Materiały źródłowe

• #1 Amenorrhea: A Systematic Approach to Diagnosis and Management – PubMed

  https://pubmed.ncbi.nlm.nih.gov/31259490/

  Menstrual patterns can be an indicator of overall health and self-perception of well-being. Primary amenorrhea, defined as the lifelong absence of menses, requires evaluation if menarche has not occurred by 15 years of age or three years post-thelarche. Secondary amenorrhea is characterized by cessation of previously regular menses for three months or previously irregular menses for six months and warrants evaluation. Clinicians may consider etiologies of amenorrhea categorically as outflow tract abnormalities, primary ovarian insufficiency, hypothalamic or pituitary disorders, other endocrine gland disorders, sequelae of chronic disease, physiologic, or induced. […] The history should include menstrual onset and patterns, eating and exercise habits, presence of psychosocial stressors, body weight changes, medication use, galactorrhea, and chronic illness. Additional questions may target neurologic, vasomotor, hyperandrogenic, or thyroid-related symptoms. The physical examination should identify anthropometric and pubertal development trends. All patients should be offered a pregnancy test and assessment of serum follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone levels. Additional testing, including karyotyping, serum androgen evaluation, and pelvic or brain imaging, should be individualized. Patients with primary ovarian insufficiency can maintain unpredictable ovary function and may require hormone replacement therapy, contraception, or infertility services. Functional hypothalamic amenorrhea may indicate disordered eating and low bone density. Treatment should address the underlying cause. Patients with polycystic ovary syndrome should undergo screening and intervention to attenuate metabolic disease and endometrial cancer risk. Amenorrhea can be associated with clinically challenging pathology and may require lifelong treatment. Patients will benefit from ample time with the clinician, sensitivity, and emotional support.

• #2 Amenorrhea: A Systematic Approach to Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2019/0701/p39.html

  Menstrual patterns can be an indicator of overall health and self-perception of well-being. Primary amenorrhea, defined as the lifelong absence of menses, requires evaluation if menarche has not occurred by 15 years of age or three years post-thelarche. Secondary amenorrhea is characterized by cessation of previously regular menses for three months or previously irregular menses for six months and warrants evaluation. […] All patients should be offered a pregnancy test and assessment of serum follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone levels. Additional testing, including karyotyping, serum androgen evaluation, and pelvic or brain imaging, should be individualized. […] Patients with primary ovarian insufficiency should be treated with hormone therapy until the age of natural menopause (50 to 51 years of age) to reduce the risk of osteoporosis, cardiovascular disease, and urogenital atrophy.

• #3 Amenorrhea: An Approach to Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2013/0601/p781.html

  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. […] 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. […] A detailed history, examination, and laboratory analysis will identify most causes. […] The initial workup includes a pregnancy test and serum luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone levels. […] If the presence of endogenous estradiol secretion is not evident from the physical examination (e.g., breast development), serum estradiol may be measured.

• #4

  https://step2.medbullets.com/evidence/23939500

  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. […] Primary amenorrhea, which by definition is failure to reach menarche, is often the result of chromosomal irregularities leading to primary ovarian insufficiency (e.g., Turner syndrome) or anatomic abnormalities (e.g., Mllerian agenesis). […] Secondary amenorrhea is defined as the cessation of regular menses for three months or the cessation of irregular menses for six months. […] Most cases of secondary amenorrhea can be attributed to polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, or primary ovarian insufficiency.

• #5 Azthena logo with the word Azthena

  https://www.news-medical.net/health/Amenorrhea-Diagnosis-and-Treatment.aspx

  Amenorrhea can result from various causes and the treatment of the condition depends mainly on the cause. Therefore, it is important that the origin of amenorrhea is established during the diagnostic process to ensure that the appropriate and effective treatment is given. […] During the initial consultation, it is important to discuss the medical history and symptoms that may be associated with amenorrhea and have an impact on the diagnosis. […] If a woman with amenorrhea is sexually active, it is worthwhile to conduct a pregnancy test. Pregnancy is a common cause amenorrhea and should always be considered in sexually active women, even if they use contraceptive methods. […] Laboratory examination of a blood sample is useful in the diagnosis of amenorrhea, as it can help to understand any hormonal imbalances that may be associated with the condition.

• #6 Amenorrhea: A Systematic Approach to Diagnosis and Management – PubMed

  https://pubmed.ncbi.nlm.nih.gov/31259490/

  Menstrual patterns can be an indicator of overall health and self-perception of well-being. Primary amenorrhea, defined as the lifelong absence of menses, requires evaluation if menarche has not occurred by 15 years of age or three years post-thelarche. Secondary amenorrhea is characterized by cessation of previously regular menses for three months or previously irregular menses for six months and warrants evaluation. Clinicians may consider etiologies of amenorrhea categorically as outflow tract abnormalities, primary ovarian insufficiency, hypothalamic or pituitary disorders, other endocrine gland disorders, sequelae of chronic disease, physiologic, or induced. […] The history should include menstrual onset and patterns, eating and exercise habits, presence of psychosocial stressors, body weight changes, medication use, galactorrhea, and chronic illness. Additional questions may target neurologic, vasomotor, hyperandrogenic, or thyroid-related symptoms. The physical examination should identify anthropometric and pubertal development trends. All patients should be offered a pregnancy test and assessment of serum follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone levels. Additional testing, including karyotyping, serum androgen evaluation, and pelvic or brain imaging, should be individualized. Patients with primary ovarian insufficiency can maintain unpredictable ovary function and may require hormone replacement therapy, contraception, or infertility services. Functional hypothalamic amenorrhea may indicate disordered eating and low bone density. Treatment should address the underlying cause. Patients with polycystic ovary syndrome should undergo screening and intervention to attenuate metabolic disease and endometrial cancer risk. Amenorrhea can be associated with clinically challenging pathology and may require lifelong treatment. Patients will benefit from ample time with the clinician, sensitivity, and emotional support.

• #7 Amenorrhea: A Systematic Approach to Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2019/0701/p39.html

  Secondary amenorrhea is the cessation of previously regular menses for three months or previously irregular menses for six months and warrants evaluation. […] A detailed history should include menstrual patterns (if any), pregnancy and breastfeeding history, eating and exercise habits, psychosocial stressors (e.g., perfectionist behaviors), changes in body weight, fractures, medication or substance use, chronic illness, and timing of breast and pubic hair development. […] In all cases, pregnancy should be excluded with a pregnancy test. Serum patterns of follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone identify most endocrine causes of amenorrhea. […] Karyotyping should also be considered in patients of short stature to evaluate for Turner syndrome. […] Pelvic ultrasonography or magnetic resonance imaging (MRI) can identify abnormal reproductive anatomy or detect an androgen-secreting tumor.

• #8 Amenorrhea: Causes, Symptoms, & Treatment

  https://www.webmd.com/infertility-and-reproduction/absence-periods

  Amenorrhea Diagnosis […] Since many things can cause amenorrhea, it may take time to find the exact reason behind your missed periods. […] Your doctor will ask about your medical history and do a physical and pelvic exam. If you’re sexually active, they’ll likely begin with a pregnancy test to rule that out. […] They may ask you questions such as: […] How old were you when you had your first period? […] Do any of your family members have a history of missed periods? […] What is the typical length of your menstrual cycle? […] Have you gained or lost weight recently? […] Do you exercise a lot? Are you an athlete? […] Are you under a lot of stress? […] What are your eating habits like? […] It may take several kinds of tests to find the cause of amenorrhea, such as: […] Blood tests. These measure the level of hormones such as follicle-stimulating hormone (FSH), thyroid-stimulating hormone, prolactin, and androgens. Too much or too little of these sex hormones can interfere with the menstrual cycle.

• #9 Secondary Amenorrhea – Stepwise diagnostic approach and treatment for absent menstrual periods in a | Blog

  https://www.advancedfertility.com/blog/secondary-amenorrhea-stepwise-diagnostic-approach-and-treatment-for-absent-menstrual-periods-in-a-wo

  Secondary amenorrhea is the absence of menstrual periods for 6 months in a woman who had previously been regular, or for 12 months in a woman who had irregular periods. […] The diagnostic evaluation should lead to the correct diagnosis if the problem is approached in a logical stepwise manner. […] A good history can reveal the etiologic diagnosis in up to 85% of cases of amenorrhea. […] Signs of androgen excess such as hirsutism (excess hair growth) and clitoromegaly (enlargement of the clitoris). […] If the history and physical exam are suggestive of a certain etiology then the initial workup can be tailored appropriately. […] Both hypothyroidism and hyperprolactinemia can cause primary or secondary amenorrhea. […] The progestational challenge test is performed by giving a progestin (medication).

• #10 Amenorrhea

  https://elsevier.health/en-US/preview/reproductive-health/amenorrhea-clinical-overview

  Amenorrhea is absence or abnormal cessation of menstruation in women of reproductive age. […] Majority of cases are associated with polycystic ovary syndrome, hyperprolactinemia, hypothalamic amenorrhea, or primary ovarian insufficiency (ovarian failure). […] Primary amenorrhea is defined as failure to reach menarche by age 15 years in adolescent girls with otherwise normal secondary sexual development or within 5 years after breast development that occurred before age 10 years. […] Secondary amenorrhea is defined as cessation of previously regular menses for 3 months or longer, cessation of previously irregular menses for 6 months or longer, or fewer than 9 menstrual cycles per year in females with oligomenorrhea. […] Diagnose based on history, physical examination, and measurement of serum hCG, follicle-stimulating hormone, prolactin, and TSH levels.

• #11 Amenorrhea: Types, Causes, Symptoms, Diagnosis & Treatment

  https://my.clevelandclinic.org/health/diseases/3924-amenorrhea

  Amenorrhea is missing one or more periods. Talk to your healthcare provider if you’re older than 15 and haven’t gotten your first period (primary amenorrhea) or you’ve missed a period for three or more months (secondary amenorrhea). Amenorrhea is often a sign of a treatable condition. With treatment, your regular menstrual cycle will usually resume. […] Contact a healthcare provider if you miss a period. They’ll ask you about your symptoms and medical history, including your menstrual history. Your provider will perform a physical exam and a pelvic exam. […] Your healthcare provider may want to do some tests, including: Pregnancy test. Blood tests to check your hormone levels and detect thyroid or adrenal gland disorders. Genetic testing, if you have primary ovarian insufficiency and are younger than 40. MRI, if your provider suspects a problem with your pituitary gland. Ultrasound, if your provider suspects an issue with your ovaries or uterus.

• #12 Amenorrhea – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/amenorrhea/diagnosis-treatment/drc-20369304

  During your appointment, your doctor will perform a pelvic exam to check for any problems with your reproductive organs. If you’ve never had a period, your doctor may examine your breasts and genitals to see if you’re experiencing the normal changes of puberty. […] Amenorrhea can be a sign of a complex set of hormonal problems. Finding the underlying cause can take time and may require more than one kind of testing. […] A variety of blood tests may be necessary, including: […] Pregnancy test. This will probably be the first test your doctor suggests, to rule out or confirm a possible pregnancy. […] Thyroid function test. Measuring the amount of thyroid-stimulating hormone (TSH) in your blood can determine if your thyroid is working properly. […] Ovary function test. Measuring the amount of follicle-stimulating hormone (FSH) in your blood can determine if your ovaries are working properly.

• #13 Amenorrhea: Types, Causes, Symptoms, Diagnosis & Treatment

  https://my.clevelandclinic.org/health/diseases/3924-amenorrhea

  Amenorrhea is missing one or more periods. Talk to your healthcare provider if you’re older than 15 and haven’t gotten your first period (primary amenorrhea) or you’ve missed a period for three or more months (secondary amenorrhea). Amenorrhea is often a sign of a treatable condition. With treatment, your regular menstrual cycle will usually resume. […] Contact a healthcare provider if you miss a period. They’ll ask you about your symptoms and medical history, including your menstrual history. Your provider will perform a physical exam and a pelvic exam. […] Your healthcare provider may want to do some tests, including: Pregnancy test. Blood tests to check your hormone levels and detect thyroid or adrenal gland disorders. Genetic testing, if you have primary ovarian insufficiency and are younger than 40. MRI, if your provider suspects a problem with your pituitary gland. Ultrasound, if your provider suspects an issue with your ovaries or uterus.

• #14 Amenorrhea: A Systematic Approach to Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2019/0701/p39.html

  Menstrual patterns can be an indicator of overall health and self-perception of well-being. Primary amenorrhea, defined as the lifelong absence of menses, requires evaluation if menarche has not occurred by 15 years of age or three years post-thelarche. Secondary amenorrhea is characterized by cessation of previously regular menses for three months or previously irregular menses for six months and warrants evaluation. […] All patients should be offered a pregnancy test and assessment of serum follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone levels. Additional testing, including karyotyping, serum androgen evaluation, and pelvic or brain imaging, should be individualized. […] Patients with primary ovarian insufficiency should be treated with hormone therapy until the age of natural menopause (50 to 51 years of age) to reduce the risk of osteoporosis, cardiovascular disease, and urogenital atrophy.

• #15 Amenorrhea – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK482168/

  The evaluation varies depending on the age of the patient and the findings on the exam. Initially, however, the following diagnostic studies are indicated in all patients with amenorrhea: Urine pregnancy test, Serum FSH, LH, and estradiol, Serum prolactin, Serum thyroid-stimulating hormone (TSH), Pelvic ultrasound. […] The treatment for amenorrhea is based on correcting the underlying etiology and monitoring the patient for complications.

• #16 Amenorrhea – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/amenorrhea/diagnosis-treatment/drc-20369304

  During your appointment, your doctor will perform a pelvic exam to check for any problems with your reproductive organs. If you’ve never had a period, your doctor may examine your breasts and genitals to see if you’re experiencing the normal changes of puberty. […] Amenorrhea can be a sign of a complex set of hormonal problems. Finding the underlying cause can take time and may require more than one kind of testing. […] A variety of blood tests may be necessary, including: […] Pregnancy test. This will probably be the first test your doctor suggests, to rule out or confirm a possible pregnancy. […] Thyroid function test. Measuring the amount of thyroid-stimulating hormone (TSH) in your blood can determine if your thyroid is working properly. […] Ovary function test. Measuring the amount of follicle-stimulating hormone (FSH) in your blood can determine if your ovaries are working properly.

• #17 Amenorrhea: An Approach to Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2013/0601/p781.html

  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. […] 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. […] A detailed history, examination, and laboratory analysis will identify most causes. […] The initial workup includes a pregnancy test and serum luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone levels. […] If the presence of endogenous estradiol secretion is not evident from the physical examination (e.g., breast development), serum estradiol may be measured.

• #18 Hypothalamic Amenorrhea Guideline Resources | Endocrine Society

  https://www.endocrine.org/clinical-practice-guidelines/hypothalamic-amenorrhea

  In a patient with suspected FHA, we recommend excluding pregnancy and performing a full physical examination, including a gynecological examination (external, and in selected cases, bimanual), to evaluate the possibility of organic etiologies of amenorrhea. […] In adolescents and women with suspected FHA, we recommend obtaining the following screening laboratory tests: -human chorionic gonadotropin, complete blood count, electrolytes, glucose, bicarbonate, blood urea nitrogen, creatinine, liver panel, and (when appropriate) sedimentation rate and/or C-reactive protein levels. […] As part of an initial endocrine evaluation for patients with FHA, we recommend obtaining the following laboratory tests: serum thyroid-stimulating hormone (TSH), free thyroxine (T4), prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol (E2), and anti-Mllerian hormone (AMH).

• #19 Amenorrhea: Causes, Symptoms, & Treatment

  https://www.webmd.com/infertility-and-reproduction/absence-periods

  Imaging tests. Ultrasound, CT, and MRI can look for problems with your reproductive organs or detect tumors. […] Hormone challenge test. Your doctor will give you hormonal medication. If you don’t have vaginal bleeding after stopping it, low estrogen could be the cause of amenorrhea. […] Hysteroscopy. Your doctor will put a small lighted camera through your vagina and cervix to look for anything unusual inside your uterus. […] Genetic screening. These tests check for genetic issues, such as changes to the FMR1 gene, that can stop the ovaries from working properly. […] Chromosome tests (karyotype). These look for missing, extra, or rearranged cells in certain chromosomes that could explain your symptoms (Turner Syndrome, for example).

• #20 Amenorrhea: Causes, Symptoms, Diagnosis and Treament

  https://www.datelinehealthafrica.org/amenorrhea-causes-symptoms-diagnosis-and-treatment

  Amenorrhea is the medical term used to describe the absence of menstrual periods that is either permanent or temporary. It may be primary or secondary. […] Secondary amenorrhea is the absence of menstrual bleeding in a woman who had been menstruating but later stops menstruating for at least three consecutive months in the absence of pregnancy, lactation (production of breast milk), use of hormonal birth control pills, or menopause. […] After taking a good history and performing physical examination, a doctor may perform the following tests to determine the cause of the amenorrhea: Blood tests. These may be performed to determine the levels of hormones secreted by the pituitary gland (FSH, LH, TSH, and prolactin) and the ovaries (estrogen). […] CT scan or ultrasonography of the pelvis. These may be performed to assess the abnormalities of the genital tract or to look for polycystic ovaries.

• #21 Amenorrhea: Symptoms, Causes and Treatments – familydoctor.org

  https://familydoctor.org/condition/amenorrhea/

  Your doctor may order additional tests to rule out or determine a cause. A karyotype test looks at your chromosomes. A genetic test looks for the mutated FMR1 gene. Imaging tests can look at your female organs. A blood test can check your: Thyroid function (thyroid-stimulating hormone, or TSH, levels). Ovary function (follicle-stimulating hormone, or FSH, and luteinizing hormone, or LH, levels). Testosterone (“male hormone”) levels, which can detect PCOS. Estrogen (“female hormone”) levels.

• #22 Amenorrhea – Wikipedia

  https://en.wikipedia.org/wiki/Amenorrhea

  Amenorrhea can be diagnosed in female children by age 14 if no secondary sex characteristics, such as enlarged breasts and body hair, are present. In the absence of secondary sex characteristics, the most common cause of amenorrhea is low levels of FSH and LH caused by a delay in puberty. […] Evaluation of primary amenorrhea begins with a pregnancy test, prolactin, FSH, LH, and TSH levels. Abnormal TSH levels prompt evaluation for hyper- and hypo-thyroidism with additional thyroid function tests. Elevated prolactin levels prompt evaluation of the pituitary with an MRI to assess for any masses or malignancies. A pelvic ultrasound can also be obtained in the initial evaluation. If a uterus is not present on ultrasound, karyotype analysis and testosterone levels are obtained to assess for MRKH or androgen insensitivity syndrome. If a uterus is present, LH and FSH levels are used to make a diagnosis. Low levels of LH and FSH suggest delayed puberty or functional hypothalamic amenorrhea. Elevated levels of FSH and LH suggest primary ovarian insufficiency, typically due to Turner syndrome. Normal levels of FSH and LH can suggest an anatomical outflow obstruction.

• #23 Amenorrhea: Causes, Symptoms, Diagnosis And Treatment

  https://www.novaivffertility.com/fertility-help/amenorrhea

  Amenorrhea is a medical condition in which a woman of reproductive age fails to menstruate. […] The basic requirement for normal menstrual function includes four anatomically and functionally distinct structural components: the genital outflow tract (uterus and vagina), ovary, pituitary, and hypothalamus, thus providing a natural hierarchy for organizing the diagnostic evaluation of amenorrhea. […] The evaluation of primary amenorrhea is done at these levels: Detailed history along with family history, Physical examination, Ultrasonography, MRI pelvis, Hormonal evaluation – FSH, LH, Estradiol, Karyotyping, Fragile X mutations, Autoimmune screening, TSH and prolactin levels, MRI brain, BHCG for pregnancy. […] It has to be remembered that all investigations will not be done in all who present with amenorrhea. The sequence of investigations will be guided based on the history and physical examination.

• #24 Amenorrhea – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/amenorrhea/diagnosis-treatment/drc-20369304

  Prolactin test. Low levels of the hormone prolactin may be a sign of a pituitary gland tumor. […] Male hormone test. If you’re experiencing increased facial hair and a lowered voice, your doctor may want to check the level of male hormones in your blood. […] For this test, you take a hormonal medication for seven to 10 days to trigger menstrual bleeding. Results from this test can tell your doctor whether your periods have stopped due to a lack of estrogen. […] Depending on your signs and symptoms and the result of any blood tests you’ve had your doctor might recommend one or more imaging tests, including: […] Ultrasound. This test uses sound waves to produce images of internal organs. If you have never had a period, your doctor may suggest an ultrasound test to check for any abnormalities in your reproductive organs.

• #25 Azthena logo with the word Azthena

  https://www.news-medical.net/health/Amenorrhea-Diagnosis-and-Treatment.aspx

  Other diagnostic tests that may help include imaging tests such as ultrasound imaging, computed tomography (CT) scan, and magnetic resonance imaging (MRI). […] If a lack of estrogen is suspected as a cause of amenorrhea, a hormone challenge test may be indicated. This involves administration of a hormonal medication to induce menstrual bleeding. […] Finally, a hysteroscopy may be recommended if the cause remains unidentified after other diagnostic testing methods. This involves the insertion of a camera into the uterus via a thin line through the vagina and cervix and allows the area to be viewed for any causative abnormalities.

• #26 Hypothalamic Amenorrhea Guideline Resources | Endocrine Society

  https://www.endocrine.org/clinical-practice-guidelines/hypothalamic-amenorrhea

  After excluding pregnancy, we suggest administering a progestin challenge in patients with FHA to induce withdrawal bleeding (as an indication of chronic estrogen exposure) and ensure the integrity of the outflow tract. […] We recommend a brain magnetic resonance imaging (MRI) (with pituitary cuts and contrast) in adolescents or women with presumed FHA and a history of severe or persistent headaches; persistent vomiting that is not self-induced; change in vision, thirst, or urination not attributable to other causes; lateralizing neurologic signs; and clinical signs and/or laboratory results that suggest pituitary hormone deficiency or excess. […] In patients with FHA wishing to conceive, after a complete fertility workup, we suggest: treatment with pulsatile gonadotropin-releasing hormone (GnRH) as a first line, followed by gonadatropin therapy and induction of ovulation when GnRH is not available.

• #27 Secondary Amenorrhea – Stepwise diagnostic approach and treatment for absent menstrual periods in a | Blog

  https://www.advancedfertility.com/blog/secondary-amenorrhea-stepwise-diagnostic-approach-and-treatment-for-absent-menstrual-periods-in-a-wo

  If the patient experiences withdrawal bleeding after the progestin medication is stopped then she has estrogen present but is not ovulating (anovulation). […] If no withdrawal bleeding occurs, either the patient has very low estrogen levels – or there is a problem with the outflow tract such as uterine synechiae (adhesions) or cervical stenosis (scarring). […] Chronic anovulation should be managed by periodic progestin withdrawal, or oral contraceptive pills if the patient does not currently desire pregnancy. […] If adhesions are found, they should be hysteroscopically lysed if the woman wants pregnancy or regular periods. […] If the patient did bleed after the combined hormonal regimen (or if that step was skipped) the next test to obtain is an FSH level. […] If the FSH is greater than 30-40 MIU/ml, the patient probably has ovarian failure.

• #28 Hypothalamic Amenorrhea Guideline Resources | Endocrine Society

  https://www.endocrine.org/clinical-practice-guidelines/hypothalamic-amenorrhea

  After excluding pregnancy, we suggest administering a progestin challenge in patients with FHA to induce withdrawal bleeding (as an indication of chronic estrogen exposure) and ensure the integrity of the outflow tract. […] We recommend a brain magnetic resonance imaging (MRI) (with pituitary cuts and contrast) in adolescents or women with presumed FHA and a history of severe or persistent headaches; persistent vomiting that is not self-induced; change in vision, thirst, or urination not attributable to other causes; lateralizing neurologic signs; and clinical signs and/or laboratory results that suggest pituitary hormone deficiency or excess. […] In patients with FHA wishing to conceive, after a complete fertility workup, we suggest: treatment with pulsatile gonadotropin-releasing hormone (GnRH) as a first line, followed by gonadatropin therapy and induction of ovulation when GnRH is not available.

• #29 Amenorrhea – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/amenorrhea/diagnosis-treatment/drc-20369304

  Prolactin test. Low levels of the hormone prolactin may be a sign of a pituitary gland tumor. […] Male hormone test. If you’re experiencing increased facial hair and a lowered voice, your doctor may want to check the level of male hormones in your blood. […] For this test, you take a hormonal medication for seven to 10 days to trigger menstrual bleeding. Results from this test can tell your doctor whether your periods have stopped due to a lack of estrogen. […] Depending on your signs and symptoms and the result of any blood tests you’ve had your doctor might recommend one or more imaging tests, including: […] Ultrasound. This test uses sound waves to produce images of internal organs. If you have never had a period, your doctor may suggest an ultrasound test to check for any abnormalities in your reproductive organs.

• #30 Amenorrhea: Types, Causes, Symptoms, Diagnosis & Treatment

  https://my.clevelandclinic.org/health/diseases/3924-amenorrhea

  Amenorrhea is missing one or more periods. Talk to your healthcare provider if you’re older than 15 and haven’t gotten your first period (primary amenorrhea) or you’ve missed a period for three or more months (secondary amenorrhea). Amenorrhea is often a sign of a treatable condition. With treatment, your regular menstrual cycle will usually resume. […] Contact a healthcare provider if you miss a period. They’ll ask you about your symptoms and medical history, including your menstrual history. Your provider will perform a physical exam and a pelvic exam. […] Your healthcare provider may want to do some tests, including: Pregnancy test. Blood tests to check your hormone levels and detect thyroid or adrenal gland disorders. Genetic testing, if you have primary ovarian insufficiency and are younger than 40. MRI, if your provider suspects a problem with your pituitary gland. Ultrasound, if your provider suspects an issue with your ovaries or uterus.

• #31 Amenorrhea: Causes, Symptoms, Diagnosis and Treament

  https://www.datelinehealthafrica.org/amenorrhea-causes-symptoms-diagnosis-and-treatment

  CT scan or MRI of the head. Either of these may be performed to exclude pituitary and hypothalamic causes of amenorrhea. […] If the above tests are inconclusive, the following additional tests may be performed: Thyroid function tests, Determination of prolactin levels, Hysterosalpingogram (X-ray test) or saline infusion sonography (SIS), both of which examine the uterus, Laparoscopy or Hysteroscopy (visual inspection of the pelvic organs and uterine cavity respectively). […] Medical treatment of amenorrhea will depend on its cause. Once the cause is determined, treatment is tailored to correcting the underlying disease, and the expectation is that such medication use will restore menstruation. […] If a pituitary or hypothalamic tumor is established, surgery and in some cases, radiation therapy may be indicated. […] Women with intrauterine adhesions require dissolution of the scar tissue. […] Surgical procedures required for other genital tract abnormalities depend on the specific clinical situation.

• #32 Menstrual disorders Information | Mount Sinai – New York

  https://www.mountsinai.org/health-library/report/menstrual-disorders

  A menstrual diary is a helpful way to keep track of changes in menstrual cycles. […] Blood tests can help rule out other conditions that cause menstrual disorders. […] Imaging techniques are often used to detect certain conditions that may be causing menstrual disorders. […] When heavy or abnormal bleeding occurs, an endometrial (uterine) biopsy may be performed in a medical office. […] Hysteroscopy is a procedure that can detect the presence of fibroids, polyps, or other causes of bleeding. […] Dilation and Curettage (D&C) is a more invasive procedure. […] Diagnostic laparoscopy, an invasive surgical procedure, is used to diagnose and treat endometriosis, a common cause of dysmenorrhea.

• #33 Amenorrhea

  https://elsevier.health/en-US/preview/reproductive-health/amenorrhea-clinical-overview

  In patients with primary amenorrhea, also perform pelvic ultrasonography to evaluate for absence of uterus or other structural abnormalities. […] Further testing is directed by initial test findings and clinical context; may include karyotype tests, pituitary MRI scanning, serum androgen levels, or progesterone challenge test. […] Amenorrhea indicates failure of the hypothalamic-pituitary-gonadal axis to induce cyclic changes in the endometrium that result in menses; also may indicate absence of end organs or obstruction of the outflow tract. […] May result from abnormality at any level of the reproductive tract; however, majority of cases of nonphysiologic amenorrhea are associated with polycystic ovary syndrome, hyperprolactinemia, hypothalamic amenorrhea, or primary ovarian insufficiency (ovarian failure).

• #34 Amenorrhea: An Approach to Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2013/0601/p781.html

  Pelvic ultrasonography can help confirm the presence or absence of a uterus, and can identify structural abnormalities of reproductive tract organs. […] Hormone therapy (e.g., 100 mcg of daily transdermal estradiol or 0.625 mg of daily conjugated equine estrogen [Premarin] on days 1 through 26 of the menstrual cycle, and 10 mg of cyclic medroxyprogesterone acetate for 12 days [e.g., days 14 through 26] of the menstrual cycle) until the average age of natural menopause is usually recommended to decrease the likelihood of osteoporosis, ischemic heart disease, and vasomotor symptoms. […] Patients with primary ovarian insufficiency should be counseled about possible fertility, because up to 10% of such patients may achieve temporary and unpredictable remission. […] Treatment of functional hypothalamic amenorrhea involves nutritional rehabilitation as well as reductions in stress and exercise levels.

• #35 Hypothalamic Amenorrhea Guideline Resources | Endocrine Society

  https://www.endocrine.org/clinical-practice-guidelines/hypothalamic-amenorrhea

  After excluding pregnancy, we suggest administering a progestin challenge in patients with FHA to induce withdrawal bleeding (as an indication of chronic estrogen exposure) and ensure the integrity of the outflow tract. […] We recommend a brain magnetic resonance imaging (MRI) (with pituitary cuts and contrast) in adolescents or women with presumed FHA and a history of severe or persistent headaches; persistent vomiting that is not self-induced; change in vision, thirst, or urination not attributable to other causes; lateralizing neurologic signs; and clinical signs and/or laboratory results that suggest pituitary hormone deficiency or excess. […] In patients with FHA wishing to conceive, after a complete fertility workup, we suggest: treatment with pulsatile gonadotropin-releasing hormone (GnRH) as a first line, followed by gonadatropin therapy and induction of ovulation when GnRH is not available.

• #36 Amenorrhea – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/amenorrhea/diagnosis-treatment/drc-20369304

  Magnetic resonance imaging (MRI). MRI uses radio waves with a strong magnetic field to produce exceptionally detailed images of soft tissues within the body. Your doctor may order an MRI to check for a pituitary tumor. […] If other testing reveals no specific cause, your doctor may recommend a hysteroscopy a test in which a thin, lighted camera is passed through your vagina and cervix to look at the inside of your uterus. […] Treatment depends on the underlying cause of your amenorrhea. In some cases, birth control pills or other hormone therapies can restart your menstrual cycles. Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. If a tumor or structural blockage is causing the problem, surgery may be necessary.

• #37 Azthena logo with the word Azthena

  https://www.news-medical.net/health/Amenorrhea-Diagnosis-and-Treatment.aspx

  Other diagnostic tests that may help include imaging tests such as ultrasound imaging, computed tomography (CT) scan, and magnetic resonance imaging (MRI). […] If a lack of estrogen is suspected as a cause of amenorrhea, a hormone challenge test may be indicated. This involves administration of a hormonal medication to induce menstrual bleeding. […] Finally, a hysteroscopy may be recommended if the cause remains unidentified after other diagnostic testing methods. This involves the insertion of a camera into the uterus via a thin line through the vagina and cervix and allows the area to be viewed for any causative abnormalities.

• #38 Amenorrhea: Causes, Symptoms, Diagnosis and Treament

  https://www.datelinehealthafrica.org/amenorrhea-causes-symptoms-diagnosis-and-treatment

  CT scan or MRI of the head. Either of these may be performed to exclude pituitary and hypothalamic causes of amenorrhea. […] If the above tests are inconclusive, the following additional tests may be performed: Thyroid function tests, Determination of prolactin levels, Hysterosalpingogram (X-ray test) or saline infusion sonography (SIS), both of which examine the uterus, Laparoscopy or Hysteroscopy (visual inspection of the pelvic organs and uterine cavity respectively). […] Medical treatment of amenorrhea will depend on its cause. Once the cause is determined, treatment is tailored to correcting the underlying disease, and the expectation is that such medication use will restore menstruation. […] If a pituitary or hypothalamic tumor is established, surgery and in some cases, radiation therapy may be indicated. […] Women with intrauterine adhesions require dissolution of the scar tissue. […] Surgical procedures required for other genital tract abnormalities depend on the specific clinical situation.

• #39 Menstrual disorders Information | Mount Sinai – New York

  https://www.mountsinai.org/health-library/report/menstrual-disorders

  A menstrual diary is a helpful way to keep track of changes in menstrual cycles. […] Blood tests can help rule out other conditions that cause menstrual disorders. […] Imaging techniques are often used to detect certain conditions that may be causing menstrual disorders. […] When heavy or abnormal bleeding occurs, an endometrial (uterine) biopsy may be performed in a medical office. […] Hysteroscopy is a procedure that can detect the presence of fibroids, polyps, or other causes of bleeding. […] Dilation and Curettage (D&C) is a more invasive procedure. […] Diagnostic laparoscopy, an invasive surgical procedure, is used to diagnose and treat endometriosis, a common cause of dysmenorrhea.

• #40 Amenorrhea – Wikipedia

  https://en.wikipedia.org/wiki/Amenorrhea

  Amenorrhea can be diagnosed in female children by age 14 if no secondary sex characteristics, such as enlarged breasts and body hair, are present. In the absence of secondary sex characteristics, the most common cause of amenorrhea is low levels of FSH and LH caused by a delay in puberty. […] Evaluation of primary amenorrhea begins with a pregnancy test, prolactin, FSH, LH, and TSH levels. Abnormal TSH levels prompt evaluation for hyper- and hypo-thyroidism with additional thyroid function tests. Elevated prolactin levels prompt evaluation of the pituitary with an MRI to assess for any masses or malignancies. A pelvic ultrasound can also be obtained in the initial evaluation. If a uterus is not present on ultrasound, karyotype analysis and testosterone levels are obtained to assess for MRKH or androgen insensitivity syndrome. If a uterus is present, LH and FSH levels are used to make a diagnosis. Low levels of LH and FSH suggest delayed puberty or functional hypothalamic amenorrhea. Elevated levels of FSH and LH suggest primary ovarian insufficiency, typically due to Turner syndrome. Normal levels of FSH and LH can suggest an anatomical outflow obstruction.

• #41 Primary Amenorrhea in Adolescents: Approach to Diagnosis and Management

  https://www.mdpi.com/2673-396X/4/3/38

  The diagnosis must be promptly confirmed. When necessary, estrogen replacement therapy should be proposed for pubertal development and psychological improvement. […] In the presence of an adolescent girl with PA, the diagnosis can be guided by her history, physical examination, imaging studies, hormone evaluation, and karyotyping. First and foremost, it is imperative to rule out pregnancy. […] PA evaluation begins by collecting the patient’s medical history (general health and lifestyles), particularly to identify chronic diseases and exposure to radiation or chemotherapy during infancy. It is important to obtain information about the history of galactorrhea, headache, and cyclical abdominal pain. […] The initial hormone evaluation is limited to the serum-follicle-stimulating hormone (FSH) and luteinizing hormone (LH), testosterone and prolactin. Pregnancy must be ruled out because adolescents may ovulate before the first period. A karyotype should be obtained in all adolescents with high FSH serum levels. […] PA management depends on the underlying causes and the patient’s health status, psychological concerns, and goals.

• #42 Amenorrhea: A Rational Approach to the Diagnostic Work-Up – Ohio Academy of Family Physicians

  https://www.ohioafp.org/wfmu-article/amenorrhea-a-rational-approach-to-the-diagnostic-work-up/

  Amenorrhea, or absence of menstrual bleeding, is a clinical problem that family physicians often encounter. There are several published approaches to the diagnosis, but I would like to present one based upon careful interpretation of the history and physical examination findings, relying upon a basic understanding of reproductive endocrinology. By following this method, one is less likely to omit a step in the work-up or overlook a potential diagnosis. […] Amenorrhea can be primary or secondary. Although many of the same underlying conditions can present as either primary or secondary, it is useful to separate the two as this rapidly helps eliminate some possible causes. […] Primary amenorrhea (PA) can be divided into two categories: with sexual infantilism (or absence of breast development by age 13) or with normal secondary sexual characteristics.

• #43 Amenorrhea – Wikipedia

  https://en.wikipedia.org/wiki/Amenorrhea

  Amenorrhea can be diagnosed in female children by age 14 if no secondary sex characteristics, such as enlarged breasts and body hair, are present. In the absence of secondary sex characteristics, the most common cause of amenorrhea is low levels of FSH and LH caused by a delay in puberty. […] Evaluation of primary amenorrhea begins with a pregnancy test, prolactin, FSH, LH, and TSH levels. Abnormal TSH levels prompt evaluation for hyper- and hypo-thyroidism with additional thyroid function tests. Elevated prolactin levels prompt evaluation of the pituitary with an MRI to assess for any masses or malignancies. A pelvic ultrasound can also be obtained in the initial evaluation. If a uterus is not present on ultrasound, karyotype analysis and testosterone levels are obtained to assess for MRKH or androgen insensitivity syndrome. If a uterus is present, LH and FSH levels are used to make a diagnosis. Low levels of LH and FSH suggest delayed puberty or functional hypothalamic amenorrhea. Elevated levels of FSH and LH suggest primary ovarian insufficiency, typically due to Turner syndrome. Normal levels of FSH and LH can suggest an anatomical outflow obstruction.

• #44 Amenorrhea Differential Diagnoses

  https://emedicine.medscape.com/article/252928-differential

  Primary amenorrhea is defined either as absence of menses by age 14 years with the absence of growth or development of secondary sexual characteristics (eg, breast development) or as absence of menses by age 16 years with normal development of secondary sexual characteristics. […] Secondary amenorrhea is defined as the cessation of menstruation for at least 6 months or for at least 3 of the previous 3 cycle intervals. […] Diagnoses unique to primary amenorrhea include vaginal agenesis, androgen insensitivity syndrome, Turner syndrome (45,X), and mosaicism. […] Since regular menstruation reflects a properly functioning hypothalamic-pituitary-gonadal axis, a logical approach is to consider disorders based upon the levels of control of the menstrual cycle: uterus, ovary, pituitary, and hypothalamus.

• #45 Amenorrhea – Wikipedia

  https://en.wikipedia.org/wiki/Amenorrhea

  Amenorrhea can be diagnosed in female children by age 14 if no secondary sex characteristics, such as enlarged breasts and body hair, are present. In the absence of secondary sex characteristics, the most common cause of amenorrhea is low levels of FSH and LH caused by a delay in puberty. […] Evaluation of primary amenorrhea begins with a pregnancy test, prolactin, FSH, LH, and TSH levels. Abnormal TSH levels prompt evaluation for hyper- and hypo-thyroidism with additional thyroid function tests. Elevated prolactin levels prompt evaluation of the pituitary with an MRI to assess for any masses or malignancies. A pelvic ultrasound can also be obtained in the initial evaluation. If a uterus is not present on ultrasound, karyotype analysis and testosterone levels are obtained to assess for MRKH or androgen insensitivity syndrome. If a uterus is present, LH and FSH levels are used to make a diagnosis. Low levels of LH and FSH suggest delayed puberty or functional hypothalamic amenorrhea. Elevated levels of FSH and LH suggest primary ovarian insufficiency, typically due to Turner syndrome. Normal levels of FSH and LH can suggest an anatomical outflow obstruction.

• #46 Evaluation and management of primary amenorrhea – UpToDate

  https://www.uptodate.com/contents/evaluation-and-management-of-primary-amenorrhea

  Primary amenorrhea is usually the result of a genetic or anatomical abnormality. However, all causes of secondary amenorrhea can also present as primary amenorrhea. In a large case series of primary amenorrhea, the most common etiologies were gonadal dysgenesis, including Turner syndrome – 43 percent.

• #47 Amenorrhea – Wikipedia

  https://en.wikipedia.org/wiki/Amenorrhea

  Secondary amenorrhea’s most common and most easily diagnosable causes are pregnancy, thyroid disease, and hyperprolactinemia. A pregnancy test is a common first step for diagnosis. Similar to primary amenorrhea, evaluation of secondary amenorrhea also begins with a pregnancy test, prolactin, FSH, LH, and TSH levels. A pelvic ultrasound is also obtained. Abnormal TSH should prompt a thyroid workup with a full thyroid function test panel. Elevated prolactin should be followed with an MRI to look for masses. If LH and FSH are elevated, menopause or primary ovarian insufficiency should be considered. Normal or low levels of FSH and LH prompts further evaluation with patient history and the physical exam. Testosterone, DHEA-S, and 17-hydroxyprogesterone levels should be obtained if there is evidence of excess androgens, such as hirsutism or acne. 17-hydroxyprogesterone is elevated in congenital adrenal hyperplasia. Elevated testosterone and amenorrhea can suggest PCOS. Elevated androgens can also be present in ovarian or adrenal tumors, so additional imaging may also be needed. History of disordered eating or excessive exercise should raise concern for hypothalamic amenorrhea. Headache, vomiting, and vision changes can be signs of a tumor and needs evaluation with MRI. Finally, a history of gynecologic procedures should lead to evaluation of Asherman syndrome with a hysteroscopy or progesterone withdrawal bleeding test.

• #48 Secondary Amenorrhea: Workup and Diagnosis   – The ObG Project

  https://www.obgproject.com/2016/11/07/secondary-amenorrhea-workup-diagnosis/

  Secondary amenorrhea occurs when menses stop for 3 or more months. The most common causes of secondary amenorrhea include pregnancy, polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, and ovarian failure. Most secondary amenorrhea is anovulatory. When ovulatory dysfunction occurs, menstrual flow may not occur, and anovulatory amenorrhea is the result. Ovulatory amenorrhea occurs when anatomic abnormalities (outflow obstruction, intrauterine adhesions) prevent normal menstrual flow despite normal hormonal cycles. […] An evaluation for secondary amenorrhea should be considered if menses have been absent for over 3 months, or there is oligomenorrhea resulting in less than 9 cycles a year. […] Always rule out pregnancy. Initial tests should include: TSH, prolactin, FSH, LH and E2.

• #49 Amenorrhea: A Rational Approach to the Diagnostic Work-Up – Ohio Academy of Family Physicians

  https://www.ohioafp.org/wfmu-article/amenorrhea-a-rational-approach-to-the-diagnostic-work-up/

  A patient with PA and low estrogen levels will have elevated FSH levels if the pituitary and hypothalamus are normal. Therefore, low (or inappropriately normal) FSH levels, in the presence of estrogen deficiency, indicate that the underlying problem is central and not ovarian. […] Primary amenorrhea with normal pubertal development is an indication that estrogen production is normal. In these cases, one should consider the possibility of an anatomic abnormality of the genital tract, and careful pelvic examination with ultrasonography are essential. […] Pregnancy is always a consideration in patients with secondary amenorrhea (SA) and must be excluded regardless of the patients age or reported sexual activity. […] The first step is to determine if estrogen levels are normal. This can be accomplished by measuring serum estradiol level or by administration of a progestin such as medroxyprogesterone (Provera) for ten days.

• #50 Secondary Amenorrhea – Stepwise diagnostic approach and treatment for absent menstrual periods in a | Blog

  https://www.advancedfertility.com/blog/secondary-amenorrhea-stepwise-diagnostic-approach-and-treatment-for-absent-menstrual-periods-in-a-wo

  If the patient experiences withdrawal bleeding after the progestin medication is stopped then she has estrogen present but is not ovulating (anovulation). […] If no withdrawal bleeding occurs, either the patient has very low estrogen levels – or there is a problem with the outflow tract such as uterine synechiae (adhesions) or cervical stenosis (scarring). […] Chronic anovulation should be managed by periodic progestin withdrawal, or oral contraceptive pills if the patient does not currently desire pregnancy. […] If adhesions are found, they should be hysteroscopically lysed if the woman wants pregnancy or regular periods. […] If the patient did bleed after the combined hormonal regimen (or if that step was skipped) the next test to obtain is an FSH level. […] If the FSH is greater than 30-40 MIU/ml, the patient probably has ovarian failure.

• #51 Amenorrhea: A Rational Approach to the Diagnostic Work-Up – Ohio Academy of Family Physicians

  https://www.ohioafp.org/wfmu-article/amenorrhea-a-rational-approach-to-the-diagnostic-work-up/

  A consistently elevated FSH level (usually above 30 mIU/ml) is diagnostic of premature ovarian failure or early menopause. […] Patients with SA who have normal estrogen production (or have withdrawal bleeding after progestin administration) are diagnosed with chronic anovulation. Polycystic ovarian syndrome is a very common endocrinopathy occurring in about 7% of women in the reproductive age group. […] The family physician should avoid indiscriminately ordering many tests to evaluate patients with amenorrhea. Rather, following this simple and rational scheme, the diagnosis is readily established and appropriate therapy can be instituted.

• #52 Amenorrhea: Practice Essentials, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/252928-overview

  First and foremost, it is imperative to rule out pregnancy. Additional diagnoses of primary amenorrhea usually result from a genetic or anatomic abnormality. […] The relative prevalence of primary amenorrhea (percentages rounded to the nearest tenth) includes hypergonadotropic hypogonadism (48.5% of cases), hypogonadotropic hypogonadism (27.8%), and eugonadism (pubertal delay with normal gonadotropins; 23.7%). […] Disorders associated with a low or normal FSH, which account for 66% of cases of secondary amenorrhea, include the following: Weight loss/anorexia, Nonspecific hypothalamic, Chronic anovulation including PCOS, Hypothyroidism, Cushing syndrome, Pituitary tumor, empty sella, Sheehan syndrome. […] Hyperandrogenic states as a cause of secondary amenorrhea (2%) include the following: Polycystic ovarian syndrome (PCOS), Ovarian tumor, Non-classic CAH, Undiagnosed.

• #53 Amenorrhea – Wikipedia

  https://en.wikipedia.org/wiki/Amenorrhea

  Secondary amenorrhea’s most common and most easily diagnosable causes are pregnancy, thyroid disease, and hyperprolactinemia. A pregnancy test is a common first step for diagnosis. Similar to primary amenorrhea, evaluation of secondary amenorrhea also begins with a pregnancy test, prolactin, FSH, LH, and TSH levels. A pelvic ultrasound is also obtained. Abnormal TSH should prompt a thyroid workup with a full thyroid function test panel. Elevated prolactin should be followed with an MRI to look for masses. If LH and FSH are elevated, menopause or primary ovarian insufficiency should be considered. Normal or low levels of FSH and LH prompts further evaluation with patient history and the physical exam. Testosterone, DHEA-S, and 17-hydroxyprogesterone levels should be obtained if there is evidence of excess androgens, such as hirsutism or acne. 17-hydroxyprogesterone is elevated in congenital adrenal hyperplasia. Elevated testosterone and amenorrhea can suggest PCOS. Elevated androgens can also be present in ovarian or adrenal tumors, so additional imaging may also be needed. History of disordered eating or excessive exercise should raise concern for hypothalamic amenorrhea. Headache, vomiting, and vision changes can be signs of a tumor and needs evaluation with MRI. Finally, a history of gynecologic procedures should lead to evaluation of Asherman syndrome with a hysteroscopy or progesterone withdrawal bleeding test.

• #54 Secondary Amenorrhea – Stepwise diagnostic approach and treatment for absent menstrual periods in a | Blog

  https://www.advancedfertility.com/blog/secondary-amenorrhea-stepwise-diagnostic-approach-and-treatment-for-absent-menstrual-periods-in-a-wo

  Once ovarian failure is confirmed, consideration should be given to 3 possibilities: Mosaicism involving a Y chromosome, Fragile X syndrome, Autoimmune disease. […] Patients who do not bleed after the progestin challenge but do bleed after estrogen/progestin and have normal or low FSH and LH levels have hypothalamic amenorrhea. […] Some medications (e.g. phenothiazines) as well as extremes of weight loss, stress or exercise can cause this type of secondary amenorrhea. […] If amenorrhea and lack of withdrawal bleeding persists, prolactin levels should be measured annually since a small microadenoma could be „hiding”. […] Weight loss as a result of anorexia nervosa is an important diagnosis to make because of the mortality rate of 5-15%. […] If the state is persistent, hormone replacement therapy should be considered for protection against osteoporosis.

• #55 Amenorrhea Differential Diagnoses

  https://emedicine.medscape.com/article/252928-differential

  The differential diagnosis of amenorrhea is broad and can range from genetic abnormalities to endocrine disorders and psychological, environmental, and structural anomalies. […] In the differential diagnosis of primary or secondary amenorrhea, the most important step in diagnosis is to exclude pregnancy. Always consider pregnancy first. After pregnancy is excluded, an algorithmic approach is followed to narrow the diagnostic possibilities. […] Causes of primary and secondary amenorrhea overlap considerably; therefore, ascertaining the patient’s sexual development is the key to differentiating these conditions.

• #56 Amenorrhea differential diagnosis – wikidoc

  https://www.wikidoc.org/index.php/Amenorrhea_differential_diagnosis

  As amenorrhea manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. Primary amenorrhea must be differentiated from other diseases that cause lack of menstrual cycle, such as Mullerian agenesis, 3-beta-hydroxysteroid dehydrogenase type 2 deficiency, androgen insensitivity syndrome, Kallmann syndrome, Turner syndrome, and 17-alpha-hydroxylase deficiency. In contrast, secondary amenorrhea must be differentiated from other diseases that cause menstrual cycle arrest, such as primary ovarian insufficiency, hypothyroidism, hyperprolactinemia, polycystic ovary syndrome, and Asherman’s syndrome. […] Primary amenorrhea must be differentiated from other diseases that cause lack of menstrual cycle, such as Mullerian agenesis, 3-beta-hydroxysteroid dehydrogenase type 2 deficiency, androgen insensitivity syndrome, Kallmann syndrome, Turner syndrome, and 17-alpha-hydroxylase deficiency. In contrast, secondary amenorrhea must be differentiated from other diseases that cause menstrual cycle arrest, such as primary ovarian insufficiency, hypothyroidism, hyperprolactinemia, polycystic ovary syndrome, and Asherman’s syndrome.

• #57 Amenorrhea Differential Diagnoses

  https://emedicine.medscape.com/article/252928-differential

  Primary amenorrhea is defined either as absence of menses by age 14 years with the absence of growth or development of secondary sexual characteristics (eg, breast development) or as absence of menses by age 16 years with normal development of secondary sexual characteristics. […] Secondary amenorrhea is defined as the cessation of menstruation for at least 6 months or for at least 3 of the previous 3 cycle intervals. […] Diagnoses unique to primary amenorrhea include vaginal agenesis, androgen insensitivity syndrome, Turner syndrome (45,X), and mosaicism. […] Since regular menstruation reflects a properly functioning hypothalamic-pituitary-gonadal axis, a logical approach is to consider disorders based upon the levels of control of the menstrual cycle: uterus, ovary, pituitary, and hypothalamus.

• #58 Amenorrhea: Practice Essentials, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/252928-overview

  Amenorrhea is the absence of menstrual bleeding. […] In females of reproductive age, diagnosing amenorrhea is a matter of first determining whether pregnancy is the etiology. In the absence of pregnancy, the challenge is to determine the exact cause of absent menses. […] Primary amenorrhea is the failure of menses to occur by age 16 years, in the presence of normal growth and secondary sexual characteristics. […] If by age 13 menses has not occurred and the onset of puberty, such as breast development, is absent, a workup for primary amenorrhea should start. […] Secondary amenorrhea is defined as the cessation of menses sometime after menarche has occurred. […] Oligomenorrhea is defined as menses occurring at intervals longer than 35 days apart. […] For a post-menarchal girl or a reproductive-aged woman to experience a menstrual cycle interval of more than 90 days is statistically unusual. Practically speaking, this should be an indication for an evaluation to seek the cause.

• #59 Amenorrhea

  https://elsevier.health/en-US/preview/reproductive-health/amenorrhea-clinical-overview

  In patients with primary amenorrhea, also perform pelvic ultrasonography to evaluate for absence of uterus or other structural abnormalities. […] Further testing is directed by initial test findings and clinical context; may include karyotype tests, pituitary MRI scanning, serum androgen levels, or progesterone challenge test. […] Amenorrhea indicates failure of the hypothalamic-pituitary-gonadal axis to induce cyclic changes in the endometrium that result in menses; also may indicate absence of end organs or obstruction of the outflow tract. […] May result from abnormality at any level of the reproductive tract; however, majority of cases of nonphysiologic amenorrhea are associated with polycystic ovary syndrome, hyperprolactinemia, hypothalamic amenorrhea, or primary ovarian insufficiency (ovarian failure).

• #60 Amenorrhea: Practice Essentials, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/252928-overview

  First and foremost, it is imperative to rule out pregnancy. Additional diagnoses of primary amenorrhea usually result from a genetic or anatomic abnormality. […] The relative prevalence of primary amenorrhea (percentages rounded to the nearest tenth) includes hypergonadotropic hypogonadism (48.5% of cases), hypogonadotropic hypogonadism (27.8%), and eugonadism (pubertal delay with normal gonadotropins; 23.7%). […] Disorders associated with a low or normal FSH, which account for 66% of cases of secondary amenorrhea, include the following: Weight loss/anorexia, Nonspecific hypothalamic, Chronic anovulation including PCOS, Hypothyroidism, Cushing syndrome, Pituitary tumor, empty sella, Sheehan syndrome. […] Hyperandrogenic states as a cause of secondary amenorrhea (2%) include the following: Polycystic ovarian syndrome (PCOS), Ovarian tumor, Non-classic CAH, Undiagnosed.

• #61 Amenorrhea

  https://elsevier.health/en-US/preview/reproductive-health/amenorrhea-clinical-overview

  Amenorrhea is absence or abnormal cessation of menstruation in women of reproductive age. […] Majority of cases are associated with polycystic ovary syndrome, hyperprolactinemia, hypothalamic amenorrhea, or primary ovarian insufficiency (ovarian failure). […] Primary amenorrhea is defined as failure to reach menarche by age 15 years in adolescent girls with otherwise normal secondary sexual development or within 5 years after breast development that occurred before age 10 years. […] Secondary amenorrhea is defined as cessation of previously regular menses for 3 months or longer, cessation of previously irregular menses for 6 months or longer, or fewer than 9 menstrual cycles per year in females with oligomenorrhea. […] Diagnose based on history, physical examination, and measurement of serum hCG, follicle-stimulating hormone, prolactin, and TSH levels.

• #62

  https://step2.medbullets.com/evidence/23939500

  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. […] Primary amenorrhea, which by definition is failure to reach menarche, is often the result of chromosomal irregularities leading to primary ovarian insufficiency (e.g., Turner syndrome) or anatomic abnormalities (e.g., Mllerian agenesis). […] Secondary amenorrhea is defined as the cessation of regular menses for three months or the cessation of irregular menses for six months. […] Most cases of secondary amenorrhea can be attributed to polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, or primary ovarian insufficiency.

• #63 Amenorrhea: An Approach to Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2013/0601/p781.html

  Prolactin levels can be elevated because of medications, pituitary adenoma, hypothyroidism, or mass lesion compromising normal hypothalamic inhibition. […] Amenorrhea can be caused by previous central nervous system infection, trauma, or autoimmune destruction of the pituitary. […] PCOS is a multifactorial endocrine disorder, usually involving peripheral insulin resistance. […] All evaluations for amenorrhea should begin with a pregnancy test. […] Severe hyperthyroidism is more likely to cause amenorrhea than mild hyperthyroidism or hypothyroidism, and the serum thyroid-stimulating hormone level should be measured in the evaluation of amenorrhea.

• #64 Amenorrhea: Practice Essentials, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/252928-overview

  First and foremost, it is imperative to rule out pregnancy. Additional diagnoses of primary amenorrhea usually result from a genetic or anatomic abnormality. […] The relative prevalence of primary amenorrhea (percentages rounded to the nearest tenth) includes hypergonadotropic hypogonadism (48.5% of cases), hypogonadotropic hypogonadism (27.8%), and eugonadism (pubertal delay with normal gonadotropins; 23.7%). […] Disorders associated with a low or normal FSH, which account for 66% of cases of secondary amenorrhea, include the following: Weight loss/anorexia, Nonspecific hypothalamic, Chronic anovulation including PCOS, Hypothyroidism, Cushing syndrome, Pituitary tumor, empty sella, Sheehan syndrome. […] Hyperandrogenic states as a cause of secondary amenorrhea (2%) include the following: Polycystic ovarian syndrome (PCOS), Ovarian tumor, Non-classic CAH, Undiagnosed.

• #65 Amenorrhea

  https://elsevier.health/en-US/preview/reproductive-health/amenorrhea-clinical-overview

  Diagnose based on history, physical examination, and laboratory tests. […] Initial testing consists of serum hCG, follicle-stimulating hormone, prolactin, and TSH levels; some sources also suggest measuring estradiol. […] If uterus is absent, perform karyotype testing and obtain serum testosterone levels. […] If serum prolactin levels are persistently elevated and other causes have been excluded, perform pituitary MRI. […] If TSH level is outside reference range, perform thyroid function tests to exclude thyroid disease. […] If follicle-stimulating hormone level is low or within reference range, evaluate for anatomic outflow tract abnormalities, polycystic ovary syndrome, endocrine disorders, and causes of hypothalamic pituitary disorders. […] If follicle-stimulating hormone level is elevated, evaluate for causes of ovarian insufficiency.

• #66 Amenorrhea – Wikipedia

  https://en.wikipedia.org/wiki/Amenorrhea

  Secondary amenorrhea’s most common and most easily diagnosable causes are pregnancy, thyroid disease, and hyperprolactinemia. A pregnancy test is a common first step for diagnosis. Similar to primary amenorrhea, evaluation of secondary amenorrhea also begins with a pregnancy test, prolactin, FSH, LH, and TSH levels. A pelvic ultrasound is also obtained. Abnormal TSH should prompt a thyroid workup with a full thyroid function test panel. Elevated prolactin should be followed with an MRI to look for masses. If LH and FSH are elevated, menopause or primary ovarian insufficiency should be considered. Normal or low levels of FSH and LH prompts further evaluation with patient history and the physical exam. Testosterone, DHEA-S, and 17-hydroxyprogesterone levels should be obtained if there is evidence of excess androgens, such as hirsutism or acne. 17-hydroxyprogesterone is elevated in congenital adrenal hyperplasia. Elevated testosterone and amenorrhea can suggest PCOS. Elevated androgens can also be present in ovarian or adrenal tumors, so additional imaging may also be needed. History of disordered eating or excessive exercise should raise concern for hypothalamic amenorrhea. Headache, vomiting, and vision changes can be signs of a tumor and needs evaluation with MRI. Finally, a history of gynecologic procedures should lead to evaluation of Asherman syndrome with a hysteroscopy or progesterone withdrawal bleeding test.

• #67 Secondary amenorrhea

  https://www.nursingcenter.com/clinical-resources/nursing-pocket-cards/amenorrhea

  Primary amenorrhea is evaluated most efficiently by determining if a uterus is present, as well as focusing on the presence or absence of breast development and initial lab values. Initial laboratory testing should include the following: Human chorionic gonadotropin (hCG), Follicle-stimulating hormone (FSH) (estradiol [E2] can be helpful if FSH is abnormal), Thyroid-stimulating hormone (TSH), Prolactin (PRL), Free and total testosterone and dehydroepiandrosterone sulfate (DHEAS), if clinical signs of hyperandrogenism are present. […] A serum hCG test is recommended as a first step in evaluating any female with secondary amenorrhea, even in those who have had a negative urine hCG test at home. Once pregnancy has been ruled out, evaluation of disorders leading to amenorrhea should be based upon the levels of control of the menstrual cycle: hypothalamus, pituitary, ovary, and uterus. Initial laboratory testing should include the following: Serum HCG, FSH, Serum PRL, TSH, Serum total testosterone, if there is clinical evidence of hyperandrogenism.

• #68

  https://step2.medbullets.com/evidence/23939500

  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. […] Patients with primary ovarian insufficiency can maintain unpredictable ovarian function and should not be presumed infertile. […] Patients with hypothalamic amenorrhea should be evaluated for eating disorders and are at risk for decreased bone density. […] Patients with polycystic ovary syndrome are at risk for glucose intolerance, dyslipidemia, and other aspects of metabolic syndrome. […] Patients with Turner syndrome (or variant) should be treated by a physician familiar with the appropriate screening and treatment measures. […] Treatment goals for patients with amenorrhea may vary considerably, and depend on the patient and the specific diagnosis.

• #69 Amenorrhea: A Systematic Approach to Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2019/0701/p39.html

  Menstrual patterns can be an indicator of overall health and self-perception of well-being. Primary amenorrhea, defined as the lifelong absence of menses, requires evaluation if menarche has not occurred by 15 years of age or three years post-thelarche. Secondary amenorrhea is characterized by cessation of previously regular menses for three months or previously irregular menses for six months and warrants evaluation. […] All patients should be offered a pregnancy test and assessment of serum follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone levels. Additional testing, including karyotyping, serum androgen evaluation, and pelvic or brain imaging, should be individualized. […] Patients with primary ovarian insufficiency should be treated with hormone therapy until the age of natural menopause (50 to 51 years of age) to reduce the risk of osteoporosis, cardiovascular disease, and urogenital atrophy.

• #70 Amenorrhea: Practice Essentials, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/252928-overview

  Amenorrhea is the absence of menstrual bleeding. […] In females of reproductive age, diagnosing amenorrhea is a matter of first determining whether pregnancy is the etiology. In the absence of pregnancy, the challenge is to determine the exact cause of absent menses. […] Primary amenorrhea is the failure of menses to occur by age 16 years, in the presence of normal growth and secondary sexual characteristics. […] If by age 13 menses has not occurred and the onset of puberty, such as breast development, is absent, a workup for primary amenorrhea should start. […] Secondary amenorrhea is defined as the cessation of menses sometime after menarche has occurred. […] Oligomenorrhea is defined as menses occurring at intervals longer than 35 days apart. […] For a post-menarchal girl or a reproductive-aged woman to experience a menstrual cycle interval of more than 90 days is statistically unusual. Practically speaking, this should be an indication for an evaluation to seek the cause.

• #71 Amenorrhea: A Rational Approach to the Diagnostic Work-Up – Ohio Academy of Family Physicians

  https://www.ohioafp.org/wfmu-article/amenorrhea-a-rational-approach-to-the-diagnostic-work-up/

  Amenorrhea, or absence of menstrual bleeding, is a clinical problem that family physicians often encounter. There are several published approaches to the diagnosis, but I would like to present one based upon careful interpretation of the history and physical examination findings, relying upon a basic understanding of reproductive endocrinology. By following this method, one is less likely to omit a step in the work-up or overlook a potential diagnosis. […] Amenorrhea can be primary or secondary. Although many of the same underlying conditions can present as either primary or secondary, it is useful to separate the two as this rapidly helps eliminate some possible causes. […] Primary amenorrhea (PA) can be divided into two categories: with sexual infantilism (or absence of breast development by age 13) or with normal secondary sexual characteristics.

• #72 Amenorrhea: Causes, Symptoms, & Treatment

  https://www.webmd.com/infertility-and-reproduction/absence-periods

  Amenorrhea Diagnosis […] Since many things can cause amenorrhea, it may take time to find the exact reason behind your missed periods. […] Your doctor will ask about your medical history and do a physical and pelvic exam. If you’re sexually active, they’ll likely begin with a pregnancy test to rule that out. […] They may ask you questions such as: […] How old were you when you had your first period? […] Do any of your family members have a history of missed periods? […] What is the typical length of your menstrual cycle? […] Have you gained or lost weight recently? […] Do you exercise a lot? Are you an athlete? […] Are you under a lot of stress? […] What are your eating habits like? […] It may take several kinds of tests to find the cause of amenorrhea, such as: […] Blood tests. These measure the level of hormones such as follicle-stimulating hormone (FSH), thyroid-stimulating hormone, prolactin, and androgens. Too much or too little of these sex hormones can interfere with the menstrual cycle.

• #73 Amenorrhea | Causes, Risks, Diagnosis & Treatment

  https://www.cincinnatichildrens.org/health/a/amenorrhea

  Amenorrhea is the term used for the absence of menses (periods). It is either primary or secondary. […] Primary amenorrhea is classified as not starting menses by age 16. […] Secondary amenorrhea is absence of menstruation for three cycles after having had a menstrual period for longer than two years. […] Your child’s healthcare provider will do a complete exam to determine the cause of the absent menstrual cycle; this includes questions related to your medical history. The physical exam will include checking private areas for determination of normal pubertal development. […] Blood is often obtained in order to check hormone levels and other things that may have an effect on the menstrual cycle. […] In some cases, an ultrasound may be performed to look at internal body parts for abnormalities.

• #74 Amenorrhea | Boston Children’s Hospital

  https://www.childrenshospital.org/conditions/amenorrhea

  Amenorrhea can have many different causes that’s why it’s so important that a teen girl with amenorrhea be checked out by an expert. […] The first step in treating amenorrhea is to determine what’s causing it, so a complete and accurate diagnosis is extremely important. […] If your daughter hasn’t had her first menstrual cycle by 15, or if more than three years have passed since she started developing breasts, she should see a physician. […] The health care provider will start by taking her medical history and asking questions about other health issues, weight loss, weight gain, concerns about eating disorders, medications she’s taking, excess hair growth and acne, sexual activity, and family history of problems with menstrual cycles. […] The health care provider may also perform blood tests to check her hormone levels and a pregnancy test, so that they can consider all the possible causes of amenorrhea.

• #75 Amenorrhea – Gynecology and Obstetrics – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/gynecology-and-obstetrics/menstrual-abnormalities/amenorrhea

  Amenorrhea (the absence of menstruation) can be primary or secondary. […] Primary amenorrhea is failure of menses to occur by age 15 years in patients with normal growth and secondary sexual characteristics. However, absence of menarche and of any breast development by age 13 should prompt evaluation for primary amenorrhea. […] Secondary amenorrhea is the absence of menses for 3 months in patients with regular menstrual cycles or for 6 months in patients with irregular menses. […] Amenorrhea can be classified based on a number of different criteria, such as primary or secondary. […] Girls are evaluated for primary amenorrhea if menarche has not occurred and they reach one of the following milestones: Age 13 and they have no signs of puberty (eg, breast development, growth spurt); Three years after thelarche (onset of breast development); Age 15 (in patients with normal growth and development of secondary sexual characteristics).

• #76 Amenorrhea in adolescents: a narrative review – Newbery – Pediatric Medicine

  https://pm.amegroups.org/article/view/4922/html

  Failure to attain menarche is primary amenorrhea. Evaluation is needed if menarche has not occurred by: age 15 years in females with normal secondary sexual development; age 13 years in females lacking any secondary sexual characteristics; within five years after thelarche. On the other hand, secondary amenorrhea is defined as menstrual cessation for at least three months in those with previously established regular menses, or lack of menses for over six months in patients who previously experienced irregular menses. […] Another classification of identifying causes of amenorrhea is understanding the regulatory processes that occur at the HPO axis and outflow tract. Any disruption of the normal signaling within the axis may manifest as primary or secondary amenorrhea. […] A hormonal work-up is always helpful, and obtaining the FSH, TSH, prolactin, and serum androgen levels can identify specific etiologies.

• #77 Amenorrhea in Adolescents and Teens | Phoenix Children’s Hospital

  https://phoenixchildrens.org/specialties-conditions/amenorrhea-adolescents-and-teens

  Amenorrhea is a menstrual condition characterized by absent menstrual periods for more than 3 monthly menstrual cycles. […] Diagnosis begins with a gynecologist or other health care provider evaluating a female’s medical history and a complete physical examination. This includes a pelvic examination. A diagnosis of amenorrhea can only be certain when the health care provider rules out other menstrual disorders, medical conditions, or medicines that may be causing or making the condition worse. […] Young women who haven’t had their first menstrual period by age 15 should be evaluated promptly. Making an early diagnosis and starting treatment as soon as possible is very important.

• #78 Hypothalamic Amenorrhea: Causes, Symptoms & Treatment

  https://my.clevelandclinic.org/health/diseases/24431-hypothalamic-amenorrhea

  Hypothalamic amenorrhea is when your hypothalamus causes your period to stop. Common causes include excessive exercise, stress and undereating. […] Healthcare providers diagnose hypothalamic amenorrhea after ruling out other conditions that can cause you to stop menstruating. These could include thyroid or adrenal gland disorders or pregnancy. […] Your provider will also ask for your medical history, perform a physical exam and pelvic exam and order several tests. These tests may include: Blood tests to check levels of hormones that affect menstruation. These could include estrogen, prolactin, FSH and LH. […] The main treatment healthcare providers use for hypothalamic amenorrhea is lifestyle changes. Lifestyle changes may include limiting vigorous exercise, gaining weight or finding ways to reduce stress levels.

• #79 Hypothalamic Amenorrhea: Symptoms, Causes and Treatments – Hertility Health

  https://hertilityhealth.com/blog/hypothalamic-amenorrhea

  Hypothalamic amenorrhea (HA) is when your menstrual cycle and ovulation are interrupted due to the influence of the hypothalamus gland, located in the brain. […] Testing your hormones is the first step toward getting a diagnosis. […] It is usually a diagnosis of exclusion, which requires healthcare providers to rule out other conditions that could be interrupting the menstrual cycle. Your doctor may consider the following blood hormone tests to base their diagnosis on: […] GnRH levels are tested to analyse the function of the hypothalamus, with a low GnRH result being indicative of a dysfunctional hypothalamus. Low levels of FSH, LH and E2, may also indicate hypothalamic amenorrhea. […] If youve received a diagnosis of hypothalamic amenorrhea, your pathway to care and treatment options will usually be tailored according to the cause.

• #80 Hypothalamic Amenorrhea Guideline Resources | Endocrine Society

  https://www.endocrine.org/clinical-practice-guidelines/hypothalamic-amenorrhea

  In a patient with suspected FHA, we recommend excluding pregnancy and performing a full physical examination, including a gynecological examination (external, and in selected cases, bimanual), to evaluate the possibility of organic etiologies of amenorrhea. […] In adolescents and women with suspected FHA, we recommend obtaining the following screening laboratory tests: -human chorionic gonadotropin, complete blood count, electrolytes, glucose, bicarbonate, blood urea nitrogen, creatinine, liver panel, and (when appropriate) sedimentation rate and/or C-reactive protein levels. […] As part of an initial endocrine evaluation for patients with FHA, we recommend obtaining the following laboratory tests: serum thyroid-stimulating hormone (TSH), free thyroxine (T4), prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol (E2), and anti-Mllerian hormone (AMH).

• #81 Amenorrhea: Practice Essentials, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/252928-overview

  Hypothalamic dysfunction results in decreased or inhibited GnRH secretion, which affects the pulsatile release of pituitary gonadotropins, LH and FSH, causing anovulation. A common cause of amenorrhea is functional hypothalamic amenorrhea. […] It is characterized by abnormal hypothalamic GnRH secretion, decreased gonadotropin pulsations, low or normal LH concentrations, absent LH surges, abnormal follicular development, and low serum estradiol. […] Functional hypothalamic amenorrhea can be caused by eating disorders, exercise, or high levels of prolonged physical or mental stress. […] A deficiency in FSH and LH may result from GnRH receptor gene mutations, although such mutations are rare. […] Primary amenorrhea caused by hyperprolactinemia is a rare condition characterized by the onset of thelarche and pubarche at appropriate ages but arrest of pubertal development before menarche.

• #82 Amenorrhea: Practice Essentials, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/252928-overview

  Hypothalamic dysfunction results in decreased or inhibited GnRH secretion, which affects the pulsatile release of pituitary gonadotropins, LH and FSH, causing anovulation. A common cause of amenorrhea is functional hypothalamic amenorrhea. […] It is characterized by abnormal hypothalamic GnRH secretion, decreased gonadotropin pulsations, low or normal LH concentrations, absent LH surges, abnormal follicular development, and low serum estradiol. […] Functional hypothalamic amenorrhea can be caused by eating disorders, exercise, or high levels of prolonged physical or mental stress. […] A deficiency in FSH and LH may result from GnRH receptor gene mutations, although such mutations are rare. […] Primary amenorrhea caused by hyperprolactinemia is a rare condition characterized by the onset of thelarche and pubarche at appropriate ages but arrest of pubertal development before menarche.

• #83

  https://step2.medbullets.com/evidence/23939500

  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. […] Patients with primary ovarian insufficiency can maintain unpredictable ovarian function and should not be presumed infertile. […] Patients with hypothalamic amenorrhea should be evaluated for eating disorders and are at risk for decreased bone density. […] Patients with polycystic ovary syndrome are at risk for glucose intolerance, dyslipidemia, and other aspects of metabolic syndrome. […] Patients with Turner syndrome (or variant) should be treated by a physician familiar with the appropriate screening and treatment measures. […] Treatment goals for patients with amenorrhea may vary considerably, and depend on the patient and the specific diagnosis.

• #84 Amenorrhea in adolescents: a narrative review – Newbery – Pediatric Medicine

  https://pm.amegroups.org/article/view/4922/html

  Once the diagnosis of PCOS is established, the mainstay of treatment is oral contraceptives. These are effective in regulating menstrual cycles and lowering androgen levels. […] Weight recovery is a therapeutic goal in ED, but there is no consensus concerning target weight. […] Similar to the management of functional hypothalamic amenorrhea in females with ED, approach to the female adolescent athlete entails a multidisciplinary team, with emphasis on prevention of future lapses as well as treatment of current dysfunction. […] Further investigation is warranted when a young adolescent presents with amenorrhea. It is crucial during evaluation to determine likely causes as existing treatment modalities may be available.

• #85 Amenorrhea: An Approach to Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2013/0601/p781.html

  Prolactin levels can be elevated because of medications, pituitary adenoma, hypothyroidism, or mass lesion compromising normal hypothalamic inhibition. […] Amenorrhea can be caused by previous central nervous system infection, trauma, or autoimmune destruction of the pituitary. […] PCOS is a multifactorial endocrine disorder, usually involving peripheral insulin resistance. […] All evaluations for amenorrhea should begin with a pregnancy test. […] Severe hyperthyroidism is more likely to cause amenorrhea than mild hyperthyroidism or hypothyroidism, and the serum thyroid-stimulating hormone level should be measured in the evaluation of amenorrhea.

• #86

  https://step2.medbullets.com/evidence/23939500

  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. […] Patients with primary ovarian insufficiency can maintain unpredictable ovarian function and should not be presumed infertile. […] Patients with hypothalamic amenorrhea should be evaluated for eating disorders and are at risk for decreased bone density. […] Patients with polycystic ovary syndrome are at risk for glucose intolerance, dyslipidemia, and other aspects of metabolic syndrome. […] Patients with Turner syndrome (or variant) should be treated by a physician familiar with the appropriate screening and treatment measures. […] Treatment goals for patients with amenorrhea may vary considerably, and depend on the patient and the specific diagnosis.

• #87 Amenorrhea – Wikipedia

  https://en.wikipedia.org/wiki/Amenorrhea

  Secondary amenorrhea’s most common and most easily diagnosable causes are pregnancy, thyroid disease, and hyperprolactinemia. A pregnancy test is a common first step for diagnosis. Similar to primary amenorrhea, evaluation of secondary amenorrhea also begins with a pregnancy test, prolactin, FSH, LH, and TSH levels. A pelvic ultrasound is also obtained. Abnormal TSH should prompt a thyroid workup with a full thyroid function test panel. Elevated prolactin should be followed with an MRI to look for masses. If LH and FSH are elevated, menopause or primary ovarian insufficiency should be considered. Normal or low levels of FSH and LH prompts further evaluation with patient history and the physical exam. Testosterone, DHEA-S, and 17-hydroxyprogesterone levels should be obtained if there is evidence of excess androgens, such as hirsutism or acne. 17-hydroxyprogesterone is elevated in congenital adrenal hyperplasia. Elevated testosterone and amenorrhea can suggest PCOS. Elevated androgens can also be present in ovarian or adrenal tumors, so additional imaging may also be needed. History of disordered eating or excessive exercise should raise concern for hypothalamic amenorrhea. Headache, vomiting, and vision changes can be signs of a tumor and needs evaluation with MRI. Finally, a history of gynecologic procedures should lead to evaluation of Asherman syndrome with a hysteroscopy or progesterone withdrawal bleeding test.

• #88

  https://step2.medbullets.com/evidence/23939500

  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. […] Patients with primary ovarian insufficiency can maintain unpredictable ovarian function and should not be presumed infertile. […] Patients with hypothalamic amenorrhea should be evaluated for eating disorders and are at risk for decreased bone density. […] Patients with polycystic ovary syndrome are at risk for glucose intolerance, dyslipidemia, and other aspects of metabolic syndrome. […] Patients with Turner syndrome (or variant) should be treated by a physician familiar with the appropriate screening and treatment measures. […] Treatment goals for patients with amenorrhea may vary considerably, and depend on the patient and the specific diagnosis.

• #89 Amenorrhea – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/amenorrhea/symptoms-causes/syc-20369299

  Many types of medical problems can cause hormonal imbalance, including polycystic ovary syndrome (PCOS), thyroid malfunction, pituitary tumor, and premature menopause. […] Problems with the sexual organs themselves also can cause amenorrhea. Examples include uterine scarring, lack of reproductive organs, and structural abnormality of the vagina. […] If you don’t ovulate and don’t have menstrual periods, you can’t become pregnant. […] The causes of amenorrhea can cause other problems as well, including infertility and problems with pregnancy, psychological stress, osteoporosis and cardiovascular disease, and pelvic pain.

• #90 Amenorrhea – What You Need to Know

  https://www.drugs.com/cg/amenorrhea.html

  Treatment will depend on what is causing your amenorrhea. You may be given birth control pills to restart and regulate your periods. You may need medicines to treat medical conditions such as a thyroid or pituitary disorder, or PCOS. Surgery may fix a problem that is preventing blood from flowing through your vagina, or to remove a tumor. […] Amenorrhea may lead to infertility (not able to have children). You may also develop osteoporosis. Osteoporosis is a serious condition that causes bones to become weak, brittle, and easily fractured.

• #91 Amenorrhea – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/amenorrhea/symptoms-causes/syc-20369299

  Many types of medical problems can cause hormonal imbalance, including polycystic ovary syndrome (PCOS), thyroid malfunction, pituitary tumor, and premature menopause. […] Problems with the sexual organs themselves also can cause amenorrhea. Examples include uterine scarring, lack of reproductive organs, and structural abnormality of the vagina. […] If you don’t ovulate and don’t have menstrual periods, you can’t become pregnant. […] The causes of amenorrhea can cause other problems as well, including infertility and problems with pregnancy, psychological stress, osteoporosis and cardiovascular disease, and pelvic pain.

• #92 What Is Amenorrhea? Symptoms, Causes, Diagnosis, Treatment, and Prevention

  https://www.everydayhealth.com/amenorrhea/guide/

  Generally blood tests are also done, including a pregnancy test as well as those that measure a variety of hormones such as estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid hormones, and others. […] If these tests do not uncover the cause of the amenorrhea, a head CT scan or MRI may be ordered to look for a tumor. […] Once the cause of the amenorrhea has been identified and treated, the menstrual period should return. […] Because many different conditions can be behind your missed periods, treatment varies depending on the cause. […] Surgery for amenorrhea is uncommon but may be recommended in certain situations. […] When lifestyle factors bring on amenorrhea, shifting to a healthier way of life can bring a regular cycle back. […] To best regulate your menstrual cycle, maintain a healthy body weight and do a proper amount of exercise. […] When there is no natural explanation, though, it can be a sign that your hormonal or reproductive system is not working properly. […] Several underlying conditions that include amenorrhea as a symptom may cause significant complications.

• #93 Amenorrhea: Causes, Treatment, and Prevention

  https://www.healthline.com/health/amenorrhea

  Amenorrhea is the absence of menstrual bleeding, which can impact things like bone density and fertility. […] If you miss your monthly period for 3 straight months after having regular cycles for the previous 9 months, you may have secondary amenorrhea. This type of amenorrhea is more common. […] See your doctor if you’ve missed three periods in a row or you’re 16 years old and haven’t started menstruating. It may be a sign of an underlying medical condition that requires treatment. […] To diagnose the cause of your missed periods, your doctor will first rule out pregnancy and menopause. They’ll likely ask you to describe your symptoms and medical history. […] Your doctor may perform a pelvic exam. They may also order diagnostic tests, such as urine, blood, or imaging tests, to help them make a diagnosis. […] In most cases, amenorrhea and its underlying causes are treatable. Ask your doctor for more information about your condition, treatment options, and long-term outlook.

• #94 Amenorrhea

  https://elsevier.health/en-US/preview/reproductive-health/amenorrhea-clinical-overview

  Diagnose based on history, physical examination, and laboratory tests. […] Initial testing consists of serum hCG, follicle-stimulating hormone, prolactin, and TSH levels; some sources also suggest measuring estradiol. […] If uterus is absent, perform karyotype testing and obtain serum testosterone levels. […] If serum prolactin levels are persistently elevated and other causes have been excluded, perform pituitary MRI. […] If TSH level is outside reference range, perform thyroid function tests to exclude thyroid disease. […] If follicle-stimulating hormone level is low or within reference range, evaluate for anatomic outflow tract abnormalities, polycystic ovary syndrome, endocrine disorders, and causes of hypothalamic pituitary disorders. […] If follicle-stimulating hormone level is elevated, evaluate for causes of ovarian insufficiency.

• #95

  https://step2.medbullets.com/evidence/23939500

  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. […] Primary amenorrhea, which by definition is failure to reach menarche, is often the result of chromosomal irregularities leading to primary ovarian insufficiency (e.g., Turner syndrome) or anatomic abnormalities (e.g., Mllerian agenesis). […] Secondary amenorrhea is defined as the cessation of regular menses for three months or the cessation of irregular menses for six months. […] Most cases of secondary amenorrhea can be attributed to polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, or primary ovarian insufficiency.

• #96 Primary Amenorrhea in Adolescents: Approach to Diagnosis and Management

  https://www.mdpi.com/2673-396X/4/3/38

  Primary amenorrhea (PA) describes the complete absence of menses by the age of 15 years. It is a devastating diagnosis that can affect the adolescent’s view of her femininity, sexuality, fertility and self-image. A normal menstrual cycle can occur only in the presence of: a properly functioning hypothalamus–pituitary axis, well-developed and active ovaries, outflow tract without abnormalities. Any dysfunction in any of these players can result in amenorrhea. PA evaluation includes the patient’s medical history, physical examination, pelvic ultrasonography and initial hormone evaluation, limited to the serum-follicle-stimulating hormone (FSH) and luteinizing hormone, testosterone and prolactin. A karyotype should be obtained in all adolescents with high FSH serum levels. The main causes of PA, whether or not accompanied by secondary sexual characteristics, include endocrine defects of the hypothalamus–pituitary–ovarian axis, genetic defects of the ovary, metabolic diseases, autoimmune diseases, infections, iatrogenic causes (radiotherapy, chemotherapy), environmental factors and Müllerian tract defects. PA management depends on the underlying causes. Estrogen replacement therapy at puberty has mainly been based on personal experience. PA can be due to endocrine, genetic, metabolic, anatomical and environmental disorders that may have severe implications on reproductive health later in life. In some complex cases, a multidisciplinary team best manages the adolescent, including a pediatrician endocrinologist, gynecologist, geneticist, surgeon, radiologist, and psychologist.

• #97 Amenorrhea ICD-10-CM Codes | 2023

  https://www.carepatron.com/icd/amenorrhea

  Amenorrhea refers to the absence of menstruation in women who are of reproductive age. This condition can be caused by various underlying factors, and for accurate diagnosis and billing purposes, the ICD-10 (International Classification of Diseases, 10th Revision) coding system provides specific codes to represent these causes. […] Accurate diagnosis and treatment of amenorrhea involve a thorough medical history, physical examination, hormonal tests, imaging studies, and sometimes genetic testing. […] Proper evaluation and management of amenorrhea are crucial to address the underlying causes and improve the patient’s well-being and reproductive health. […] Patients experiencing amenorrhea should seek medical attention to determine the cause and receive appropriate treatment or guidance to address their specific situation.

• #98 Amenorrhea – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/amenorrhea/diagnosis-treatment/drc-20369304

  Magnetic resonance imaging (MRI). MRI uses radio waves with a strong magnetic field to produce exceptionally detailed images of soft tissues within the body. Your doctor may order an MRI to check for a pituitary tumor. […] If other testing reveals no specific cause, your doctor may recommend a hysteroscopy a test in which a thin, lighted camera is passed through your vagina and cervix to look at the inside of your uterus. […] Treatment depends on the underlying cause of your amenorrhea. In some cases, birth control pills or other hormone therapies can restart your menstrual cycles. Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. If a tumor or structural blockage is causing the problem, surgery may be necessary.

• #99 Amenorrhea: Types, Causes, Symptoms, Diagnosis & Treatment

  https://my.clevelandclinic.org/health/diseases/3924-amenorrhea

  Diagnosing amenorrhea can be challenging. If the cause of amenorrhea isn’t obvious, such as pregnancy or menopause, your provider may ask you to keep a record of changes in your menstrual cycle. This history of your periods can help your provider figure out a diagnosis. […] If your period stopped because of menopause, lactation or pregnancy, your provider won’t need to treat it. In other cases, your treatment will depend on the cause and may include: Following a diet and exercise plan that help you maintain a weight that’s healthy for you. Stress management techniques. Changing exercise levels. Hormonal treatment (medication), as prescribed by your healthcare provider. Surgery (in rare cases). […] Most cases of amenorrhea are treatable. With treatment, your periods should start to happen regularly. It can take a few months for your periods to come back, but in most cases, they will. Talk to your healthcare provider about what you can expect with treatment.

• #100 Amenorrhea: A Systematic Approach to Diagnosis and Management – PubMed

  https://pubmed.ncbi.nlm.nih.gov/31259490/

  Menstrual patterns can be an indicator of overall health and self-perception of well-being. Primary amenorrhea, defined as the lifelong absence of menses, requires evaluation if menarche has not occurred by 15 years of age or three years post-thelarche. Secondary amenorrhea is characterized by cessation of previously regular menses for three months or previously irregular menses for six months and warrants evaluation. Clinicians may consider etiologies of amenorrhea categorically as outflow tract abnormalities, primary ovarian insufficiency, hypothalamic or pituitary disorders, other endocrine gland disorders, sequelae of chronic disease, physiologic, or induced. […] The history should include menstrual onset and patterns, eating and exercise habits, presence of psychosocial stressors, body weight changes, medication use, galactorrhea, and chronic illness. Additional questions may target neurologic, vasomotor, hyperandrogenic, or thyroid-related symptoms. The physical examination should identify anthropometric and pubertal development trends. All patients should be offered a pregnancy test and assessment of serum follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone levels. Additional testing, including karyotyping, serum androgen evaluation, and pelvic or brain imaging, should be individualized. Patients with primary ovarian insufficiency can maintain unpredictable ovary function and may require hormone replacement therapy, contraception, or infertility services. Functional hypothalamic amenorrhea may indicate disordered eating and low bone density. Treatment should address the underlying cause. Patients with polycystic ovary syndrome should undergo screening and intervention to attenuate metabolic disease and endometrial cancer risk. Amenorrhea can be associated with clinically challenging pathology and may require lifelong treatment. Patients will benefit from ample time with the clinician, sensitivity, and emotional support.

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