- Definition. (1) No menses by age 14 years and no other evidence of pubertal development, (2) no menses by age 16 despite presence of other pubertal signs, or (3) previous menstrual cycles but now without menses for a time equivalent to three cycles or 6 months.
- Physiologic amenorrhea is seen in prepubescent girls, during pregnancy and lactation (breastfeeding), and after menopause.
- Pathologic (non-physiologic) amenorrhea occurs in 3–4% of reproductive age women and should be investigated to determine the underlying etiology.
- Due to significant overlap, prior categorization of amenorrhea as primary or secondary should be avoided.
- Proper evaluation requires a systematic approach to making a correct diagnosis (Figure 22.1).
Anatomic disorders
Inherited
- Frequent cause in adolescents:
1 Müllerian agenesis (Mayer–Rokitansky–Küster–Hauser syndrome; 1/5,000 female births) involves the congenital absence of all or part of the uterus and vagina. Treatment: creation of a neovagina by progressive dilation or surgery (McIndoe operation).
2 Imperforate hymen (1/2,000) and transverse vaginal septum (1/70,000 women) are distal outflow tract obstructions. Treatment: hymenectomy/excision.
Acquired
1 Intrauterine synechiae (Asherman syndrome) after vigorous uterine curettage in early pregnancy may lead to scarring that interferes with normal endometrial growth and shedding. Treatment: hysteroscopic lysis of intrauterine adhesions and stimulation of the endometrium with estrogen.
2 Cervical stenosis may result from D&C (dilation and curettage), cone biopsy, or infection. Treatment: dilation of the cervix.
Endocrine disorders
Hypergonadotropic hypogonadism (premature ovarian failure)
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