From the Guidelines
Amenorrhea should be evaluated and managed based on its underlying cause, with a focus on addressing stressors, ensuring adequate nutrition, and regulating hormonal imbalances to improve morbidity, mortality, and quality of life. The diagnosis of amenorrhea involves a thorough history, physical examination, and laboratory tests, including pregnancy test, thyroid function, prolactin levels, and possibly FSH/LH levels 1. Secondary amenorrhea is commonly caused by pregnancy, polycystic ovary syndrome (PCOS), hypothalamic dysfunction, hyperprolactinemia, premature ovarian insufficiency, or thyroid disorders. Treatment depends on the underlying cause:
- for PCOS, combined hormonal contraceptives or cyclic progestin therapy can regulate cycles
- for hypothalamic amenorrhea, addressing underlying stressors and ensuring adequate nutrition is essential
- for hyperprolactinemia, bromocriptine or cabergoline may be prescribed 1. Patients with amenorrhea should be monitored for complications like endometrial hyperplasia or decreased bone density, especially if estrogen levels are low 1. Lifestyle modifications including maintaining healthy weight, managing stress, and avoiding excessive exercise can help restore normal menstrual function in many cases. Key factors to consider in the evaluation and management of amenorrhea include:
- Menstrual history and physical examination to assess for signs of hormonal imbalances or other underlying causes
- Laboratory tests to rule out pregnancy, thyroid disorders, and other hormonal imbalances
- Pelvic ultrasound and endometrial sampling to rule out other gynaecological pathologies
- Treatment of underlying causes, such as PCOS, hypothalamic amenorrhea, or hyperprolactinemia, to regulate menstrual cycles and improve quality of life. According to the most recent study 1, functional hypothalamic amenorrhea (FHA) is a common cause of secondary amenorrhea, and its diagnosis and management should focus on addressing stressors, ensuring adequate nutrition, and regulating hormonal imbalances.
From the Research
Definition and Classification of Amenorrhea
- Amenorrhea is defined as the absence of menstruation, which can be primary (before menarche) or secondary (after menarche) 2, 3, 4.
- Primary amenorrhea is often caused by chromosomal irregularities, primary ovarian insufficiency, or anatomic abnormalities, while secondary amenorrhea can be attributed to polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, or primary ovarian insufficiency 2.
Diagnosis and Evaluation of Amenorrhea
- A systematic evaluation, including a detailed history, physical examination, and laboratory assessment of selected serum hormone levels, can usually identify the underlying cause of amenorrhea 2, 3.
- Initial workup of primary and secondary amenorrhea includes a pregnancy test and serum levels of luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone 2, 3.
- Additional testing, such as karyotyping, serum androgen evaluation, and pelvic or brain imaging, should be individualized 3.
Differentiation between Functional Hypothalamic Amenorrhea and Polycystic Ovary Syndrome
- Functional hypothalamic amenorrhea (FHA) can be differentiated from polycystic ovary syndrome (PCOS) based on clinical and biochemical parameters, such as body mass index (BMI), luteinizing hormone (LH) levels, and LH to follicle-stimulating hormone (FSH) ratio 5.
- BMI had the greatest predictive performance for FHA, followed by estradiol, LH, and LH:FSH ratio 5.
Treatment of Amenorrhea
- Treatment goals for patients with amenorrhea may vary considerably and depend on the patient and the specific diagnosis 2.
- Patients with primary ovarian insufficiency can maintain unpredictable ovarian function and may require hormone replacement therapy, contraception, or infertility services 2, 3.
- Patients with polycystic ovary syndrome should undergo screening and intervention to attenuate metabolic disease and endometrial cancer risk 2, 3.
- Gonadotropins, such as follicle-stimulating hormone (FSH), can be used for ovulation induction in women with PCOS who do not ovulate or conceive on clomiphene citrate or letrozole 6.