creation date: 2026-01-19 17:41
tags: Workups
Amenorrhea
Background
Primary amenorrhea refers to the lifelong absence of menses.
Secondary amenorrhea refers to the cessation of:
- Previously regular menses for 3 months
- Previously irregular menses for 6 months
Pathophysiology
Differential Diagnosis
Outflow tract abnormalities:
- Cervical stenosis
- Intrauterine adhesions
- Congenital abnormalities
Primary ovarian insufficiency: - Autoimmune
- Chemotherapy or radiation
- Gonadal dysgenesis
Hypothalamic or pituitary disorders: - Autoimmune disease
- Brain radiation
- Constitutional delay of puberty
- Functional energy deficit or stress (eg. eating disorder)
- Gonadotropin deficiency
- Hyperprolactinemia
- Infarction, infection, infiltrative disease
- Medications or drugs (eg. cocaine)
- Trauma or surgery
- Tumour
Other endocrine gland disorders: - Adrenal insufficiency
- Androgen-secreting tumour
- Cushings
- Uncontrolled diabetes mellitus
- Polycystic ovary syndrome
- Thyroid disease
Chronic disease: - Celiac disease
- Inflammatory bowel disease
Physiologic or induced: - Breastfeeding
- Contraception
- Exogenous androgens
- Menopause
- Pregnancy
Initial Evaluation
History
A detail history should include:
- Menstrual pattern if any
- Pregnancy and breastfeeding history
- Eating and exercise habits
- Psychosocial stressors
- Changes in body weight, fractures, medications, chronic illness, and timing of breast and pubic hair development
Associated findings may include:
- Galactorrhea, headaches, visual field defects (hypothalamic or pituitary disease)
- Acne, hirsutism (hyperandrogenism)
- Vasomotor symptoms such as hot flashes or night sweats (primary ovarian insufficiency)
Family history should include:
- Age of menarche of relatives
- Any chronic disease history
Physical Exam
Objective exam should include:
- Review trends in height, weight, and BMI
- Signs of low estrogen (atrophic vaginal mucosae, abnormal breast development)
- Signs of outflow tract obstruction (shortened vagina)
- Signs of hyperandrogenism (virilization)
Investigations
In all cases, testing should include:
- Pregnancy test
- FSH, LH (HPO dysfunction)
- Prolactin
- TSH (thyroid disease)
- CBC and metabolic panel (anemia and chronic diseases)
Other tests may include:
- AMH
- Estrodiol
- Free and total testosterone
- Karyotyping
In some cases, imaging may be indicated:
- MRI of adrenal glands
- MRI of brain
- Pelvic organ ultrasonography