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    Amenorrhea

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    Sep.14.2024

    Amenorrhea

    Synopsis

    Key Points

    • 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 r1
    • 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,r2 or fewer than 9 menstrual cycles per year in females with oligomenorrhea r1
    • Diagnose based on history, physical examination, and measurement of serum hCG, follicle-stimulating hormone, prolactin, and TSH levels
      • 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
    • Management is based on the underlying cause and generally consists of treating cause (if possible) and providing hormone therapy to achieve physiologic hormone levels, relieve symptoms, and prevent complications (eg, osteoporosis, infertility)

    Pitfalls

    • Always perform pregnancy test; sexual history may corroborate results but does not replace pregnancy test
    • Counsel patients who have primary ovarian failure about possible fertility; spontaneous pregnancy can occur and contraception should be used unless pregnancy is desired

    Terminology

    Clinical Clarification

    • Amenorrhea is absence or abnormal cessation of menstruation in women of reproductive age r1
    • Amenorrhea not related to menopause, pregnancy, or lactation occurs in 3% to 4% of women r1
      • Majority of cases are accounted for by polycystic ovary syndrome, hyperprolactinemia, hypothalamic amenorrhea, or primary ovarian insufficiency (ovarian failure) r1

    Classification

    • Primary amenorrhea r1
      • 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
        • Failure of breast development to start by age 13 years also requires evaluation
    • Secondary amenorrhea r1
      • Defined as cessation of previously regular menses for 3 months or longer, cessation of previously irregular menses for 6 months or longer,r2 or fewer than 9 menstrual cycles per year in women with oligomenorrhea r1

    Diagnosis

    Clinical Presentation

    History

    • Suspect primary amenorrhea if any of the following are true: r1
      • Absence of menarche by age 15 years in adolescent girls with otherwise normal secondary sexual development c1
      • Absence of menarche within 5 years after breast development that occurred before age 10 years c2
      • Absence of menarche and breast development by age 13 years c3
    • Suspect secondary amenorrhea if any of the following are true: r1
      • Absence of menses for 3 months or longer if previously regular, or 6 months or longer if previously irregular c4c5
      • Fewer than 9 menstrual cycles per year in women with oligomenorrhea c6
    • Evaluate for potential underlying cause of amenorrhea: r1
      • Sexual history may indicate possible pregnancy c7
      • Family history of delayed menarche suggests constitutional delay of puberty r1c8
      • Vasomotor symptoms (eg, night sweats, hot flashes) may indicate primary ovarian insufficiency or natural menopause r3c9c10c11c12c13c14
      • Previous chemotherapy or radiation therapy may suggest impairment of specific organ (eg, brain, pituitary gland, ovaries) r1c15c16c17c18c19c20
      • Severe and/or persistent headaches, intractable vomiting, or changes in thirst, urination, or vision may indicate a central nervous system tumor or empty sella syndrome r1c21c22c23c24c25c26c27c28c29c30c31c32
      • Galactorrhea may indicate a pituitary tumor r4c33
      • Cyclic abdominal pain may indicate imperforate hymen or transverse vaginal septum r1c34c35
      • Prior or current use of illegal or prescription drugs (eg, opiates, antipsychotics, antidepressants, antihypertensives, antihistamines) may alter prolactin levels r1c36c37c38c39c40c41c42c43
      • Acne, increased facial hair, and male pattern hair loss may indicate hyperandrogenism, polycystic ovary syndrome, ovarian or adrenal tumor, congenital adrenal hyperplasia, or Cushing syndrome r2c44c45c46c47c48c49c50c51c52c53c54c55c56c57c58c59c60c61
      • Temperature intolerance, palpitations, diarrhea, constipation, or tremor may suggest thyroid disease r2c62c63c64c65c66
      • History of dieting, weight loss, malnutrition, eating disorders, excessive exercise, or psychosocial stress may suggest functional hypothalamic amenorrhea r4c67c68c69c70c71c72

    Physical examination

    • Measure height, weight, and BMI r1
      • Results lower than reference range may indicate constitutional delay of puberty or Turner syndrome r1c73c74d1
      • Elevated BMI may be associated with polycystic ovary syndrome r1c75
      • Low BMI may be associated with functional hypothalamic amenorrhea r4c76
    • Evaluate for clinical signs associated with specific underlying causes
      • Goiter or thyroid nodule indicate thyroid disorder c77c78
      • Dysmorphic features such as webbed neck, low hairline, and short stature indicate Turner syndrome r1c79c80c81
      • Central obesity, buffalo hump, striae, and hypertension indicate Cushing syndrome c82c83c84c85
      • Hirsutism (particularly facial hair), acne, or male pattern baldness may indicate hyperandrogenism, caused by polycystic ovary syndrome (most commonly), ovarian or adrenal tumor, congenital adrenal hyperplasia, or Cushing syndrome r1
    • Evaluate secondary sexual characteristics (ie, breast development and pubic hair growth) and determine Tanner stage r1
      • Tanner stage inconsistent with age may indicate constitutional delay of puberty, Turner syndrome, or other rare gonadal anomalies r2c86c87c88
    • Inspect external genitalia and perform pelvic and speculum examination (if no vaginal obstruction) r1
      • Clitoromegaly suggests an androgen-secreting tumor or congenital adrenal hyperplasia r2c89c90
      • Bulging, bluish mass at entrance to vagina suggests imperforate hymen r5c91c92
      • Short, blind vaginal pouch suggests a transverse vaginal septum, müllerian agenesis, or androgen insensitivity syndrome r5c93c94c95c96c97c98
      • Thin or red vaginal mucosa may indicate low estrogen levels r1c99c100
      • Absent or abnormal cervix or uterus suggests müllerian agenesis or androgen insensitivity syndrome r1c101c102c103c104c105c106
      • Cervical scarring may suggest intrauterine synechiae caused by an operation on the uterus (Asherman syndrome) r1c107

    Causes and Risk Factors

    Causes

    • 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 r6c108c109c110
    • 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) r1c111c112c113c114
    • Anatomic causes r1
      • Congenital
        • Müllerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome) c115
        • Complete androgen insensitivity syndrome (testicular feminization) c116
        • Imperforate hymen c117
        • Transverse vaginal septum c118
        • Isolated vaginal agenesis c119
        • Isolated cervical agenesis c120
        • Congenital endometrial hypoplasia or aplasia c121c122
      • Acquired
        • Intrauterine synechiae (Asherman syndrome) c123
        • Cervical stenosis c124
        • Head trauma/concussion r7
    • Primary ovarian insufficiency (eg, ovarian failure, primary hypogonadism, hypergonadotropic hypogonadism) r6r8c125
      • Congenital
        • Gonadal dysgenesis c126
          • Turner syndrome (45,X) c127
          • Mosaicism c128
          • Pure gonadal dysgenesis (46,XX or 46,XY) c129
          • Fragile X premutation c130
        • Gonadal agenesis c131
        • Enzymatic deficiencies r1c132
          • 17α-hydroxylase deficiency c133
          • 17,20-lyase deficiency c134
          • Aromatase deficiency c135
      • Acquired
        • Chemotherapy or radiation therapy c136c137
        • Mumps oophoritis c138
        • Autoimmune oophoritis c139
        • Idiopathic c140
    • Hypothalamic causes r1
      • Dysfunction due to: r1
      • Isolated gonadotropin deficiency (ie, Kallmann syndrome, idiopathic hypogonadotropic hypogonadism) r1c150c151c152
      • Infection (eg, tuberculosis, meningitis, syphilis) r1c153c154c155
      • Chronic systemic disease r1c156
      • Hypothalamic tumor r1c157
      • Traumatic brain injury c158
    • Pituitary causes r1c159
      • Pituitary tumors (prolactinomas or other hormone-secreting pituitary tumors) r1c160c161
      • Autoimmune disease (eg, lymphocytic hypophysitis) c162c163
      • Empty sella syndrome c164
      • Galactosemia c165
      • Hyperprolactinemia c166
      • Medications (eg, antidepressants, antihistamines, antipsychotics, antihypertensives, opioids) r2c167c168c169c170c171
      • Cocaine use r2c172
      • Sheehan syndrome c173
      • Sarcoidosis c174
      • Panhypopituitarism c175
      • Hemochromatosis c176
    • Other endocrine gland disorders r1
      • Congenital or adult-onset adrenal hyperplasia c177c178
      • Cushing syndrome c179
      • Thyroid disease r1c180
      • Ovarian tumors (androgen producing) r1c181
      • Arterial aneurysm c182
      • Constitutional delay of puberty c183
      • Gonadotropin mutations c184
    • Polycystic ovary syndrome
    • Physiologic r2
    • Iatrogenic
      • Hormonal contraception c188
      • Exogenous androgen use c189

    Risk factors and/or associations

    Age
    • Primary amenorrhea is diagnosed in adolescent girls aged 15 years or older who have never menstruated r1c190
    • Secondary amenorrhea is diagnosed in women of reproductive age in whom menstruation has ceased r1c191
    Genetics
    • X chromosomal causes (ie, mutations, alterations, or absence of X chromosome) c192
      • Turner syndrome (OMIM #309585r10) r1c193
        • 45,X karyotype r1
      • Pure gonadal dysgenesis r6c194
        • 46,XX karyotype
      • Swyer syndrome (OMIM #400044,r11OMIM #233420r12) r1c195
        • 46,XY karyotype with female external genitalia
      • Mutations in POF1 (OMIM #311360r13) r6c196
      • Fragile X premutations c197
        • FMR1 mutations (band Xq27) r3
      • Mutations on POF2 A or B (OMIM #300511r14, OMIM #300604r15) r6c198c199
      • Mutations in POF4r6c200
      • Trisomy X with or without mosaicism r6c201
      • Mutations in 5 centromere r6
    • Autosomal causes r6
      • Mutations involving enzymes with reproductive effects
        • 17α-hydroxylase deficiency (OMIM #202110r16) r3c202
          • CYP17A1 mutations (10q24.3) r3
        • Galactosemia (OMIM #230400r17) r3c203
          • GALT mutations r3
        • Aromatase deficiency (OMIM #107910r18) r3c204
          • CYP19A1 mutations r3
      • Mutations involving reproductive hormones and their receptors and actions r6
        • Mutations in inhibin A (INHA) c205
        • Follicle-stimulating hormone or luteinizing hormone receptor mutations c206c207
      • Other known genetic mutations
        • Blepharophimosis, ptosis, epicanthus inversus syndrome (OMIM #110100r19) r3c208
          • FOXL2 mutations r3
        • Autoimmune polyendocrine syndrome, type 1 (OMIM #240300r20) r3c209
          • AIRE mutations
        • Autoimmune polyendocrine syndrome, type 2 (OMIM #269200r21) r3c210
        • Congenital disorder of glycosylation, type 1A (OMIM #212065r22) r3c211
          • PMM2 mutations
        • Progressive external ophthalmoplegia with mitochondrial DNA deletions (OMIM #157640r23) r3c212
          • POLG mutations
        • Central nervous system leukodystrophy and ovarian failure r6c213
          • ELF2B mutations
        • BMP15 mutations r6c214
        • STAG3 mutations r6c215
        • Ataxia-telangiectasia (OMIM #208900r24) r3c216
          • ATM mutations
        • Bloom syndrome (OMIM #210900r25) r3c217
          • BLM mutations
        • Lipoid congenital adrenal hyperplasia (OMIM #600617r26) r3c218
          • STAR mutations
        • Werner syndrome (OMIM #277700r27) r3c219
          • WRN mutations
        • Fanconi anemia (OMIM #227650r28) r3c220
          • Fanconi anemia mutations (eg, FANCA, FANCC, FANCG) r3
    Other risk factors/associations
    • Women who compete in sports activities are 3 times more likely to have primary or secondary amenorrhea r1c221
      • Highest prevalence is in long-distance runners r1c222

    Diagnostic Procedures

    Primary diagnostic tools

    • Diagnose based on history, physical examination, and laboratory tests r1c223
    • Initial testing consists of serum hCG, follicle-stimulating hormone, prolactin, and TSH levels; some sources also suggest measuring estradiolr1
      • 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
      • If uterus is absent, perform karyotype testing and obtain serum testosterone levels r1
        • 46,XX and female-range serum testosterone level indicates müllerian agenesis as the cause of amenorrhea r1
        • 46,XY and male-range serum testosterone level indicates androgen insensitivity as the cause of amenorrhea r1
      • If serum prolactin levels are persistently elevated and other causes have been excluded, perform pituitary MRI r1
      • If TSH level is outside reference range, perform thyroid function tests to exclude thyroid disease r1
      • 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
        • May require pelvic ultrasonography; measurement of serum luteinizing hormone, testosterone, dehydroepiandrosterone sulfate, and 17-hydroxyprogesterone levels; or pituitary MRI r1r29
        • Consider progesterone challenge to induce withdrawal bleeding or hysteroscopy to evaluate for Asherman syndrome if patient has history of obstetric or gynecologic procedures r30
        • Consider possible eating disorder, excessive exercise, weight loss, or chronic disease as cause r1
      • If follicle-stimulating hormone level is elevated, evaluate for causes of ovarian insufficiency r1r31
        • Confirm by repeating follicle-stimulating hormone measurement in 1 month and evaluating serum estradiol r3
        • May require testing for 17α-hydroxylase deficiency, karyotype and genetic analysis, or screening for autoimmune causes of ovarian insufficiency (eg, levels of TSH, thyroid autoantibodies, fasting glucose, electrolytes) r1

    Laboratory

    • Serum hCG r1c224
      • Positive test result indicates pregnancy as the cause of amenorrhea
    • TSH r1c225c226
      • Low levels (less than 0.01 milliunits/L) indicate hyperthyroidism r32
      • High levels (greater than 4.5 milliunits/L) indicate hypothyroidism r33
    • Prolactin r1c227c228c229c230c231
      • High levels can be associated with pituitary adenoma, other neoplasms, hypothyroidism, and illicit or prescription drug use
    • Follicle-stimulating hormone r1c232
      • High levels (basal follicle-stimulating hormone greater than 30-40 milliunits/mL) are associated with primary ovarian insufficiency and Turner syndrome r31
      • Low levels are associated with functional hypothalamic amenorrhea and hypothalamic-pituitary disorders r1
      • Levels within reference range may be observed in polycystic ovary syndrome, Asherman syndrome, and several other potential causes of amenorrhea
    • Luteinizing hormone c233
      • Low levels are associated with functional hypothalamic amenorrhea and hypothalamic-pituitary disorders r1
    • Estradiol r1c234
      • Low levels (less than 50 pg/mL) suggest abnormal ovarian function r31
    • Free and total testosterone and dehydroepiandrosterone sulfate r1c235c236
      • High levels can indicate hyperandrogenism, polycystic ovary syndrome, ovarian or adrenal tumor, congenital aqueductal stenosis, or Cushing syndrome
    • 17-hydroxyprogesterone r4c237
      • Elevated levels may indicate late-onset adrenal hyperplasia
    • Karyotype analysis r1c238
      • Abnormal karyotype may indicate Turner syndrome (45,X), müllerian agenesis (46,XX), complete androgen insensitivity syndrome (46,XY) or 5-alpha reductase deficiency (46,XY), and other rare chromosomal disorders
    • Genetic testing c239
      • FMR1 gene mutation in fragile X syndrome carriers is associated with primary ovarian insufficiency r2

    Imaging

    • Pelvic ultrasonography r1c240
      • Evaluate presence and morphology of uterus and morphology of ovaries for insight into underlying cause of amenorrhea
        • Absent or abnormal uterus suggests a rare congenital cause, such as müllerian agenesis or androgen insensitivity syndrome r1
        • Intrauterine adhesions or synechiae may be evident (also known as Asherman syndrome) r1
        • Presence of ovarian cysts indicates polycystic ovary syndrome r1
    • MRI of the head or sella to determine potential causes of amenorrhea r1c241c242
      • Lesions within the sellar/suprasellar region suggest pituitary tumor or nonfunctioning adenoma r34
      • Abnormalities, obstruction, or narrowing of the cerebral aqueduct indicate congenital aqueductal stenosis r1

    Functional testing

    • Progesterone challenge test c243
      • Consider in patients with laboratory test results within reference range and a history of obstetric or gynecologic instrumentation
      • Administer oral medroxyprogesterone at 10 mg daily for 7 to 10 days; withdrawal bleeding on cessation excludes an outflow tract abnormality and suggests adequate endogenous estrogen level r2
      • If patient fails to bleed on withdrawal of medroxyprogesterone, administer estrogen and progestin together (eg, oral conjugated estrogen at 2.5 mg/day for 25 days with oral medroxyprogesterone at 5-10 mg/day added for the final 10 days of therapy); failure to bleed indicates endometrium is abnormal owing to scarring r6
      • Confirm presence of intrauterine synechiae by visualizing the endometrial cavity with ultrasonography

    Procedures

    Hysteroscopy c244
    General explanation
    • Direct visualization of the cervical canal and endometrial cavity using a hysteroscope inserted into the vagina r35
    Indication
    • To confirm intrauterine synechiae in patients with a history of obstetric or gynecologic procedures who do not bleed on progesterone challenge r1
    Contraindications
    • Significant obliteration of the cavity r35
    Complications
    • Complications are rare and may include: r35
      • Pelvic infection
      • Hemorrhage
      • Cervical injury
      • Uterus perforation
    Interpretation of results
    • Presence of intrauterine adhesions indicates amenorrhea is caused by Asherman syndrome r1

    Differential Diagnosis

    Most common

    • Differential diagnosis of amenorrhea
      • Pregnancy r1c245
        • Causes cessation of menses
        • Differentiated from other causes of amenorrhea based on sexual history and positive pregnancy test result or ultrasonogram showing presence of fetus
      • Menopause c246d2
        • Defined as absence of menstruation for 1 year or longer
        • Average age 49 to 52 years; preceded by period of perimenopause, which may be characterized by irregular menses and symptoms associated with hypoestrogenism
        • Differentiated from other causes of amenorrhea based on patient age, symptoms, and elevated follicle-stimulating hormone level r31
    • Differential diagnosis based on underlying cause c247
      • Functional hypothalamic amenorrhea r4c248
        • Absence or cessation of menses due to suppression of the hypothalamic-pituitary-ovarian axis in absence of organic or anatomic diseases r4
        • Characterized by suppression of gonadotropin-releasing hormone pulsatility r4
        • Differentiated from other common causes of amenorrhea based on history, physical examination, and laboratory tests r4
          • Possible patient history of excessive exercise, weight loss, dieting, or psychological stress
          • No signs of anatomic abnormality or hyperandrogenism (eg, acne, hirsutism) r4
          • Typically, serum estradiol level is low and luteinizing hormone and follicle-stimulating hormone levels are low to within reference range r4
      • Primary ovarian insufficiency r1c249
        • Characterized by ovarian follicle depletion or dysfunction with cessation of menses before age 40 years; may be caused by a variety of genetic or acquired (eg, chemotherapy, radiation therapy) factors
        • Accounts for approximately 12% of secondary amenorrhea cases r1
        • Differentiated from other common causes of amenorrhea based on history, physical examination, and laboratory tests r1
          • Follicle-stimulating hormone levels are persistently within menopausal range with associated estrogen deficiency
          • Karyotyping may reveal genetic cause r1
      • Polycystic ovary syndrome r1c250d3
        • Endocrine disorder associated with peripheral insulin resistance, hyperandrogenism, polycystic ovaries, and ovulatory dysfunction
        • 24% of patients present with amenorrhea; 76% present with oligomenorrhea r1
        • Characterized by follicle-stimulating hormone levels that are low or within reference range, chronic anovulation, hyperandrogenism, and infertility r1
        • Differentiated from other common causes of amenorrhea based on history, physical examination, and laboratory test results
          • Patients are commonly overweight or obese and often present with oligomenorrhea rather than amenorrhea
          • Clinical or biochemical signs of hyperandrogenism may be present
          • Follicle-stimulating hormone levels are typically low to within reference range
          • Ultrasonogram demonstrates polycystic ovaries
      • Hyperprolactinemia c251
        • Elevated serum prolactin level; may result from pituitary or hypothalamic tumor, medications, or hypothyroidism
        • Accounts for approximately 13% of secondary amenorrhea cases r1
        • Differentiated from other common causes of amenorrhea based on history, physical examination, and laboratory tests
          • Women may present with galactorrhea
          • Characterized by serum prolactin levels higher than 25 mcg/L r36
          • MRI of pituitary may reveal adenoma

    Treatment

    Goals

    • Treat the underlying cause of amenorrhea if possible
    • Achieve or restore fertility, if desired
    • Prevent complications associated with amenorrhea

    Disposition

    Recommendations for specialist referral

    • Refer to or consult with obstetrician-gynecologist
    • Refer to reproductive endocrinologist or infertility specialist if pregnancy is desired

    Treatment Options

    Treatment is determined by the underlying cause of amenorrhea; treatment of most common causes of amenorrhea are outlined here r1

    • Primary ovarian insufficiency r3
      • Treat with estrogen and progestin to support bone, cardiovascular, and sexual health r1
        • May be daily transdermal, oral, or vaginal estradiol with cyclic progesterone for 10 to 12 days each month; oral contraceptive pills may be used if contraception is also desired r31
          • Oral contraceptive pills provide higher doses of estrogen and progesterone than necessary for hormone replacement alone r31
        • Adolescents and young women may need higher doses of estrogen than menopausal women to ensure adequate replacement and prevent bone loss r31
        • In adolescents with absent or incomplete breast development, initiate low-dose estrogens and increase slowly before administering graduated progesterones until breast development is complete r1
    • Polycystic ovary syndrome r29
      • Treatment aims to restore reproductive function, if desired; reduce associated hirsutism and acne; and prevent long-term complications resulting from insulin resistance. May consist of: r29
        • Weight loss and exercise if overweight r2
        • Low-dose oral contraceptive pills. Generally, those containing progestins with less androgenic effects (eg, desogestrel, norethindrone, norgestimate, drospirenone) are preferred
        • Metformin r2r37
        • Antiandrogen therapy
    • Functional hypothalamic amenorrhea r1
      • Recommend lifestyle changes (eg, increased caloric intake, reduced exercise, stress reduction) r9
      • If menstrual cycle does not return after lifestyle changes, treat with estrogen and progestin to support bone, cardiovascular, and sexual health; oral contraceptive pills may be used if contraception is desired
      • Endocrine Society clinical practice guidelines suggest against patients with functional hypothalamic amenorrhea taking oral contraceptive pills for the sole purpose of regaining menses or improving bone mineral density r9
    • Hyperprolactinemia r1
      • May treat prolactinomas with surgical resection or dopamine agonists
      • If hyperprolactinemia is drug-induced, medication change is recommended
      • If hyperprolactinemia is caused by hypothyroidism, thyroid supplementation is recommended

    Drug therapy

    • Biguanides (oral hypoglycemic agents) c252
      • Metformin r29c253
        • Metformin Hydrochloride Oral tablet; Adult females: 500 mg PO 3 times per daily. Normal menstruation returns in 33% after 1 month. When added to clomiphene for infertility, approx. 86% ovulate compared to 8% on clomiphene alone. Weight loss and diet control recommended to prevent metformin-failure in severely obese patients.
    • Oral contraceptives r1c254
      • Estrogen-progestin c255c256c257c258
        • Follow dose as for routine contraception
          • Ethinyl Estradiol, Desogestrel Oral tablet, Inert Oral tablet; Adults and Adolescents: 1 tablet (0.15 mg desogestrel and 30 mcg ethinyl estradiol) PO daily for 21 days, followed by 7 days without drug.
          • Norethindrone Acetate, Ethinyl Estradiol Oral tablet; Adults: 1 tablet (containing either 1 mg norethindrone acetate in combination with 20 mcg of ethinyl estradiol or alternatively, 1.5 mg norethindrone acetate in combination with 30 mcg of ethinyl estradiol) PO once daily for 21 days, followed by a period of 7 days without drug.
          • Drospirenone, Ethinyl Estradiol Oral tablet, Inert Oral tablet; Adults: 3 mg drospirenone; 0.02 to 0.03 mg ethinyl estradiol PO once daily for 21 to 24 days, followed by 4 to 7 days of inert, inactive tablets as for routine contraception.
          • Inert Oral tablet, Norgestimate, Ethinyl Estradiol Oral tablet; Adult and Adolescent females: Follow dose as for routine contraception.
      • Progestogens c259
        • Medroxyprogesterone Acetate Oral tablet; Adult and Adolescent females: 5 to 10 mg PO once daily for 5 to 10 days, starting anytime during the cycle; usually given later in cycle (days 16 to 21). If the endometrium has been primed with estrogens, administer 10 mg PO once daily for 10 days starting on the 16th day of the cycle. Withdrawal bleeding usually occurs 3 to 7 days after discontinuation of therapy.
    • Dopamine agonists r1c260c261c262c263
      • Cabergoline Oral tablet; Adults: Initially, 0.25 mg PO twice per week. Then, may titrate by 0.25 mg/dose no more than every 4 weeks up to 1 mg PO twice per week if needed. Use lowest effective dose. Once weekly administration has also been found effective at dosages of 0.5 to 3 mg/week PO.

    Nondrug and supportive care

    • Supplement with adequate vitamin D and calcium to support bone health r5
    • Psychosocial support

    Comorbidities c264

    Monitoring

    • Follow-up is based on underlying cause, clinical response to treatment, and patient's desire for fertility versus contraception
    • Follow-up may include bone-density monitoring every 1 to 2 years in adolescents with estrogen deficiency; however, this is not universally recommended r31

    Complications and Prognosis

    Complications

    • Osteoporosis r9c265d4
    • Infertility r38c266
    • Psychological distress c267
    • Cardiovascular disease (increased risk in patients with early loss of ovarian function; added risk in patients with Turner syndrome) c268c269
    • Endocrine disorders (increased risk of hypothyroidism, adrenal insufficiency, and diabetes in patients with primary ovarian insufficiency) c270c271c272
    • Metabolic syndrome (in patients with polycystic ovary syndrome) r29c273
    • Gonadal tumors (occur in up to 25% of women with a Y chromosome) r1c274
    • Endometrial hyperplasia and endometrial cancer (in patients with unopposed estrogen, such as those with polycystic ovary syndrome) c275c276
    • Pregnancy can occur, and may be unexpected/unwanted

    Prognosis

    • Depends on underlying cause of amenorrhea
      • Most women resume menses upon treatment of underlying cause r1
    • Women with hypothalamic functional amenorrhea who seek pregnancy may expect ovulation rates of approximately 90% and conception rates of approximately 30% per ovulatory cycle after gonadotropin therapy r6
    • Women with premature ovarian failure may achieve pregnancy via in vitro fertilization with oocyte donation, but induction of ovulation with gonadotropin therapy rarely results in pregnancy r6

    Screening and Prevention

    Screening c277

    Prevention c278

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