating hormone (TSH) 4
  • Consider additional testing based on initial findings (karyotyping, androgen levels, pelvic/brain imaging) 4

Management Based on Etiology

Contraceptive-Related Amenorrhea

LNG-IUD Related Amenorrhea

• Provide reassurance as amenorrhea with LNG-IUD is common (approximately 50% of users by 2 years) and not harmful 1
• If amenorrhea occurs abruptly, consider ruling out pregnancy if clinically indicated 1
• If amenorrhea persists and is unacceptable to the patient, counsel on alternative contraceptive methods 1

DMPA (Depot Medroxyprogesterone Acetate) Related Amenorrhea

• Counsel that amenorrhea is common after ≥1 year of continuous DMPA use and is not harmful 1
• Provide reassurance that no medical treatment is required 1
• If amenorrhea is unacceptable to the patient, consider alternative contraceptive methods 1
• For patients who wish to reverse DMPA-induced amenorrhea, treatment with combined oral contraceptives has been shown to be more effective than placebo 1

Non-Contraceptive Related Amenorrhea

Polycystic Ovary Syndrome (PCOS)

• Screen for and address metabolic complications (glucose intolerance, dyslipidemia) 4
• Cyclical progestogen administration or sequential estrogen plus progestogen can be used to induce menstrual bleeding 3
• Combined hormonal contraceptives are indicated for patients with acne and hirsutism 3
• For fertility concerns, consider ovulation induction with medications such as clomiphene citrate 5, 3

Hypothalamic Amenorrhea

• Evaluate for disordered eating, excessive exercise, and stress 2, 4
• Address underlying causes through lifestyle modifications and psychological support 3
• Consider sequential estrogen and progestogen therapy to prevent estrogen deficiency 3
• Monitor for decreased bone density, which is a risk in this population 4

Hyperprolactinemia

• Evaluate for pituitary adenoma with appropriate imaging 3
• Treatment options include:
  • Prolactin-lowering drugs for patients desiring fertility 3
  • Cyclical progestogen or hormone replacement therapy for menstrual regulation 3
  • Combined hormonal contraceptives if contraception is needed 3

Primary Ovarian Insufficiency

• Hormone replacement therapy is indicated to prevent complications of hypoestrogenism (cardiovascular disease, osteoporosis) 3
• Patients should not be presumed infertile as unpredictable ovarian function may occur 2, 4
• Consider referral to reproductive endocrinology for fertility concerns 4

Special Considerations

Chemotherapy-Induced Amenorrhea

• Cessation of menses due to chemotherapy alone does not necessarily indicate permanent menopause 1
• Hormone levels and absence of menses are unreliable indicators of menopause during treatment with tamoxifen 1
• Evidence is insufficient to recommend bone-modifying agents as adjuvant treatment in this population 1

Anatomical Causes

• For congenital outflow tract obstructions (transverse vaginal septum, imperforate hymen), surgical correction is indicated 6
• For müllerian agenesis, confirm 46,XX karyotype and provide appropriate counseling 6

Treatment Goals

• Prevent complications such as osteoporosis, endometrial hyperplasia, and cardiovascular disease 6
• Preserve fertility when possible and desired 6
• Address patient concerns about amenorrhea and its impact on quality of life 4
• In primary amenorrhea, facilitate progression of normal pubertal development 6