What are the guidelines for a 17-year-old female experiencing amenorrhea (absence of menstruation) for 4 months?

Management of Amenorrhea in a 17-Year-Old Female

A 17-year-old female with amenorrhea for 4 months requires prompt evaluation and referral to gynecology/endocrinology, as this meets the clinical definition of secondary amenorrhea and may indicate premature ovarian insufficiency or other serious underlying conditions.

Definition and Initial Assessment

• Secondary amenorrhea is defined as the absence of menstrual cycles for ≥4 months in a previously menstruating female 1
• For adolescents, this duration of amenorrhea is considered abnormal even in the early gynecologic years, as the 95th percentile for time interval between cycles is 90 days 2

Initial Evaluation

• Pregnancy test should be the first step in any amenorrhea evaluation 3, 4

• Detailed history focusing on:

  • Previous menstrual patterns 4
  • Weight changes, eating habits, and exercise patterns 4
  • Medication use that might affect cycle regularity 1
  • Symptoms of hyperandrogenism (hirsutism, acne) 1
  • Symptoms of thyroid dysfunction 4
  • History of cancer treatment, particularly with alkylating agents or radiation 1

• Physical examination should assess:

  • Pubertal development (Tanner staging) 1
  • Signs of hyperandrogenism 1
  • Signs of thyroid dysfunction 4

Laboratory Assessment

• Initial laboratory evaluation should include:

  • Follicle-stimulating hormone (FSH) and estradiol 1
  • Luteinizing hormone (LH) 4
  • Thyroid-stimulating hormone (TSH) 4
  • Prolactin 1, 4

• If amenorrhea persists and initial labs are normal, consider:

  • Anti-Müllerian hormone (AMH) in conjunction with FSH and estradiol for females ≥25 years 1

Referral Criteria

• Referral to gynecology/endocrinology is recommended for any adolescent with:
  • Amenorrhea for ≥4 months 1
  • Primary amenorrhea by 16 years of age 1

Management Approach

If Pregnancy Test is Negative:

1. Rule out structural causes:

   • Consider pelvic ultrasound if physical examination suggests anatomical abnormalities 1

2. Evaluate for endocrine disorders:

   • Polycystic ovary syndrome (PCOS): Often presents with irregular cycles and signs of hyperandrogenism 5
   • Hypothalamic amenorrhea: Associated with stress, excessive exercise, or nutritional deficiency 5
   • Hyperprolactinemia: May be associated with galactorrhea 1
   • Primary ovarian insufficiency: Particularly in those with history of cancer treatment 1
   • Thyroid dysfunction: Can cause menstrual irregularities 4

3. Consider medication-induced amenorrhea:

   • Certain medications including mood-altering drugs, antibiotics, and anti-inflammatory drugs can alter cycle regularity 1

Treatment Based on Etiology:

• Hypothalamic amenorrhea:

  • Evaluate for disordered eating and low bone density 4
  • Address underlying causes (stress, excessive exercise, nutritional deficiencies) 5
  • Consider hormone replacement therapy to prevent bone density loss 1

• Polycystic ovary syndrome:

  • Screen for metabolic disorders (glucose intolerance, dyslipidemia) 4
  • Consider hormonal contraception for cycle regulation and management of hyperandrogenism 5

• Primary ovarian insufficiency:

  • Consider sex steroid replacement therapy 1
  • Referral to reproductive endocrinology for fertility concerns 1

• Medication-induced amenorrhea:

  • Consider alternative medications or barrier contraception until effect on cycle is determined 1

Special Considerations for Cancer Survivors

• Survivors treated with alkylating agents or radiation to fields that include the ovaries are at high risk for premature ovarian insufficiency 1
• These patients require specialized follow-up and consideration of hormone replacement therapy 1

Follow-up

• If amenorrhea persists and the patient finds it unacceptable despite appropriate evaluation and management, counsel on alternative methods of hormonal management 1
• Monitor bone health in patients with prolonged hypoestrogenic states 2
• Provide emotional support and education about the condition and treatment options 4

Pitfalls to Avoid

• Do not dismiss amenorrhea as a normal variant in adolescents - absence of menses for >3 months warrants evaluation 2
• Do not assume infertility in patients with primary ovarian insufficiency, as unpredictable ovarian function may persist 3, 4
• Do not overlook the importance of the ovary as an endocrine organ that maintains bone health 2