Current Evaluation Of Amenorrhea

Current evaluation of amenorrhea
The Practice Committee of the American Society for Reproductive Medicine
Birmingham, Alabama

Amenorrhea is the absence or abnormal cessation of the menses. Primary and secondary amenorrhea describe the
occurrence of amenorrhea before and after menarche, respectively. (Fertil SterilÒ 2008;90:S219–25. Ó2008 by
American Society for Reproductive Medicine.)Amenorrhea is the absence or abnormal cessation of the menses (1). Primary and secondary amenorrhea describe the
occurrence of amenorrhea before and after menarche, respectively. The majority of the causes of primary and secondary
amenorrhea are similar. Timing of the evaluation of primary
amenorrhea recognizes the trend to earlier age at menarche
and is therefore indicated when there has beena failure to
menstruate by age 15 in the presence of normal secondary sexual development (two standard deviations above the mean of
13 years), or within five years after breast development if
that occurs before age 10 (2). Failure to initiate breast development by age 13 (two standard deviations above the mean of 10
years) also requires investigation (2). In women with regular
menstrualcycles, a delay of menses for as little as one week
may require the exclusion of pregnancy; secondary amenorrhea lasting three months and oligomenorrhea involving less
than nine cycles a year require investigation.
The prevalence of amenorrhea not due to pregnancy, lactation or menopause is approximately 3% to 4% (3, 4). Although the list of potential causes of amenorrhea is long
(Table 1), themajority of cases are accounted for by four conditions: polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, and ovarian failure. Other causes
are seldom encountered in a typical reproductive medicine
practice. In highly specialized referral centres, only 10 to
15 patients per annum were seen with primary amenorrhea,
and a similar number with secondary amenorrhea (5–7).
TheWorld Health Organization (WHO) has summarized
the causes: in WHO group I there is no evidence of endogenous estrogen production, normal or low FSH levels, normal
prolactin levels, and no evidence of a lesion in the hypothalamic-pituitary region; WHO group II is associated with evidence of estrogen production and normal levels of prolactin
and FSH; and WHO group III involves elevated serum FSHlevels indicating gonadal failure (8).
Amenorrhea may occur with sexual ambiguity or virilization, but usually in these cases amenorrhea is not the primary
Educational Bulletin
Reviewed June 2008.
Received February 20, 2004; revised and accepted February 20, 2004.
No reprints will be available.
Correspondence to: Practice Committee, American Society for Reproductive Medicine, 1209 MontgomeryHighway, Birmingham, Alabama
35216 .

0015-0282/08/$34.00
doi:10.1016/j.fertnstert.2008.08.038

complaint. The sexual ambiguity or virilization should be
evaluated as separate disorders, mindful that amenorrhea is
an important component of their presentation (9).
EVALUATION OF THE PATIENT
History, physical examination, and estimation of follicle
stimulating hormone (FSH), thyroidstimulating hormone
(TSH), and prolactin will identify the most common causes
of amenorrhea (Fig. 1). The presence of breast development
means there has been previous estrogen action. Excessive testosterone secretion is suggested most often by hirsutism and
rarely by increased muscle mass or other signs of virilization.
The history and physical examination should include a thorough assessment of theexternal and internal genitalia.
The genital examination is abnormal in approximately
15% of women with primary amenorrhea. A blind or absent
vagina with breast development usually indicates Mullerian
agenesis, transverse vaginal septum, or androgen insensitivity syndrome. If a genital examination is not feasible, an
abdominal ultrasound may be useful to confirm the presence
or absence of...