Polycystic ovary syndrome approach bmj best practice. Feb 06, 2020 management often involves a multidisciplinary approach, with a focus on lifestyle modification. Once pregnancy has been ruled out, a logical approach to women with either primary or secondary amenorrhea is to consider. Sep 16, 2003 prolactin is a pituitary hormone that plays a pivotal role in a variety of reproductive functions. Because of these varying clinical pictures, classifying amenorrhea according to those symptoms that may occur with it table 1 is helpful in organizing a practical approach to its diagnosis. A systematic approach to the evaluation of amenorrhea will aid in the diagnosis and treatment of its cause. Evaluation of primary amenorrhea approach bmj best practice. Amenorrhea is the transient or permanent absence of menstrual flow and may be subdivided into primary and secondary presentations, relative to menarche. Amenorrhea is common presenting complain in large number of gynaecological disorders.
Menopause is a clinical diagnosis, based on the absence of menses for 12 months. Secondary amenorrhea is a symptom that can be caused by many pathological states and some patients will not demonstrate an obvious etiology, therefore, correct diagnosis requires a systematic evaluation. Oct 14, 2019 in the differential diagnosis of primary or secondary amenorrhea, the most important step in diagnosis is to exclude pregnancy. Evaluation and management of amenorrhea related to congenital. Physiological states of amenorrhoea are seen, most commonly, during pregnancy and lactation breastfeeding, the latter also forming the basis of a form of contraception known as the lactational amenorrhoea method. This is a corrected version of the article that appeared in print. Amenorrhea is defined as the absence of menses in a woman in the reproductive age and can be classified into primary or secondary amenorrhea primary amenorrhea is the absence of menstrual blood flow in a woman who is older than 16 years of age with secondary sexual characteristics, or who is older than 14 years and without secondary sexual characteristics, who had never had menses. Primary amenorrhea is a symptom with a substantial list of. In most cases, there is plausible treatment for amenorrhea. Oligo or anovulation may manifest as menstrual bleeding at intervals of less than 21 days or greater than 35 days legro rs, arslanian sa, ehrmann da, et al.
Intended learning outcomes a student should be able to. Haefner, md professor, michigan medicine ann arbor, michigan, usa august 19, 2017. A systematic approach to diagnosis and management menstrual patterns can be an indicator of overall. Amenorrhea in adults causes and management medical. Although amenorrhea may result from a number of different conditions, a systematic evaluation including a detailed history, physical examination, and laboratory assessment of selected serum hormone levels can usually identify the underlying cause. Evaluating a patient for secondary amenorrhea and its underlying cause begins with a careful history and physical examination. Amenorrhea in adolescents newbery pediatric medicine. The definition amenorrhea is divided into two categories. Amenorrhea an approach to diagnosis and management afp 20. An initial secondary amenorrhea workup includes thyroid stimulating hormone tsh, prolactin, follicle stimulating hormone fsh, and luteinizing hormone. Multiple tests and repeated measurements are often needed.
Amenorrhea nursing pocket cards lippincott nursingcenter. Three structural entities must be considered the hypothalamopituitary axis, the ovaries, and the uterovaginal outflow tract. Klein, md, mph, san antonio military medical center, san antonio, texas, merrily a. The clinician should proceed cautiously and select appropriate laboratory studies which will be of maximal benefit to the patient. May be repeated in one month if needed to clarify diagnosis. Amenorrhea, the absence of menstrual bleeding, can be either primary or secondary. An approach to diagnosis and management a more recent article on amenorrhea is available. Secondary amenorrhea testing algorithm arup consult.
Outside the reproductive years, there is absence of menses during childhood and after menopause. Nov 19, 20 amenorrhea amenorrhea is a term describing the absence of a womans menstrual period during the age when the woman is reproductive. The etiologic and diagnostic considerations for oligomenorrhea are. Depending on the cause and consequences of the hyperprolactinemia, selected patients require treatment. Although amenorrhea may result from a number of different conditions, a systematic evaluation including a detailed history, physical examination, and laboratory. Nov 14, 2019 what is the definition of amenorrhea, primary and secondary amenorrhea. Pdf disruptions in the menstrual cycle are a common complaint in primary care and womens health. The overall goals of management of secondary amenorrhea are the same as for primary amenorrhea. Amenorrhea etiologic approach to diagnosis augusta. See epidemiology and causes of secondary amenorrhea and evaluation and management of primary amenorrhea and abnormal uterine bleeding in adolescents. Oestrogendeficient amenorrhea is associated with reduced bone mineral density and increased fracture risk, while oestrogenreplete amenorrhea can lead to dysfunctional. Amenorrhea the absence of menstrual bleeding may represent an anatomic or endocrine etiology. Amenorrhea is the term used when a woman or adolescent girl is not having menstrual periods. Classification of amenorrhea prepuberty pregnancy related menopause primary secondary amenorrhea physiological pathological 5.
An evidencebased approach to differential diagnosis henderson mc, tierney lm, jr. Women who have missed at least three menstrual periods in a row have amenorrhea, as do girls who havent begun menstruation by age 15. We go over the definition of amenorrhea, causes, and treatment options for amenorrhea. Amenorrhea is the absence of a menstrual period in a woman of reproductive age. If a tumor or structural blockage is causing the problem, surgery may be necessary. After pregnancy is excluded, an algorithmic approach is followed to narrow the diagnostic possibilities. H h sinha4 1, 2, 3 senoir resident 4professor abstract. Functional hypothalamic amenorrhea due to stress is a diagnosis of exclusion. In some cases, contraceptive pills or other hormone therapies can restart your menstrual cycles. Sanchez s, gelber s, fancher t sanchez, stephany, et al chapter 46. Poth, md, uniformed health services university of the health sciences, bethesda, maryland. Secondary and primary amenorrhea definition, causes, treatment. Amenorrhea is defined as the absence of menses in a woman in the reproductive age and can be classified into primary or secondary amenorrhea primary amenorrhea is the absence of menstrual blood flow in a woman who is older than 16 years of age with secondary sexual characteristics, or who is older than 14 years and without secondary sexual characteristics, who had.
Sep 30, 2019 the management of primary amenorrhea may vary considerably depending on the patient and the specific diagnosis. Our approach is consistent with the endocrine societys 2017 clinical practice guideline for the diagnosis and treatment of fha. There is also the goal of achieving the normal physiologic levels for menstruation to occur and hopefully, deter future problems with fertility and bone health. In the differential diagnosis of primary or secondary amenorrhea, the most important step in diagnosis is to exclude pregnancy.
Amenorrhea an approach to diagnosis and management afp. A schematic approach is presented which emphasizes several readily available and inexpensive tests within the capability of most laboratories. Diagnosis and management of hyperprolactinemia cmaj. Classification of amenorrhea prepuberty pregnancy related menopause primary secondary amenorrhea physiological. A structural cause of secondary amenorrhea is asher. Secondary amenorrhea occurs when youve had at least one menstrual period and you stop menstruating for three months or longer. Using an algorithmic approach to secondary amenorrhea. Hypothalamic amenorrhea is another condition to consider in evaluating symptoms of polycystic ovary syndrome.
N2 whether amenorrhea is primary or secondary, identification of the lesion by anatomic site permits a practical approach to etiologic diagnosis and to appropriate management. Hyperprolactinemia is a common condition that can result from a number of causes, including medication use and hypothyroidism as well as pituitary disorders. Prolactin is a pituitary hormone that plays a pivotal role in a variety of reproductive functions. The approach to managing females with amenorrhea is dictated by the underlying cause.
Pathophysiology and clinical manifestations and evaluation and management of primary amenorrhea and evaluation and management of secondary amenorrhea. Amenorrhea differential diagnoses medscape reference. Treatment options differ for both primary and secondary amenorrhea. There are a number of steps your doctor will take to determine whether you have amenorrhea. Disruptions in the menstrual cycle are a common complaint in primary care and womens health. Initial workup of primary and secondary amenorrhea includes a pregnancy test and serum levels of luteinizing hormone, folliclestimulating. Klein, md, mph, san antonio military medical center, san antonio, texas. It is intended primarily for clinicians and is not an exhaustive, comprehensive arrangement of every clinical entity which could be grouped under the heading of primary amenorrhea. An approach to diagnosis and management although amenorrhea may result from a number of different conditions, a systematic evaluation including a detailed history. Treatment depends on the underlying cause of your amenorrhea. Amenorrhea is the absence or abnormal cessation of the menses physiologial amenorrhea pathologial amenorrhea 3. Most cases of secondary amenorrhea can be attributed to polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, or primary ovarian.
Amenorrhea amenorrhea is a term describing the absence of a womans menstrual period during the age when the woman is reproductive. Treatment goals for patients with amenorrhea may vary considerably, and depend on the patient and the specific diagnosis. The ultimate treatment goal depends on the womans specific personal goals i. Primary amenorrhea, which by definition is failure to reach menarche, is often the result of chromosomal irregularities leading to primary ovarian. Oct 14, 2019 functional hypothalamic amenorrhea due to stress is a diagnosis of exclusion. Amenorrhea uhmenoreeuh is the absence of menstruation one or more missed menstrual periods.
This article discusses secondary amenorrhea and provides a systematic approach to its diagnostic evaluation, with referral considerations. The most common etiologies are pregnancy and polycystic ovarian syndrome pcos. Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. The absence of menstrual bleeding may represent an anatomic or endocrine etiology. Management often involves a multidisciplinary approach, with a focus on lifestyle modification. First, your doctor will ask you about your symptoms to get a better picture of. An occult eating disorder and caloric restriction must be ruled out as a compounding factor. Diagnosis and treatment of polycystic ovary syndrome. Elicit a pertinent history to evaluate amenorrhea and list the essential. Amenorrhea in adults causes and management medical magazine. What is the definition of amenorrhea, primary and secondary amenorrhea. Mar 17, 2011 amenorrhea is the absence or abnormal cessation of the menses physiologial amenorrhea pathologial amenorrhea 3.
Amenorrhea including hypothalmic amenorrhea is a condition in which there is an absense of menstrual periods in a woman. Functional hypothalamic amenorrhea is a disorder of chronic anovulation caused by suppression of the hypothalamicpituitary axis from body weight loss, excessive exercise, or stress and may result. Management the overall goals of management of secondary amenorrhea are the same as for primary amenorrhea. Secondary amenorrhea is defined as the absence of menstrual flow in women with previously normal menstruation. The most important steps in the effective management of mullerian agenesis are correct diagnosis of the underlying condition, evaluation for associated congenital anomalies, and psychosocial counseling in addition to treatment or intervention to address the functional effects of genital anomalies. Depending on the severity, pharmacologic therapy may also be considered. Evaluation and management of primary amenorrhea uptodate. Vulvodynia approach diagnosis and treatment hope k. Oligo or amenorrhea should be present for at least 2 years after menarche or primary amenorrhea at age 16.
Evaluation and management of secondary amenorrhea uptodate. It is intended primarily for clinicians and is not an exhaustive, comprehensive arrangement of every clinical entity which could. The management of primary amenorrhea may vary considerably depending on the patient and the specific diagnosis. Although overlapping attributes exist between the two groups, the diagnostic approaches vary significantly. Serum folliclestimulating hormone fsh is recommended for diagnosis in women under 40 years of age, and may be helpful in women ages 40 to 45 years.
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