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Amenorrhea, Emergency Medicine

Basics

Description

- 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

- Low estrogen: - Atrophic vaginal mucosa - Mood swings, irritability

- High androgen: - Truncal obesity - Hirsutism - Acne - Male-pattern baldness

  • 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 oligomenorrheaMore common than primary amenorrheaPregnancy is the most common cause.

Etiology

  • Primary:Gonadal failureHypothalamic-pituitary disorderChromosomal abnormalitiesImperforate hymenTurner syndrome
  • Secondary:Pregnancy, breast-feeding, or postpartumAsherman syndrome (intrauterine adhesions)Dysfunction of the hypothalamic-pituitary-ovarian axisPolycystic ovarian syndrome (PCOS)EndocrinopathiesObesity, starvation, anorexia nervosa, or intense exerciseDrugs:Oral contraceptivesAntipsychoticsAntidepressantsCalcium channel blockersChemotherapeutic agentsDigitalisMarijuanaAutoimmune disordersOvarian failureMenopause

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 mucosaMood swings, irritability
  • High androgen:Truncal obesityHirsutismAcneMale-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)