Primary Amenorrhea and its
evaluation
Gedam DS1
1Dr D Sharad Gedam, Editor, Obs gyne Review: Journal of Obstetrics and
Gynecology & Professor L N Medical College, Bhopal, MP, India
Address for
correspondence: Dr D Sharad Gedam, Email:
editor.joog@gmail.com
Abstract
Primary and secondary Amenorrhea is most common complaint in Obstetrics
and Gynaecology. Evaluation of these patients for cause and treatment
is essential.
Keywords:
Primary Amenorrhea, menarche, Mullerian agenesis
Primary Amenorrhea is defined as failure to achieve menarche.
Evaluation should be undertaken if there is no pubertal development by
13 years of age, if menarche has not occurred five years after initial
breast development, or if the patient is 15 years or older [1,2,3].
Secondary Amenorrhea is defined as cessation of regular menstruation
for 3 months or irregular menstruation for 6 months [1,2]. Normal
menstruation last for 21-35 days.
Primary Amenorrhea is most commonly caused by chromosomal disorder
which leads primary ovarian failure (for example Turners syndrome) and
structural abnormality (i.e. Mullerian agenesis). Secondary Amenorrhea
is caused by polycystic ovarian syndrome, hypothalamic amenorrhea,
hyperprolactinemia, or primary ovarian insufficiency.
During evaluation it is important to evaluate for anatomical defect
(outflow tract obstruction), Primary ovarian failure, hypothalamic-
pituitary malfunction and endocrinal gland involvement. Patients should
be asked about eating and exercise patterns, changes in weight,
previous menses (if any), medication use, chronic illness, presence of
galactorrhea, and symptoms of androgen excess, abnormal thyroid
function. Pregnancy test should be performed in all cases. Family
history should include age at menarche and presence of chronic disease.
Although it is normal for menses to be irregular in the first few years
after menarche [4].
History
It is always important to take proper history to rule out pregnancy.
All the causes of secondary amenorrhea to be ruled out in primary
amenorrhea.
The physician should measure the patient's height, weight, and body
mass index, and perform thyroid palpation and Tanner staging. Breast
development is an excellent marker for ovarian estrogen production.
Acne, virilization, or hirsutism may suggest hyperandrogenemia. Genital
examination may reveal virilization, evidence of an outflow tract
obstruction, or a missing or malformed organ. Thin vaginal mucosa is
suggestive of low estrogen. Dysmorphic features such as a webbed neck
or low hairline may suggest Turner syndrome [5].
Evaluation
Initial evaluation includes pregnancy test and LH, FSH, Prolactin,
Thyroid function test measurement. If virilising features are there
Testosterone level should be measure. Karyotyping should be done if
syndromic disorder is suspected. Serum estradiol level measurement
should be done if there is no breast development. Evdences for chronic
disorder like Complete blood count, ESR & CRP should be
measured [5]. Further testing includes USG for Internal organ of female
genital tract & MRI if pituitary tumour is suspected.
Anatomical abnormalities include Mullerian agenesis other causes are
imperforated hymen & transverse vaginal septum. Primary ovarian
insufficiency is characterized by Postmenopausal FSH level. The ovaries
require physiologic stimulation by pituitary gonadotropins for
appropriate follicular development and estrogen production. Functional
hypothalamic amenorrhea occurs when the hypothalamic-pituitary-ovarian
axis is suppressed due to an energy deficit stemming from stress,
weight loss (independent of original weight), excessive exercise, or
disordered eating.
Prolactin levels can be increased due to drugs, pituitary diseases,
Hypothyroidism. Severe hyperthyroidism are more likely to be
responsible for amenorrhea rather than Mild to moderate Hyperthyroidism
or hypothyroidism.
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
References
1. Practice Committee of American Society for Reproductive Medicine.
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suppl):S219–S225. [PubMed]
2. Speroff L, Fritz MA. Clinical Gynecologic Endocrinology and
Infertility. 7th ed. Philadelphia, Pa.: Lippincott Williams &
Wilkins: 2005:401–464.
3. Euling SY, Herman-Giddens ME, Lee PA, et al. Examination of US
puberty-timing data from 1940 to 1994 for secular trends: panel
findings. Pediatrics. 2008;121(suppl 3):S172–S191. [PubMed]
4. Diaz A, Laufer MR, Breech LL; American Academy of Pediatrics
Committee on Adolescence; American College of Obstetricians and
Gynecologists Committee on Adolescent Health Care. Menstruation in
girls and adolescents: using the menstrual cycle as a vital sign.
Pediatrics. 2006;118(5):2245–2250. [PubMed]
5. Gordon CM. Clinical practice. Functional hypothalamic amenorrhea. N
Engl J Med. 2010;363(4):365–371. [PubMed]
How to cite this article?
Gedam DS. Primary Amenorrhea and its evaluation. Obg Rev:
J obstet Gynecol 2015;1(1):1-2. doi: 10.17511/jobg.2015.i1.05.