Amenorrhea
Definition:
- Primary
- if have breasts: no menses by age 16 years
- if no breasts: no menses by age 13 years
- Secondary – cessation of menses for >3 cycles AFTER regular menses has
been established
Hormones involved:
- Hypothalamus secretes GnRH which acts on pituitary
- Pituitary secretes FSH, LH, which acts on the ovary
- Action on the ovary depends on pattern of secretion
- Proliferative phase: FSH and LH cause follicle to secrete estrogen
- Ovulation: LH surge
- Secretory phase: LH acts on corpus luteum, which secretes estrogen and
progesterone
Differential Diagnosis (the quick version)
- Outflow tract obstruction
- Inadequate hormonal stimulation of endometrium
- ovary
- pituitary
- hypothalamus
Outflow tract obstruction
- Imperforate hymen
- Transverse vaginal septum
- Uterine synechiae (Asherman’s syndrome)
- Intrauterine scarring
- Mullerian agenesis
- Testicular feminization
Hormonal
Workup
- H&P
- Pregnancy Test
- Serum Prolactin, TSH
- Serum FSH if low estrogen state suspected
- Progestin challenge
- (+) if menstruation-like bleeding
- what is the key question or history/physical
- depending on this factor, what tests do you order?
- (-) if minimal or no bleeding
Reference:
CHLA Board Review Course 2005
Braverman PK Sondheimer, SJ: Menstrual Disorders. Pediatrics in
Review 18:17-26, 1977.
Kliegman RM et al: Practical Strategies in Pediatric Diagnosis and
Therapy. Philadelphia, WB Saunders, 1996.