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Amenorrhea

Amenorrhea is a topic covered in the 5-Minute Clinical Consult.

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5-Minute Clinical Consult

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Basics

Description

  • Primary amenorrhea
    • No menses by age 13 years with absence of secondary sexual characteristics OR
    • No menses by age 15 years with normal secondary characteristics
  • Secondary amenorrhea: cessation of menses for 3 months if previously normal menstruation or 6 months if a history of irregular cycles
  • System(s) affected: endocrine/metabolic; reproductive

Pregnancy Considerations
Pregnancy is by far the most common cause of secondary amenorrhea.

Epidemiology

Prevalence
  • Primary amenorrhea: <1% of female population
  • Secondary amenorrhea: 3–5% of female population
  • No evidence for race and ethnicity affecting prevalence

Etiology and Pathophysiology

Absence of menses that can be temporary or permanent due to dysfunction of the hypothalamus, pituitary, uterus, ovaries, or vagina

Etiology and Pathophysiology

  • Primary amenorrhea
    • Gonadal dysgenesis (e.g., Turner syndrome [45,X]) or failure (e.g., autoimmune, idiopathic)
    • Anatomic abnormalities (e.g., müllerian agenesis, imperforate hymen, transverse vaginal septum)
    • Hypothalamic–pituitary abnormalities
      • Functional hypothalamic amenorrhea (reduced GnRH secretion, e.g., weight loss/anorexia nervosa)
      • Constitutional delay of puberty
      • Central lesions (tumors, hypophysitis, granulomas)
      • Pituitary dysfunction (hyperprolactinemia, abnormal follicle-stimulating hormone [FSH], luteinizing hormone [LH], or GnRH)
      • Thyroid dysfunction
    • Polycystic ovarian syndrome (PCOS)
    • Androgen insensitivity syndrome
  • Secondary amenorrhea
    • Pregnancy
    • Hypothalamic dysfunction (reduced GnRH secretion)
      • Functional hypothalamic amenorrhea (stress, anorexia nervosa, and/or excessive exercise)
      • Hypothalamic tumors
      • Severe systemic illness (e.g., diabetes mellitus type 1 or celiac disease)
    • Pituitary disease (e.g., hyperprolactinemia, Sheehan syndrome, Cushing syndrome)
    • Thyroid disease
    • PCOS
    • Ovarian disorders (e.g., premature ovarian failure [due to chemotherapy, radiation, fragile X syndrome] or ovarian tumors)
    • Uterine disorders (e.g., intrauterine adhesions [Asherman syndrome])
  • Pathophysiology varies, depending on etiology.

Genetics
May occur with Turner syndrome or testicular feminization

Risk Factors

  • Obesity
  • Excessive exercise (commonly associated “female athlete triad”)
  • Eating disorders
  • Malnutrition
  • Anovulatory disorders
  • Stress
  • Treatment with antipsychotic medications

General Prevention

Maintenance of proper body mass index (BMI) and healthy lifestyle with respect to food and exercise

Commonly Associated Conditions

  • Premature ovarian failure may be associated with autoimmune abnormalities (autoimmune thyroiditis, type 1 diabetes).
  • PCOS is associated with insulin resistance and obesity.
  • Decreased exposure to estrogen may increase risk for osteopenia or osteoporosis.

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Citation

Stephens, Mark B., et al., editors. "Amenorrhea." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. 5minute, www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/116017/all/Amenorrhea.
Amenorrhea. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/116017/all/Amenorrhea. Accessed May 25, 2019.
Amenorrhea. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/116017/all/Amenorrhea
Amenorrhea [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 May 25]. Available from: https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/116017/all/Amenorrhea.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Amenorrhea ID - 116017 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/116017/all/Amenorrhea PB - Wolters Kluwer ET - 27 DB - 5minute DP - Unbound Medicine ER -