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| '''For patient information on primary amenorrhea, click [[Primary amenorrhea (patient information)|here]]'''
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| | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|30px|link=Amenorrhea resident survival guide]]|| <br> || <br> |
| | | [[Amenorrhea resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
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| | {{Amenorrhea}} |
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| '''For patient information on secondary amenorrhea, click [[Secondary amenorrhea (patient information)|here]]'''
| | {{CMG}}; {{AE}} {{EG}} |
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| {{DiseaseDisorder infobox | | | {{SK}}Primary amenorrhea, Secondary amenorrhea, Functional amenorrhea, Hypothalamic amenorrhea, Menstrual cycle pause. |
| Name = Amenorrhea |
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| ICD10 = {{ICD10|N|91|0|n|80}}-{{ICD10|N|91|2|n|80}} |
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| ICD9 = {{ICD9|626.0}} |
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| }}
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| {{SI}}
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| {{CMG}}
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| ==Overview== | | ==[[Amenorrhea overview|Overview]]== |
| '''Amenorrhoea''' ([[British English]]), '''amenorrhea''' ([[American English]]), or '''amenorrhœa''', is the absence of a [[menstrual period]] in a woman of reproductive age. Physiologic states of amenorrhoea are seen during [[pregnancy]] and [[breastfeeding|lactation]] (breastfeeding), the latter also forming the basis of a form of contraception known as the [[lactational amenorrhea method]]. Outside of the reproductive years there is absence of menses during childhood and after [[menopause]]. Amenorrhea can be transient, intermittent, or permanentAmenorrhoea is a symptom with many potential causes.
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| ==Classification of amenorrhea== | | ==[[Amenorrhea historical perspective|Historical Perspective]]== |
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| ===Primary amenorrhea=== | | ==[[Amenorrhea classification|Classification]]== |
| In primary amenorrhea there is absence of menarche by the age of 16.
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| Menstruation cycles never begin.
| | ==[[Amenorrhea pathophysiology|Pathophysiology]]== |
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| There will be a delay of menses one year beyond the family history of first menses.
| | ==[[Amenorrhea causes|Causes]]== |
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| There is no defining sexual characteristics by age 14. Primary amenorrhea may be caused by developmental problems such as the congenital absence of the [[uterus]], or failure of the [[ovary]] to receive or maintain egg cells. Also, delay in pubertal development will lead to primary amenorrhoea.
| | ==[[Amenorrhea differential diagnosis|Differentiating Amenorrhea from other Diseases]]== |
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| ===Secondary amenorrhea=== | | ==[[Amenorrhea epidemiology and demographics|Epidemiology and Demographics]]== |
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| Secondary amenorrhea is defined as absence of menses in a woman who had previously menstruated for at least 3 cycles or 6 months. Secondary amenorrhea is more common than primary [[Amenorrhea]].
| | ==[[Amenorrhea risk factors|Risk Factors]]== |
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| Secondary amenorrhea is often caused by hormonal disturbances from the [[hypothalamus]] and the [[pituitary gland]] or from premature [[menopause]], or intrauterine scar formation.
| | ==[[Amenorrhea screening|Screening]]== |
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| ===Oligomenorrhea=== | | ==[[Amenorrhea natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| Oligomenorrhea is a condition in which menses are infrequent. This condition is not the same as [[Amenorrhea]].
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| ==Etymology and history== | | ==Diagnosis== |
| | | [[Amenorrhea history and symptoms|History and Symptoms]] | [[Amenorrhea physical examination|Physical Examination]] | [[Amenorrhea laboratory findings|Laboratory Findings]] | [[Amenorrhea electrocardiogram|Electrocardiogram]] | [[Amenorrhea x ray|X-Ray Findings]] | [[Amenorrhea ultrasound|Echocardiography and Ultrasound]] | [[Amenorrhea CT|CT-Scan Findings]] | [[Amenorrhea MRI|MRI Findings]] | [[Amenorrhea other diagnostic studies|Other Diagnostic Studies]] | [[Amenorrhea other imaging findings|Other Imaging Findings]] |
| The term is derived from [[Greek language|Greek]]: ''a'' = negative, ''men'' = month, ''rhoia'' = flow. Derived adjectives are '''amenorrheal''' and '''amenorrheic'''. The opposite is the normal [[menstrual period]].
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| Historically, the term amenorrhea has often been used as a euphemism for "unwanted pregnancy" and many folk treatments for this condition are in fact [[abortifacient]]s.
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| [[Pregnancy]], as noted, is only one potential cause for amenorrhea; sometimes [[pseudo-pregnancy]] can be a cause for this as well.
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| == Complete Differential Diagnosis of Amenorrhea==
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| Causes include:In alphabetical order. <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
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| === Primary [[Amenorrhea]] ===
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| * [[17 beta-hydroxysteroid dehydrogenase deficiency]]
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| * [[Agonadism]]
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| * After trauma
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| * [[Anorexia Nervosa]]
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| * [[Anovulation]]
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| * [[androgen insenstivity syndrome|Complete androgen insenstivity syndrome]]
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| * [[Constitutional bradygenesis]]
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| * [[Constitutional delay of puberty]]
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| * [[Diabetes Mellitus]]
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| * Early infantile brain damage
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| * [[Gonadal dysgenesis]]
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| * [[adrenogenital syndrome|Homozygous adrenogenital syndrome]]
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| * [[Hymenal atresia]]
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| * [[Hyperandrogenism]]
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| * Hypothalamic and [[pituitary tumor]]s
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| *:* [[Hyperprolactinemia]] / [[Prolactin-secreting tumors]]
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| *:* [[Dysgerminoma]]
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| *:* [[Craniopharyngioma]]
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| * [[Idiopathic gonadotropin deficiency]]
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| * [[Kallmann's Syndrome]]
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| * [[Mayer-Rokitansky-Hauser Syndrome]]
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| * [[Mullerian dysgenesis]]
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| * Outflow tract disorders
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| * [[Pituitary insufficiency]]
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| *:* [[schistosomiasis|Pituitary schistosomiasis]]
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| *:* [[tuberculosis|Pituitary tuberculosis]]
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| *:* [[Empty Sella Syndrome]]
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| * [[Polycystic Ovary Syndrome]]
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| * Post-hormonal contraceptive [[Amenorrhea]]
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| * Severe systemic diseases
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| * [[Swyer's Syndrome]]
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| * [[Testicular feminization]]
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| * [[Turner's Syndrome]]
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| * [[Uterine atresia]]
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| * [[hypoplasia|Uterine hypoplasia]]
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| * [[Vaginal atresia]] / gynatresia
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| === Secondary [[Amenorrhea]] ===
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| * [[5-alpha-reductase deficiency]]
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| * Addiction
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| * [[Addison's Disease]]
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| * [[Adrenocortical insuffiency]]
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| * After [[curettage]]
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| * After [[hysterectomy]]
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| * After [[radiation]] (can be reversed)
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| * [[Adrenal tumor]]s
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| * [[Anovulation]]
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| * [[Asherman's Syndrome]]
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| * Autoimmune diseases
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| * Body building (and use of androgens)
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| * Castration (radiation or surgical)
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| * Central nervous system tumor (CNS)
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| * Cervical stenosis
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| * Change of environment
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| * Complete and incomplete [[androgen insensitivity]]
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| * [[Congenital adrenal hyperplasia]]
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| * Craniocerebral [[trauma]]
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| * [[Cushing's Syndrome]]
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| * [[Depression]]
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| * [[Diabetes Mellitus]]
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| * [[Encephalitis]]
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| * Enzymatic defects in [[testosterone]] biosynthesis
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| * Exposure to maternal androgens in utero
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| * [[Obesity|Extreme obesity]]
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| * During [[chemotherapy]]
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| * Functional hypothalalmic [[Amenorrhea]] due to:
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| *:* Stress
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| *:* [[Eating disorders]]
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| *:* Excessive exercise
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| *:* [[Weight loss]]
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| * Gonadotropin deficiency in tumors
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| * Hormone-active ovarian tumor
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| * [[Hermaphroditism]]
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| * Heterozygous [[adrenogenital syndrome]]
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| * [[Hyperprolactinemia]]
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| * [[Hyperthyroidism]]
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| * [[Hypothyroidism]]
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| * [[Hysterectomy]]
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| * Imprisonment
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| * [[Meningitis]]
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| * Mullerian anomalies
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| * [[Myotonic dystrophy]]
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| * [[Pituitary insufficiency]]
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| * [[Polycystic ovary syndrome]]
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| * Post-hormonal contraception
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| * Post-infection ([[mumps]], severe [[pelvic inflammatory disease]])
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| * Postoerative gonadotropin deficiency
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| * [[Pregnancy]]
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| * Premature [[menopause]]
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| * [[Prolactinoma]]
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| * [[Sheehan's Syndrome]]
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| * [[Stress]]
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| * [[Testicular feminization]]
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| * Transsexuality when taking androgens
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| * [[Turner's Syndrome]]
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| * Uterine cavity sclerosis
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| *:* Uterine [[Schistosomiasis]]
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| *:* [[Abortion]]
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| *:* Severe generalized infections of the pelvis
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| *:* Post uterine surgery
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| *:* Overzealous or repeated uterine curettage
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| *:* [[Tuberculosis]] [[endometritis]]
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| == Differential Diagnosis Organized by Category of Causes==
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| * '''Physiologic'''
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| *:* [[Pregnancy]]
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| *:* [[Lactation]]
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| *:* [[Menopause]]
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| * '''Hypothalamic'''
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| *:* Structural
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| *:*:* [[Craniopharyngioma]]
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| *:*:* [[Lymphoma]]
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| *:*:* [[Sarcoidosis]]
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| *:*:* [[Hemochromatosis]]
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| *:* Functional
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| *:*:* [[Anorexia]]/[[bulimia]]
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| *:*:* Excessive exercise/[[weight loss]]
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| *:*:* [[Stress]]
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| * ''' Pituitary '''
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| *:* Secretory tumors
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| *:*:* [[Prolactinoma]]
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| *:*:* [[Cushing’s disease]]
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| *:*:* [[Acromegaly]]
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| *:* Destructive lesions
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| *:*:* Non-functional tumors
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| *:*:* [[Sheehan's syndrome]]
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| *:*:* [[Hemochromatosis]]
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| * ''' Ovarian '''
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| *:* [[Premature ovarian failure]]
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| *:* Hyperandrogenic disorders
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| *:*:* [[polycystic ovary syndrome]] ([[PCOS]])
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| *:*:* Nonclassical [[congenital adrenal hyperplasia]] (NCCAH)
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| *:*:* Adrenal/ovarian androgen-secreting tumors
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| * ''' Anatomic '''
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| *:* Destruction of uterine cavity
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| *:*:* [[Asherman’s syndrome]]
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| *:*:* [[Tuberculosis]] ([[TB]])
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| * ''' Other '''
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| *:* [[Hyperthyroidism]]/[[hypothyroidism]]
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| *:* [[Cushing’s syndrome]]
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| ===Hormonal involvement===
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| Hypogonadotropic amenorrhoea refers to conditions where there are very low levels of serum [[FSH]] and [[LH]]. Generally, inadequate levels of these hormones lead to inadequately stimulated ovaries who then fail to produce enough [[estrogen]] to stimulate the [[endometrium]] (uterine lining), hence amenorrhoea. This is typical for conditions of pubertal delay, hypothalamic or pituitary dysfunction. In general, women with hypogonadotropic amenorrhoea are potentially fertile.
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| Hypergonadotropic amenorrhoea refers to conditions with high levels of [[FSH]] (and [[LH]]). FSH levels are typically in the menopausal range. This implies that the [[ovary]] or [[gonad]] does not respond to pituitary stimulation. Gonadal dysgenesis or premature menopause are possible causes. [[Chromosome]] testing is usually indicated in younger individuals with hypergonadotropic amenorrhoea.
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| In normogonadotropic amenorrhoea, FSH levels are in the normal range. This would suggest that the hypothalamic-pituitary-ovarian axis is functional. Amenorrhoea may be due to outflow obstruction, or abnormal ovarian regulation or excess androgens as seen in polycystic ovary syndrome.
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| Cushing's Disease/Syndrome can also cause amenorrhoea due to excessive amounts of cortisol in the blood stream.
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| ==Specific types of amenorrhoea==
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| ===Exercise amenorrhoea===
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| Female athletes or women who perform considerable amounts of exercise on a regular basis are at risk of developing 'athletic' amenorrhoea. It was thought for many years that low body fat levels and exercise related chemicals (such as beta endorphins and catecholamines) disrupt the interplay of the sex hormones estrogen and progesterone. However recent studies have shown that there are no differences in the body composition, or hormonal levels in amenorrheic athletes. Instead, amenorrhea has been shown to be directly attributable to a low energy availability. Many women who exercise at a high level do not take in enough calories to expend on their exercise as well as to maintain their normal menstrual cycles. [http://jap.physiology.org/cgi/content/full/84/1/37]
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| A second serious risk factor of amenorrhea is severe bone loss sometimes resulting in [[osteoporosis]] and [[osteopenia]]. It is the third component of an increasingly common disease known as [[female athlete triad]] syndrome. The other two components of this syndrome are [[osteoporosis]] and [[disordered eating]]. Awareness and intervention can usually prevent this occurrence in most female athletes.
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| =====High risk sports=====
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| * Cross country
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| * Ballet
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| * Track and Field
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| * Swimming
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| * Cycling
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| * Rowing
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| * Diving
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| * Figure skating
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| * Gymnastics
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| * all other intense and strenuous sports
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| ===Drug-induced amenorrhea===
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| Certain medications, particularly contraceptive medications, can induce amenorrhoea in a healthy woman. The lack of menstruation usually begins shortly after beginning the medication and can take up to a year to resume after stopping a medication. Hormonal contraceptives that [[Progestogen only pill|contain only progestogen]] like the oral contraceptive Micronor, and especially higher-dose formulations like the injectable [[Depo Provera]] commonly induce this side-effect. Recently, an [[extended cycle combined oral contraceptive pill]] which aims to purposefully induce amenorrhea (Lybrel), has been approved by the [[FDA]].
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| == Diagnostic Studies==
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| ===Laboratory Studies===
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| Any woman of child bearing potential should have a pregnancy test ordered to rule out [[pregnancy]].
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| Otherwise, consideration should be given to the following laboratory studies based upon clinical suspicion:
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| * [[Estradiol]]
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| * [[Prolactin]]
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| * [[Thyroid stimulating hormone]] ([[TSH]])
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| * [[Follicle stimulating hormone]] ([[FSH]])
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| * [[Luteinizing hormone]] ([[LH]])
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| * [[Testosterone]]
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| * [[17-hydroxyprogesterone]]
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| * [[Dehydroepiandrosterone-sulfate]] ([[DHEA-S]])
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| === Imaging Studies===
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| If a pituitary cause of amenorrhea is thought to be present, then MRI or a CT of the head should be obtained. Signs and symptoms of pituitary involvement include [[headache]], visual field cuts, and elevated [[prolactin]] levels.
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| Public ultrasound will reveal abnormalities of the mullerian structures such as uterine hypoplasia.
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| ==Treatment== | | ==Treatment== |
| Treatmentment varies depending upon the underlying condition. For those who do not plan to have biological children, treatment may be unnecessary if the underlying cause of the amenorrhoea is not threatening to the patient's health.
| | [[Amenorrhea medical therapy|Medical Therapy]] | [[Amenorrhea surgery|Surgery]] | [[Amenorrhea primary prevention|Primary Prevention]] | [[Amenorrhea secondary prevention|Secondary Prevention]] | [[Amenorrhea cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Amenorrhea future or investigational therapies|Future or Investigational Therapies]] |
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| ===Lifestyle Changes===
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| The best way to treat 'athletic' amenorrhoea is to decrease the amount and intensity of exercise. Weight gain may be helpful as well. To prevent osteoporosis, consider oral contraceptives. Pulsatile gonadotropin-releasing hormone (GnRH) or exogenous gonadotropins may be necessary.
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| ===Pharmacotherapy===
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| Hormone replacement therapy should be considered for ovarian failure. Unless receiving eggs from an [[egg donor]] or invetro fertilization, a woman is unable to conceive while she is amenorrhoeic. On the other hand, 'athletic' and drug-induced amenorrhoea has no effect on long term fertility as long as menstruation can recommence. Similarly, to treat drug-induced amenorrhea, stopping the medication on the advice of a doctor is the usual course of action.
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| In [[polycystic ovarian disease]] the following may be helpful:
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| * To decrease peripheral [[estrogen]], reduce weight
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| * To decrease ovarian [[androgen]] secretion, consider [[oral contraceptive]]s
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| * [[Clomiphene]] enhances fertility
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| * [[Endometrial hyperplasia]] is prevented by cyclic [[progesterone]]
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| ===Surgical Treatment===
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| Surgical correction may be required if an imperforate hymen is the cause.
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| ===Psychological Counseling===
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| Psychological counseling may be helpful if there is the presence of a Y chromosome or absent mullerian organs.
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| ==Prognosis==
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| Among patients with androgen insensitivity syndrome there is an increased risk of [[testicular cancer]], and surveillance should be encouraged.
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| ==References==
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| {{Reflist|2}}
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| {{Diseases of the pelvis, genitals and breasts}}
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| [[ar:انقطاع الطمث]]
| | ==Case Studies== |
| [[de:Amenorrhoe]]
| | [[Amenorrhea case study one|Case #1]] |
| [[es:Amenorrea]]
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| [[fr:Aménorrhée]]
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| [[gl:Amenorrea]]
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| [[hr:Amenoreja]]
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| [[it:Amenorrea]] | |
| [[nl:Amenorroe]]
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| [[pl:Brak miesiączki]]
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| [[pt:Amenorréia]]
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| [[ru:Аменорея]]
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| [[sr:Аменореја]]
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| [[fi:Amenorrea]]
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| [[sv:Amenorré]
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