Basics
Description
- Absence of menstruation
- Primary amenorrhea:
- No spontaneous uterine bleeding by age 16 yr or within 5 yr of breast development, which should occur by age 13.
- Secondary amenorrhea:
- Absence of uterine bleeding for 3 mo in a woman with prior regular menses or for 9 mo in a woman with prior oligomenorrhea
- More common than primary amenorrhea
- Pregnancy is the most common cause.
Etiology
- Primary:
- Gonadal failure
- Hypothalamic-pituitary disorder
- Chromosomal abnormalities
- Imperforate hymen
- Turner syndrome
- Secondary:
- Pregnancy, breast-feeding, or postpartum
- Asherman syndrome (intrauterine adhesions)
- Dysfunction of the hypothalamic-pituitary-ovarian axis
- Polycystic ovarian syndrome (PCOS)
- Endocrinopathies
- Obesity, starvation, anorexia nervosa, or intense exercise
- Drugs:
- Oral contraceptives
- Antipsychotics
- Antidepressants
- Calcium channel blockers
- Chemotherapeutic agents
- Digitalis
- Marijuana
- Autoimmune disorders
- Ovarian failure
- Menopause
Diagnosis
Signs and Symptoms
History
- Menarche and menstrual history
- Sexual activity
- Exercise, weight loss
- Chronic illness
- Medications
- Previous CNS radiation or chemotherapy
- Family history
- Infertility
Physical Exam
- Low estrogen:
- Atrophic vaginal mucosa
- Mood swings, irritability
- High androgen:
- Truncal obesity
- Hirsutism
- Acne
- Male-pattern baldness
- Thyroid exam
- Pelvic/genital exam
- Tanner staging
Essential Workup
Pregnancy test
Diagnosis Tests & Interpretation
Lab
- If pregnancy test is negative, no further testing is needed emergently.
- May send TSH, prolactin, LH, FSH for follow-up by gynecology or primary care physician
Imaging
None needed emergently unless concern for ectopic pregnancy or other emergency as directed by patients presentation
Diagnostic Procedures/Surgery
None needed emergently
Differential Diagnosis
Pregnancy
Treatment
Pre-Hospital
If amenorrhea is the result of pregnancy, stabilize patient as appropriate for pregnancy.
Ed Treatment/Procedures
Reassurance and referral for follow-up
Medication
Defer for gynecology evaluation.
Follow-Up
Disposition
Admission Criteria
No need for admission unless concern for ectopic pregnancy
Discharge Criteria
Discharge with appropriate referral.
Issues for Referral
Referral to gynecology
Followup Recommendations
Gynecology follow-up is recommended.
Pearls and Pitfalls
- Pregnancy is the most relevant etiology of amenorrhea in the emergency department.
- Urine pregnancy test (UPT) may give false negative with low urine specific gravity.
- UPT sensitivity for β-HCG level may vary depending on type/manufacturer. High concern for amenorrhea due to pregnancy, specifically an ectopic, may warrant a qualitative serum pregnancy test
- Anorexia nervosa is an important consideration in patients with amenorrhea, particularly in adolescents.
Additional Reading
- Heiman DL. Amenorrhea. Prim Care Clin Office Pract. 2009;36:1-17.
- Lentz G, Lobo R, Gershenson D, et al. Comprehensive Gynecology, 6th ed. Philadelphia, PA: Mosby; 2012.
- Rosenberg HK. Sonography of the pelvis in patients with primary amenorrhea. Endocrinol Metab Clin N Am. 2009;38:739-760.
- Santoro N. Update in hyper- and hypogonadotropic amenorrhea. J Clin Endocrinol Metab. 2011;96:3281-3288.
Codes
ICD9
- 256.8 Other ovarian dysfunction
- 626.0 Absence of menstruation
ICD10
- N91.0 Primary amenorrhea
- N91.1 Secondary amenorrhea
- N91.2 Amenorrhea, unspecified
- E28.8 Other ovarian dysfunction
SNOMED
- 14302001 Amenorrhea (finding)
- 8913004 Primary physiologic amenorrhea (finding)
- 86030004 Secondary physiologic amenorrhea (finding)
- 444769001 anovulatory amenorrhea (finding)