Amenorrhea 2

8/10/2019 Amenorrhea 2

1/22

(Advertisement)Home | Specialties | Resource Centers | CME | PDA | Contributor Recruitment

EducationJ

Articles Images CME Advanced Search Consumer Health

You are in: eMedicine Specialties Medicine! "b#$%n! Ps%c&iatr%! and Sur'er% "bstetrics#'%necolo'%

Amenorrheaast "#dated$ Ma% ! *++,

Rate t&is Article

Email to a Collea'ue

$et CME#CE -or article

A"%H&' I()&'MA%I&( Aut&or .n-ormation .ntroduction Clinical Di--erentials /or0up 1reatment Medication 2ollo34up Miscellaneous 5iblio'rap&%

Aut&or: a rence M (elson, M-, M.A ! Head o- $%necolo'ic Endocrinolo'% 6nit! .nvesti'ator! Se/omen7s Healt& Researc&! Developmental Endocrinolo'% 5ranc&! 8ational .nstitutes o- Healt&Coaut&or(s): /ladimir .a!alov, M- ! Clinical Associate! Developmental Endocrinolo'% 5ranc&! 8atiC&ild Healt& and Human Development! 8ational .nstitutes o- Healt& 9Carmen astor, M- ! A

Section o- /omen7s Healt& Researc&! 8ational .nstitutes o- Healt& a3rence M 8elson! MD! M5A! is a member o- t&e -ollo3in' medical societies: American Colle

and $%necolo'ists ! American Societ% -or Reproductive Medicine ! Association o- Pro-essors o- $%"bstetrics ! Endocrine Societ% ! and Societ% -or E;perimental 5iolo'% and Medicine Editor(s): %homas Michael rice, M- ! Associate Pro-essor o- Reproductive Endocrinolo'%! Du0e 6Medical Center9 )rancisco %alavera, harm-, h- ! Senior P&armac% Editor! eMedicine9 A

h- ! Pro-essor! Department o- "bstetrics and $%necolo'%! 6niversit% o- Ha3aii! C&ubu Hospital91au##, M- ! Consultin' Sta--! Department o- 2amil% Practice! Assumption Communit% Hospital9 andShulman, M- ! Pro-essor o- "bstetrics and $%necolo'%! 2einber' Sc&ool o- Medicine! 8ort&3ester C&ie-! Division o- Reproductive $enetics! Department o- "bstetrics and $%necolo'%! Prentice /om8ort&3estern Memorial Hospital

Disclosure
http://www.emedicine.com/http://www.emedicine.com/specialties.htmhttp://www.emedicine.com/rc/index.htmhttp://www.emedicine.com/rc/index.htmhttp://cme.emedicine.com/http://secure.emedicine.com/itemlist.wws?category=PDA+eBookshttp://secure.emedicine.com/itemlist.wws?category=PDA+eBookshttp://www.emedicine.com/asp/author_landing.asphttp://www.emedicinehealth.com/http://www.emedicine.com/asp/advanced_search.htmhttp://www.emedicinehealth.com/http://www.emedicine.com/specialties.htmhttp://www.emedicine.com/specialties.htmhttp://www.emedicine.com/med/contents.htmhttp://www.emedicine.com/med/contents.htmhttp://www.emedicine.com/med/OBSTETRICSGYNECOLOGY.htmhttp://www.topmedconsultants.com/emedicine/evaluations/mainsurvey.cfm?ecik=0030117&website=1mailto:enter%20email%20address%20here?Subject=eMedicine%20Article%20-%20Amenorrhea&Body=I%20thought%20you%20might%20be%20interested%20in%20this%20article%20from%20eMedicine.%20%20You%20may%20either%20click%20on%20the%20following%20link%20or%20copy%20and%20paste%20it%20into%20your%20browser.%0Dhttp://www.emedicine.com/med/topic117.htm%0D%0A%0D%0AeMedicine%20is%20the%20leading%20provider%20of%20clinical%20medical%20information%20for%20medical%20professionals%20and%20consumers.%20%20To%20explore%20eMedicine%20today%20visit%20http://www.emedicine.comhttp://cme.emedicine.com/wc.dll?cmeAddToCart~addtest~&type=ARTICLE&dir=med&topic=Amenorrheahttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliographyhttp://www.emedicine.com/cgi-bin/foxweb.exe/screen@d:/em/ga?book=med&authorid=5449&topicid=117http://www.nih.gov/http://www.emedicine.com/cgi-bin/foxweb.exe/screen@d:/em/ga?book=med&authorid=5449&topicid=117http://www.nih.gov/http://www.nih.gov/http://www.acog.com/http://www.acog.com/http://www.asrm.org/http://www.apgo.org/home/http://www.apgo.org/home/http://www.endo-society.org/http://www.sebm.org/http://www.emedicine.com/cgi-bin/foxweb.exe/disclosure@/em/ga?book=med&disclosure=117http://oascentral.emedicine.com/RealMedia/ads/click_lx.ads/emedicine.com/Med/ObGyn/Amenorrhea/1865400512/x33/default/empty.gif/64623533333862363433383239346230?Stroke&hdl&ldl&triglycerides&cholesterol&triglyceride&asthma&corticosteroid&http://oascentral.emedicine.com/RealMedia/ads/click_lx.ads/emedicine.com/Med/ObGyn/Amenorrhea/1101634445/Top1/eMedicine/SLP2005_3_ROS/468x60a.gif/64623533333862363433383239346230?Stroke&hdl&ldl&triglycerides&cholesterol&triglyceride&asthma&corticosteroid&http://www.emedicine.com/http://www.emedicine.com/specialties.htmhttp://www.emedicine.com/rc/index.htmhttp://cme.emedicine.com/http://secure.emedicine.com/itemlist.wws?category=PDA+eBookshttp://www.emedicine.com/asp/author_landing.asphttp://www.emedicinehealth.com/http://www.emedicine.com/asp/advanced_search.htmhttp://www.emedicinehealth.com/http://www.emedicine.com/specialties.htmhttp://www.emedicine.com/med/contents.htmhttp://www.emedicine.com/med/OBSTETRICSGYNECOLOGY.htmhttp://www.topmedconsultants.com/emedicine/evaluations/mainsurvey.cfm?ecik=0030117&website=1mailto:enter%20email%20address%20here?Subject=eMedicine%20Article%20-%20Amenorrhea&Body=I%20thought%20you%20might%20be%20interested%20in%20this%20article%20from%20eMedicine.%20%20You%20may%20either%20click%20on%20the%20following%20link%20or%20copy%20and%20paste%20it%20into%20your%20browser.%0Dhttp://www.emedicine.com/med/topic117.htm%0D%0A%0D%0AeMedicine%20is%20the%20leading%20provider%20of%20clinical%20medical%20information%20for%20medical%20professionals%20and%20consumers.%20%20To%20explore%20eMedicine%20today%20visit%20http://www.emedicine.comhttp://cme.emedicine.com/wc.dll?cmeAddToCart~addtest~&type=ARTICLE&dir=med&topic=Amenorrheahttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliographyhttp://www.emedicine.com/cgi-bin/foxweb.exe/screen@d:/em/ga?book=med&authorid=5449&topicid=117http://www.nih.gov/http://www.emedicine.com/cgi-bin/foxweb.exe/screen@d:/em/ga?book=med&authorid=5449&topicid=117http://www.nih.gov/http://www.nih.gov/http://www.acog.com/http://www.acog.com/http://www.asrm.org/http://www.apgo.org/home/http://www.apgo.org/home/http://www.endo-society.org/http://www.sebm.org/http://www.emedicine.com/cgi-bin/foxweb.exe/disclosure@/em/ga?book=med&disclosure=117http://www.emedicine.com/


2/22

I(%'& -"C%I& ( Section 2 Aut&or .n-ormation .ntroduction Clinical Di--erentials /or0up 1reatment Medication 2ollo34up Miscellaneous 5iblio'rap&%

.ac!ground$ Primar% amenorr&ea is de-ined as t&e -ailure o- menses to occur b% a'e < %ears= Seamenorr&ea is de-ined as t&e cessation o- menses once t&e% &ave be'un= "li'omenorr&ea is de-inoccurrin' at intervals lon'er t&an >, da%s= 8o consensus &as been reac&ed re'ardin' t&e point atoli'omenorr&ea becomes amenorr&ea= Some aut&ors su''est t&e absence o- menses -or < mont&samenorr&ea! but t&e basis -or t&is recommendation is unclear= Practicall% spea0in'! a 3oman a'ede;periences loss o- an establis&ed re'ular menstrual pattern s&ould &ave an evaluation to see0 t&e

1&is article addresses t&e evaluation and treatment o- 3omen 3it& amenorr&ea 3&o &ave no evidee;cess= /omen 3it& amenorr&ea 3&o do &ave evidence o- andro'en e;cess! suc& as &irsutism! vir ambi'uit%! s&ould be evaluated di--erentl% -rom 3omen 3it& amenorr&ea alone=

atho#hysiology$ Re'ular and predictable menstrual c%cles occur i- t&e ovarian &ormones estradipro'esterone are secreted in an orderl% -as&ion in response to stimulation b% t&e &%pot&alamus andCirculatin' estradiol stimulates 'ro3t& o- t&e endometrium= Pro'esterone! produced b% t&e corpus la-ter ovulation! trans-orms proli-eratin' endometrium into secretor% endometrium= .- pre'nanc% doessecretor% endometrium brea0s do3n and s&eds durin' t&e ensuin' menstrual period=

Amenorr&ea occurs i- t&e &%pot&alamus and pituitar% -ail to provide appropriate 'onadotropin stimulresultin' in inade uate production o- estradiol or in -ailure o- ovulation and pro'esterone production=also occur i- t&e ovaries -ail to produce ade uate amounts o- estradiol despite normal and appropriastimulation b% t&e &%pot&alamus and pituitar%= .n some cases! t&e &%pot&alamus! pituitar%! and ovari-unctionin' normall%! %et amenorr&ea occurs because o- ad&esions in t&e endometrial cavit% or an ocervicova'inal out-lo3 tract=

)re uency$

In the "S$ Eac& %ear! appro;imatel% ,B o- menstruatin' 3omen e;perience > mont&s o- secamenorr&ea=

Internationally$ 8o evidence indicates t&at t&e prevalence o- amenorr&ea varies accordin' tor et&nic 'roup= Ho3ever! local environmental -actors related to nutrition and t&e prevalenceundoubtedl% &ave an e--ect= 2or instance! t&e a'e o- t&e -irst menses varies b% 'eo'rap&ic lodemonstrated b% a /orld Healt& "r'ani@ation stud% comparin' countries! 3&ic& reportedmenarc&e o- >4 < %ears across centers=

Mortality3Mor4idity$ 1&e re'ular occurrence o- menses is a si'n o- 'ood &ealt&= .t means t&at t&epituitar%4ovarian a;is is -unctionin' normall% to produce ovarian &ormones and support ovulation= 1as bot& an endocrine or'an and a reproductive or'an= /&en menstrual c%cle re'ularit% is lost! t&isare not -unctionin' normall% in eit&er t&eir endocrine role or t&eir reproductive role= oss o- menstrubeen associated 3it& reduced bone densit% and increased -racture rates= 1&us! loss o- menstrual reassociated morbidit% and ma% contribute to increased mortalit%=
http://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliography


3/22

Re'ular menses is a si'n t&at t&e ovaries are producin' normal amounts o- estro'en! andro'pro'esterone= 1&ese se; &ormones pla% an important role in buildin' and maintainin' bonemenarc&e &as been associated 3it& a >4-old increase in t&e ris0 o- 3rist -racture= Menstrual clon'er t&an > da%s &as been associated 3it& a *4-old increase in 3rist -racture= Similar corr t&e ris0 o- &ip -racture! a potentiall% -atal occurrence=

Re'ular menses is also a si'n t&at t&e ovaries support ovulation and t&at t&e% contain a nor primordial -ollicles= Primordial -ollicles are composed o- an ooc%te surrounded b% a sin'le la%cells= 1&e number o- primordial -ollicles in t&e &uman ovar% pea0s durin' t&e -i-t& 'estationalappro;imatel% million= A-ter t&is initial -inite pool is in place! no additional primordial -olliclessome cases! loss o- menstrual re'ularit% is an earl% si'n o- declinin' -ertilit% and impendin' p-ailure= Also in some cases! t&is -ollicle depletion pro'resses to cause irreversible in-ertilit%= Ao- 3omen evaluated -or amenorr&ea in a tertiar% center are -ound to &ave premature ovarian

'ace$ 8o evidence su''ests t&at t&e incidence o- eit&er primar% or secondar% amenorr&ea is relate

Se $ Amenorr&ea occurs onl% in 3omen=

Age$ A lar'e stud% b% 1reolar et al ( < ) demonstrated t&at b% a'e *+ %ears! 3omen &ave establisre'ular and persistent patterns o- menstrual c%cle len't& 3it& little variation on an individual basis=and predictable menstrual c%cle len't& t&en continues until a'e ?+ %ears=

Accordin' to t&e -indin's -rom t&e 1reolar et al stud%! -e3er t&an * menses in a +4da% interval ( ,3oman a'ed *+4?+ %ears is distinctl% abnormal= 2urt&er! more t&an > menses in a +4da% interval inalso distinctl% abnormal= 2inall%! menstrual bleedin' -or more t&an + da%s in 3omen in t&is a'e 'rodistinctl% abnormal=

As 3omen a'e! a remar0abl% stead% decline occurs in mean menstrual c%cle len't&= 1&e s&ortenin'be p&%siolo'icall% lin0ed in some 3a% to t&e 3ell4establis&ed decline in t&e number o- primordial -ollit&e pool as 3omen a'e=

/&ile t&e overall median menstrual c%cle len't& is * da%s! c%cle len't& 'raduall% declines -rom a'?+ %ears= At a'e *+ %ears! t&e median c%cle len't& is * da%s! and b% a'e ?+ %ears! t&is &as declin2urt&er s&ortenin' o- t&e menstrual c%cle len't& is a 3ell4reco'ni@ed earl% si'n o- impendin' menop

.n t&e -irst %ear a-ter menarc&e! t&e -i-t& percentile -or menstrual c%cle len't& is *> da%s and tis + da%s= 5% t&e -ourt& %ear a-ter menarc&e! t&e ,t& percentile -or c%cle len't& &as declineappro;imatel% ,+ da%s= Menstrual c%cle len't& is certainl% more variable -or -emales in t&eir t

3omen a'ed *+4?+ %ears= Ho3ever! b% %ears a-ter menarc&e! c%cles are more stable9 t&e - c%cle len't& is * da%s! and t&e ,t& percentile is > da%s=

.n t&e %ear precedin' menopause! t&e -i-t& percentile -or c%cle len't& is *, da%s and t&e ,t&appro;imatel% ,+ da%s= 2our %ears be-ore menopause! t&e -i-t& percentile -or c%cle len't& is

,t& percentile -or c%cle len't& is si'ni-icantl% more re'ular! at appro;imatel% ?+ da%s= Menstcertainl% more variable durin' t&e %ears precedin' t&e menopausal transition t&an durin' t&e


4/22

?+ %ears=

C I(ICA Section Aut&or .n-ormation .ntroduction Clinical Di--erentials /or0up 1reatment Medication 2ollo34up Miscellaneous 5iblio'rap&%

History$ oss o- menstrual re'ularit% is an indication -or a care-ul revie3 o- s%stems= 1&e menstrualvie3ed as a vital si'n= oss o- menstrual re'ularit% ma% be t&e -irst clear s%mptom &eraldin' t&e onsillness or s%stemic disease= Fie3in' t&e menstrual c%cle as a vital si'n ma% lead to earlier dia'nosisintervention -or! several potentiall% li-e4t&reatenin' disorders= An arbitraril% de-ined duration o- amenpass be-ore ta0in' corrective action=

Amenorr&ea can be due to pre'nanc%! anatomic de-ects o- t&e out-lo3 tract! ovarian disorders! and&%pot&alamic disorders= .n some cases! t&e cause is -unctional! meanin' t&at t&e &%pot&alamic 'onreleasin' &ormone ($nRH) pulse 'enerator &as s&ut do3n t&e reproductive s%stem in its role as anmetabolic and ps%c&o'enic stress= Attributin' t&e loss o- menstrual re'ularit% to a recent stress-ul li- temptin'9 &o3ever! t&is approac& can dela% t&e detection o- si'ni-icant pat&olo'% t&at can &ave lon'conse uences= "ne stud% &as s&o3n t&at one t&ird o- control 3omen report a si'ni-icant stress-ul liprecedin' %ear=

Pre'nanc% is t&e most common cause o- amenorr&ea= Determinin' 3&et&er t&e patient is se;uall%s&e is usin' contraceptive met&ods is important= .n some cases! t&e &ormonal contraception itsel- mo- t&e amenorr&ea=

"-ten! time constraints do not permit practitioners to obtain a t&orou'& &istor% and revie3 o- s%mptovisit= Sc&edulin' a repeat visit to permit a more t&orou'& evaluation ma% be necessar%=

Anot&er option is to use standardi@ed &istor%4ta0in' instruments to collect t&is in-ormation in prepar visit= .n ot&er cases! patients ma% be as0ed to 0eep a menstrual calendar and return in > mont&s -or1&e importance o- t&e ovar% as an endocrine or'an t&at &elps maintain bone densit% s&ould be streto &elp ensure &er return=

.n cases o- primar% amenorr&ea! in uirin' about ot&er aspects o- 'ro3t& and pubertal developmentabsence o- an% breast development or pubertal 'ro3t& spurt b% a'e ? %ears in 'irls is distinctl% abre uires investi'ation= 5reast development! pubertal 'ro3t& spurt! and adrenarc&e are dela%ed or a3it& &%pot&alamic pituitar% -ailure= A distin'uis&in' -actor in t&e case o- isolated ovarian insu--iciencadrenarc&e occurs normall%! 3&ile estro'en4dependent breast development and t&e pubertal 'ro3tor dela%ed=

Disorders o- t&e out-lo3 tract

o A &istor% o- ot&er3ise normal 'ro3t& and pubertal development in association 3it& pri
http://oascentral.emedicine.com/RealMedia/ads/click_lx.ads/emedicine.com/Med/ObGyn/Amenorrhea/1100759813/x34/default/empty.gif/64623533333862363433383239346230?Stroke&hdl&ldl&triglycerides&cholesterol&triglyceride&asthma&corticosteroid&http://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliography


5/22

su''ests t&e possibilit% o- a con'enital out-lo3 tract abnormalit% suc& as imper-orate &o- t&e va'ina! cervi;! or uterus= 1&ese -indin's are also compatible 3it& t&e completeresistance s%ndrome=

o Prior &istor% o- a sur'ical procedure involvin' t&e endometrial cavit%! especiall% i- per-

presence o- in-ection! raises t&e possibilit% o- uterine s%nec&iae (As&erman s%ndrome) "varian disorders

o S%mptoms o- va'inal dr%ness! &ot -las&es! ni'&t s3eats! or disordered sleep ma% be ainsu--icienc% or premature ovarian -ailure= 1&e presence o- t&ese s%mptoms in %oun'timel% -urt&er evaluation=

o Prior &istor% o- c&emot&erap% or radiation t&erap% ma% be associated 3it& ovarian -ail

o A distin'uis&in' -actor in t&e case o- isolated ovarian insu--icienc% or -ailure and prima

t&at adrenarc&e occurs normall% 3&ile estro'en4dependent breast development and tspurt are absent or dela%ed=

H%pot&alamic#pituitar% disorders

o Associated 'alactorr&ea! &eadac&es! or reduced perip&eral vision could be a si'n o- i1&ese s%mptoms re uire immediate -urt&er evaluation=

o A &istor% o- &emorr&a'e a-ter c&ildbirt& can lead to -ailure o- re'ular menses to return=indication o- postpartum pituitar% necrosis= 2ailure o- lactation is an even earlier si'n=condition earl% is important because o- t&e possible development o- associated central

insu--icienc%! a potentiall% -atal condition=

o An impaired sense o- smell in association 3it& primar% amenorr&ea and -ailure o- nor development ma% be related to isolated 'onadotropin de-icienc%! as is observed in per Gallmann s%ndrome=

o Sarcoidosis can mani-est insidiousl%! 3it& development o- mild -ati'ue! malaise! anoreand -ever= 5ecause +B o- patients 3it& sarcoidosis &ave pulmonar% involvement at sdisorder! cou'& and d%spnea ma% be present=

o Hemac&romatosis ma% mani-est as 3ea0ness! lassitude! 3ei'&t loss! and a c&an'e in

2unctional impairment o- t&e &%pot&alamic $nRH pulse 'enerator

o Dietin' 3it& e;cessive restriction o- ener'% inta0e! especiall% -at restriction! ma% lead tmenstrual re'ularit% and associated bone loss= .n e;treme cases! t&e process ma% adnervosa! a potentiall% -atal condition= Associated s%mptoms are an intense -ear o- -atnima'e t&at is &eavier t&an observed= Eatin' disorders can be restrictive in nature or ca


6/22

eatin'#pur'in' t%pe=

o Ma or ps%c&iatric disorders suc& as depression! obsessive4compulsive disorder! or scdisrupt t&e menstrual c%cle= S%mptoms associated 3it& t&ese conditions ma% be deteco- s%stems=

o Autoimmune adrenal insu--icienc%! a potentiall% -atal condition! o-ten mani-ests as va's%mptoms= oss o- menstrual re'ularit% ma% be t&e -irst clear s%mptom indicatin' a neevaluation to detect t&is condition=

o oss o- menstrual re'ularit% ma% &erald t&e onset o- ot&er autoimmune endocrine diso&%pert&%roidism! &%pot&%roidism! or autoimmune l%mp&oc%tic &%pop&%sitis= 1&endocrine disorders suc& as Cus&in' s%ndrome or p&eoc&romoc%toma= A care-ul revima% &elp uncover t&ese disorders=

o Strenuous e;ercise related to a 3ide variet% o- at&letic activities can be associated 3it

development o- amenorr&ea= Elicit a &istor% re'ardin' t&e t%pe o- e;ercise activit% and3ee0=

o Abuse o- dru's suc& as cocaine and opioids &ave central e--ects t&at ma% disrupt t&eo Malnutrition and cirr&osis associated 3it& alco&olism ma% cause loss o- menstrual re'o A.DS! H.F disease! or ot&er t%pes o- immune4de-icienc% states ma% induce s%stemic i

c&ronic disease and loss o- menstrual re'ularit%=o "ccult mali'nanc% 3it& pro'ressive 3ei'&t loss and a catabolic state ma% lead to loss

re'ularit%= A care-ul revie3 o- s%stems ma% &elp uncover suc& a disorder=

hysical$ P&%sical e;amination s&ould be'in 3it& an overall assessment o- nutritional status and '

Measure &ei'&t and 3ei'&t and see0 evidence -or c&ronic disease or cac&e;ia=

H%pot&ermia! brad%cardia! &%potension! and reduced subcutaneous -at can be observed in personsanore;ia nervosa= .n cases o- -re uent vomitin'! loo0 -or possible dental erosion! reduced 'a' re-lepalate! subcon unctival &emorr&a'e! and metacarpop&alan'eal calluses or bruises=

E;amine t&e s0in -or evidence o- andro'en e;cess! suc& as &irsutism and acne= Acant&osispresent in association 3it& andro'en e;cess related to insulin resistance=

S0in e;amination -indin's can also 'ive clues to ot&er endocrine disorders= Fitili'o or increaso- t&e palmar creases ma% &erald primar% adrenal insu--icienc%= 1&in! parc&mentli0e s0in! stri

o- eas% bruisin' ma% be si'ns o- Cus&in' s%ndrome= /arm! moist s0in radiatin' e;cessive &o- &%pert&%roidism=

ar'e pituitar% tumors can cause visual4-ield cuts b% impin'in' on t&e optic tract= .n some cas-ield cuts can be detected b% simple con-rontational testin'=

Assess t&e state o- breast development= Also e;amine t&e breasts -or 'alactorr&ea= .n somedisc&ar'e can be e;pressed! %et t&e condition is not true 'alactorr&ea= .- t&e disc&ar'e is ind


7/22

be con-irmed b% -indin' -at 'lobules in t&e -luid usin' lo34po3er microscop%=

E;amine -or t&e presence o- a;illar% and pubic &air= 1&ese are a mar0er o- adrenal and ovarisecretion= .n cases o- pan&%popituitarism! sources o- andro'en are lo3 and pubic and a;illar

Also! some 3omen develop t&e combination o- autoimmune premature ovarian -ailure and a

primar% adrenal insu--icienc%= 1&ese 3omen are also mar0edl% andro'en4de-icient and &avepubic &air= 1&e same is true -or persons 3it& andro'en insensitivit% s%ndrome (testicular -emi&%dro;%lase de-icienc%! and !*+4desmolase de-icienc%=

.n cases o- primar% amenorr&ea 3it& ot&er3ise normal pubertal development! pelvic e;aminadetect imper-orate &%men! a transverse va'inal septum! or cervical or uterine aplasia=

Pelvic e;amination -indin's can provide p&%sical evidence indicatin' t&e ade uac% o- estro'1&in and pale va'inal mucosa 3it& absent ru'ae is evidence o- estro'en de-icienc%= 1&e presmucus 3it& spinnbar0eit is 'ood evidence o- estro'en e--ect= Ho3ever! evidence o- estro'enp&%sical e;amination -indin's can be misleadin' in some cases because estro'en is bein' p

result o- &i'&er t&an normal -ollicle4stimulatin' &ormone (2SH) levels (compensated ovarian i/omen 3it& 3ell4establis&ed premature ovarian -ailure o-ten &ave intermittent ovarian -ollicleproduces enou'& estro'en to &ave va'inal and cervical e--ects=

Measurin' t&e clitoris is an e--ective met&od -or determinin' t&e de'ree o- andro'en e--ect= 1can be determined b% measurin' t&e 'lans o- clitoris in t&e anteroposterior and transverse diinde; 'reater t&an >, mm * is evidence o- increased andro'en e--ect= A clitoral inde; 'reater tevidence o- virili@ation=

"varian enlar'ement ma% be -ound upon pelvic e;amination in cases o- autoimmune oop&ori&%dro;%lase de-icienc%! or !*+4desmolase de-icienc%= .n t&ese disorders! inade uate ne'ati

supplied b% t&e ovar% permits e;cessive 'onadotropin stimulation t&at ma% cause ovarian enlmultiple -ollicular c%sts= .n some cases! t&ese disorders mani-est 3it& an acute onset o- paintorsion=

A 'eneral p&%sical e;amination ma% undercover une;pected -indin's t&at are indirectl% relatemenstrual re'ularit% (e'! discover% o- &epatosplenome'al%! 3&ic& ma% lead to detection o- adisease)=

Causes$ Amenorr&ea can be divided into * 'roups! ( ) amenorr&ea 3it&out evidence o- associatedand (*) amenorr&ea 3it& evidence o- andro'en e;cess (e'! &irsutism! virili@ation! se;ual ambi'uit%)=t&e causes o- amenorr&ea associated 3it& andro'en e;cess! see Pol%c%stic "varian S%ndrome

Causes o+ amenorrhea ithout associated androgen e cess

Pre'nanc%

Anatomic de-ects o- out-lo3 tract
http://www.emedicine.com/MED/topic2173.htm


8/22

o .ntrauterine ad&esions (As&erman s%ndrome)

o .mper-orate &%men

o 1ransverse va'inal septum

o Aplasia o- t&e va'ina! cervi;! or uterus: Con'enital absence o- t&e uterus can be an iscan occur in association 3it& t&e complete andro'en resistance s%ndrome! also 0no3-emini@ation=

"varian causes

o Prodromal premature ovarian -ailure: 1&is is a state o- ovarian insu--icienc% in 3&ic& 2elevated and menses are irre'ular but not to t&e de'ree re uired to ma0e a dia'nosisovarian -ailure= .t is also re-erred to as overt ovarian insu--icienc%= 2or a more in4dept&"varian .nsu--icienc% =

o Gar%ot%picall% normal spontaneous premature ovarian -ailure: 2or an in4dept& discussi2ailure =

o 1urner s%ndrome

o Pure 'onadal d%s'enesis: 1&e term pure &ere re-ers to t&e -act t&at t&e s%ndrome spurel% a--ected t&e 'onad= 8o associated d%smorp&ic -indin's e;ist as are noted in 1u3&ic& is o-ten re-erred to as 'onadal d%s'enesis= Pure 'onadal d%s'enesis can occur?

o Autoimmune oop&oritis

o !*+4desmolase de-icienc% or 4&%dro;%lase de-icienc%

o Radiation or c&emot&erap%

o $alactosemia

o 2SH receptor mutation

Pituitar% causes

o Prolactinoma

o "t&er pituitar% tumors (Cus&in' s%ndrome! acrome'al%! t&%rotropin)o Postpartum pituitar% necrosis (S&ee&an s%ndrome)o Autoimmune &%pop&%sitiso Pituitar% radiationo Sarcoidosis
http://www.emedicine.com/MED/topic1700.htmhttp://www.emedicine.com/MED/topic3374.htmhttp://www.emedicine.com/MED/topic1700.htm


9/22

o Hemac&romatosiso H%pot&alamic causes

1umors suc& as craniop&ar%n'ioma or teratoma.n-iltrative disorder suc& as sarcoidosisGallmann s%ndrome

2unctional causeso Anore;ia#bulimiao C&ronic diseaseo /ei'&t losso Malnutritiono Depression or ot&er ps%c&iatric disorderso Recreational dru' abuseo Ps%c&otropic dru' useo E;cessive e;erciseo .diopat &ic

-I))E'E(% IA S Section 7 Aut&or .n-ormation .ntroducti on Clinical Di--erentials /or0up 1reatment Medication 2ollo34up Miscellaneous 5iblio'rap&%

Adne;al 1umors Adrenal Adenoma Adrenal Car cinoma Andro'en E;cess Anore;ia 8ervosa Anovulation

An;iet% Disorders5eni'n esi ons o- t&e "variesC4 H%dro;%lase De-icienc%Cus&in' S%ndrome Depression2ollicle4Stimulatin ' Hormone Abnormalities$erm Cell 1umorsH%datidi-orm MoleH%pert&%roidismH%popituitarism (Pa n&%popituitarism).mper-orate H%men

Gallmann S%ndrome and .diopat&ic H%po'onadotropic H%po'onadisme%di' Cell 1 umorsuteini@in' Horm one De-icienc%uteini@in' Hormone4 Releasin' Hormone De-icienc%

Menopause"varian 2ailure"varian .nsu--icienc%"varian Pol%c%stic Disease
http://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/MED/topic2830.htmhttp://www.emedicine.com/MED/topic2830.htmhttp://www.emedicine.com/MED/topic62.htmhttp://www.emedicine.com/MED/topic62.htmhttp://www.emedicine.com/MED/topic62.htmhttp://www.emedicine.com/MED/topic3489.htmhttp://www.emedicine.com/MED/topic144.htmhttp://www.emedicine.com/MED/topic146.htmhttp://www.emedicine.com/MED/topic152.htmhttp://www.emedicine.com/MED/topic3305.htmhttp://www.emedicine.com/MED/topic380.htmhttp://www.emedicine.com/MED/topic485.htmhttp://www.emedicine.com/MED/topic532.htmhttp://www.emedicine.com/MED/topic803.htmhttp://www.emedicine.com/MED/topic863.htmhttp://www.emedicine.com/MED/topic1047.htmhttp://www.emedicine.com/MED/topic1109.htmhttp://www.emedicine.com/MED/topic1137.htmhttp://www.emedicine.com/MED/topic3329.htmhttp://www.emedicine.com/MED/topic1216.htmhttp://www.emedicine.com/MED/topic1294.htmhttp://www.emedicine.com/MED/topic1341.htmhttp://www.emedicine.com/MED/topic1342.htmhttp://www.emedicine.com/MED/topic3289.htmhttp://www.emedicine.com/MED/topic1700.htmhttp://www.emedicine.com/MED/topic3374.htmhttp://www.emedicine.com/MED/topic1701.htmhttp://www.emedicine.com/MED/topic1379.htmhttp://www.emedicine.com/MED/topic2973.htmhttp://www.emedicine.com/MED/topic1867.htmhttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliographyhttp://www.emedicine.com/MED/topic2830.htmhttp://www.emedicine.com/MED/topic62.htmhttp://www.emedicine.com/MED/topic63.htmhttp://www.emedicine.com/MED/topic3489.htmhttp://www.emedicine.com/MED/topic144.htmhttp://www.emedicine.com/MED/topic146.htmhttp://www.emedicine.com/MED/topic152.htmhttp://www.emedicine.com/MED/topic3305.htmhttp://www.emedicine.com/MED/topic380.htmhttp://www.emedicine.com/MED/topic485.htmhttp://www.emedicine.com/MED/topic532.htmhttp://www.emedicine.com/MED/topic803.htmhttp://www.emedicine.com/MED/topic863.htmhttp://www.emedicine.com/MED/topic1047.htmhttp://www.emedicine.com/MED/topic1109.htmhttp://www.emedicine.com/MED/topic1137.htmhttp://www.emedicine.com/MED/topic3329.htmhttp://www.emedicine.com/MED/topic1216.htmhttp://www.emedicine.com/MED/topic1294.htmhttp://www.emedicine.com/MED/topic1341.htmhttp://www.emedicine.com/MED/topic1342.htmhttp://www.emedicine.com/MED/topic3289.htmhttp://www.emedicine.com/MED/topic1700.htmhttp://www.emedicine.com/MED/topic3374.htmhttp://www.emedicine.com/MED/topic1701.htmhttp://www.emedicine.com/MED/topic1379.htmhttp://www.emedicine.com/MED/topic2973.htmhttp://www.emedicine.com/MED/topic1867.htm


10/22

Pituitar% MacroadenomasPituitar% MicroadenomasPol%'landular Autoimm une S%ndrome! 1%pe .Pol%'landular Autoimmune S%ndrome! 1%pe ..

Pol%'landular Autoimmune S %ndrome! 1%pe ...Pre'nanc% Dia'nosisProlactinomaPseudo4Cus&in' S%ndrome

8&'9" Aut&or .n-ormation .ntroduction Clinical Di--erentials /or0up 1reatment Medication 2ollo34up Miscellaneous 5iblio'rap&%

a4 Studies$

.n most cases! clinical variables alone are not ade uate to de-ine t&e pat&op&%siolo'ic mec&3omen 3&o present 3it& > mont&s o- secondar% amenorr&ea s&ould &ave a dia'nostic evaluSpero-- et al! 2e3 problems in '%necolo'ic endocrinolo'% are as c&allen'in' or ta;in' to t&emust be concerned 3it& an arra% o- potential diseases and disorders involvin'! in man% instacarr%in' morbid and even let&al conse uences -or t&e patient=

Per-orm a pre'nanc% test= "nce pre'nanc% is e;cluded! a t&orou'& &istor%! revie3 o- s%mptoimportant= .- t&e &istor% and p&%sical e;amination -indin's do not reveal t&e cause o- t&e ameurinal%sis! and serum c&emistries s&ould be evaluated to &elp rule out s%stemic disease= Ser t&%rotropin levels s&ould also be measured routinel% in t&e initial evaluation o- amenorr&ea o

Prolactin

o Prolactin levels in e;cess o- *++ n'#m are not observed e;cept in t&e case o- prolacti(prolactinoma)= .n 'eneral! t&e serum prolactin level correlates 3it& t&e si@e o- t&e tum

o Ps%c&otropic dru's! &%pot&%roidism! stress! and meals can also raise prolactin levels=re uire -urt&er evaluation i- t&e cause is not readil% apparent=

2ollicle4stimulatin' &ormone

o An 2SH level o- appro;imatel% ?+ m.6#m is indicative o- ovarian insu--icienc%= Ho3evpatients &ave a lo3er menopausal level o- 2SH9 c&ec0 t&e re-erence ran'e -or t&e lab

o .- a repeat value in mont& con-irms t&is -indin' (ta0in' in consideration t&e above labpatient &as e;perienced at least ? mont&s o- amenorr&ea! t&en t&e dia'nosis o- prem
http://www.emedicine.com/MED/topic1868.htmhttp://www.emedicine.com/MED/topic1869.htmhttp://www.emedicine.com/MED/topic3277.htmhttp://www.emedicine.com/MED/topic1915.htmhttp://www.emedicine.com/MED/topic1936.htmhttp://www.emedicine.com/MED/topic1868.htmhttp://www.emedicine.com/MED/topic1869.htmhttp://www.emedicine.com/MED/topic3277.htmhttp://www.emedicine.com/MED/topic1915.htmhttp://www.emedicine.com/MED/topic1936.htmhttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliography


11/22

o .- t&e 2SH level is *+4?+ m.6#m in a patient 3it& disordered menses! t&en t&e dia'no0no3n as prodromal premature ovarian -ailure=

uteini@in' &ormone: uteini@in' &ormone is elevated in cases o- 4*+ l%ase de-icienc%! 4ovarian -ailure=

Estradiol

o $enerall%! 3&en considerin' measurement o- t&e estradiol level! concomitantl% dra3 alevels 3it&in t&e re-erence ran'e can be -ound intermittentl% despite t&e presence o- 32indin' a concomitantl% elevated 2SH level brin's t&is to li'&t=

o Serum estradiol levels under'o 3ide -luctuations durin' t&e normal menstrual c%cle= Dmenstrual c%cle! levels ma% be lo3er t&an ,+ p'#m = Durin' t&e preovulator% estradiolare not uncommon= .n &ealt&% menopausal 3omen! estradiol levels are routinel% lo3er

1estosterone and de&%droepiandrosterone sulp&ate: "rderin' t&ese tests is not necessar% ine;cess=

1&%rotropin and -ree t&%ro;ine (1?)

Imaging Studies$

"varian causes: 1&e in-ormation obtained 3it& ovarian ultrasound ima'in' does not c&an'eamenorr&ea! and ovarian ultrasound s&ould be reserved -or investi'ational use=

MR. -or pituitar% or &%pot&alamic causes

o MR. o- t&e pituitar% and &%pot&alamus is o-ten indicated in t&e evaluation o- amenorr&

o Re uest ima'in' o- t&e &%pot&alamic#pituitar% area speci-icall%! rat&er t&an a stud% o- tresolution=

o MR. is indicated in t&e -ollo3in' circumstances: Associated &eadac&es or visual4-ield cutsPro-ound estro'en de-icienc% 3it& ot&er3ise une;plained amenorr&eaH%perprolactinemia

&ther %ests$

Pro'esterone 3it&dra3al test

o 1&e development o- accurate and reasonabl% priced &ormonal assa%s &as called intoc&allen'e test= 1&e aut&ors do not recommend per-ormin' t&e test as part o- t&e dia'non t&e pro'esterone c&allen'e test results can cause a dela% in t&e dia'nosis o- poten


12/22

o Prior to t&e development o- readil% available assa%s to measure serum levels o- estraused as a bioassa% 3it& 3&ic& to demonstrate estro'en e--ect at t&e level o- t&e endo

++ m' o- pro'esterone in oil &as been s&o3n to predictabl% induce a 3it&dra3al bleeis at least ,+ p'#m = Ho3ever! t&e pro'esterone 3it&dra3al test can provide inappropr dela% t&e dia'nosis o- ovarian insu--icienc% and! possibl%! ot&er conditions=

o A + report b% Rebar and Connoll% demonstrated t&at nearl% ,+B o- 3omen 3it& pr 3it&dra3al bleed in response to pro'estin= 1&ese patients &ave intermittent ovarian -oldespite t&e presence o- e;tremel% elevated 2SH and luteini@in' &ormone levels=

o 1&e pro'esterone 3it&dra3al test is no substitute -or evaluatin' ovarian &ealt&= Demo-unctionin' ovaries re uires t&e concurrent measurement o- serum estradiol and 2SH=

Minnesota 8utrition Data S%stems evaluation: 1&is can be used to assess dietar% inta0e= 1&iener'%! protein! -at! and carbo&%drate content=

5ec0 Depression .nventor%: 1&is can be used to assess t&e patient7s mood= Modi-iable Activit% Juestionnaire and Pa--enbar'er Juestionnaire: 1&e Modi-iable Activit% Ju

Pa--enbar'er Juestionnaire (Go&l! ) can be used to assess t&e patient7s level o- p&%sica

Multidimensional eatin' disorder inventor% -or anore;ia and bulimia ($arner! >)

1&e bulimia test! revised! ie! t&e 56 .14R (1&elen! )

rocedures$

H%sterosalpin'o'rap&% and &%steroscop% are indicated in cases o- possible As&erman s%ndr

Sur'i cal repa ir is in dicated in di sorders o- t&e out-lo3 tract=

%'EA%ME(% Aut&or .n-ormation .ntroduction Clinical Di--erentials /or0up 1reatment Medication 2ollo34up Miscellaneous 5iblio'rap&%

Medical Care$ Medical care needs are de-ined b% t&e etiolo'% o- t&e menstrual c%cle disturbance atreatment s&ould be directed at correctin' t&e underl%in' pat&olo'%= .n t&e case o- out-lo3 tract abnot&er cases! correctin' t&e underl%in' pat&olo'% s&ould restore normal ovarian endocrine -unction a

osteoporosis= i0e3ise! correctin' t&e underl%in' pat&olo'% s&ould restore ovulation and permit 3omaintain -ertilit%=

Dopamine a'onists are e--ective in treatin' &%perprolactinemia= .n most cases! t&is treatment-unction and ovulation (see Prolactinoma )=

Hormone replacement t&erap% is re uired to maintain bone densit% in patients 3&ose underl
http://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliographyhttp://www.emedicine.com/MED/topic1915.htm


13/22

restore normal endocrine -unction=

$onadotropin t&erap% or t&e u se o- pulsatile $nRH t&erap% is re uired to induce ovulation -ounderl%in' pat&olo'% cannot be reversed=

/omen 3i t& evidence o- &%perandro'enism and disordered menses &ave man% ot&er medicPol%c%stic "varian S%ndrome )=

Surgical Care$ Some pituitar% and &%pot&alamic tumors ma% re uire sur'er% and! in some cases! r Macroadenomas )= As&erman s%ndrome re uires &%steroscopic l%sis o- t&e intrauterine ad&esions= 1out-lo3 tract abnormalities depends on t&e speci-ic clinical situation (see .mper-orate H%men

Consultations$ 1&e causes o- menstrual c%cle disturbance leadin' to t&e development o- amenorr cases! t&e situation is best addressed b% a multidisciplinar% team= 2or e;ample! a patient 3it& comp-emini@ation) 3ould bene-it -rom t&e involvement o- e;perts in endocrinolo'%! &uman 'enetics! ps%c

$eneral internal medicine specialist: .n certain cases in 3&ic& an underl%in' c&ronic diseaseinternist ma% be needed=

Medical endocrinolo'ist: .n cases o- pituitar%#&%pot&alamic tumor! ot&er endocrine disorders (adrenal insu--icienc%) ma% be involved= $enerall%! t&e e;pertise o- a medical endocrinolo'ist ipatients 3&o re uire neurosur'er% to treat t&e underl%in' condition= .n cases o- &%pert&%roidio- a medical endocrinolo'ist is re uired to treat t&e underl%in' pat&olo'%=

$eneticist: /it& &eredit ar% causes o- ame norr&ea! suc& as Gallmann s%ndrome! a 'eneticiste;tended -amil% and in counselin' patients re'ardin' t&e disorder=

Ps%c&iatrist: Cases o- ma or depression! anore;ia nervosa! bulimia nervosa! or ot&er ma or p3it& a ps%c&iatrist (see Anore;ia 8ervosa )=

Reproductive sur'eon: .n some unusual cases! suc& as 3it& va'inal a'enesis! consult 3it& ae;perience in t&e speci-ic disorder=

8utritionist: .n man% cases! e;ercise4induced amenorr&ea is due to an imbalance in ener'% icounselin' to increase ener'% inta0e 3it&out reducin' e;ercise is a means o- reversin' t&e uunder3ei'&t or 3&o appear to &ave nutritional de-iciencies s&ould receive nutritional counselimultidisciplinar% team speciali@in' in eatin' disorders=

-iet$ /omen 3it& -indin's su''estive o- an eatin' disorder s&ould be evaluated b% a multidisciplinadisorders= 8utritional counselin' alone is inade uate t&erap% -or t&ese 3omen=

.n some cases! nutritional de-iciencies induced b% dietin' and e;ercise can cause amenorr&ea evenStrict -at restriction o-ten pla%s a role= 2re uentl%! simpl% e;plainin' t&e need to balance ener'% e;pproblem= .n t&is situation! nutritional counselin' ma% be all t&at is re uired=

Activity$ More t&an &ours o- vi'orous e;ercise a 3ee0 ma% cause amenorr&ea= As noted above! i
http://www.emedicine.com/MED/topic2173.htmhttp://www.emedicine.com/MED/topic1379.htmhttp://www.emedicine.com/MED/topic1379.htmhttp://www.emedicine.com/MED/topic144.htmhttp://www.emedicine.com/MED/topic2173.htmhttp://www.emedicine.com/MED/topic1379.htmhttp://www.emedicine.com/MED/topic3329.htmhttp://www.emedicine.com/MED/topic144.htm


14/22

appropriate ad ustment o- t&e diet=

ME-ICA%I&( Aut&or .n-ormation .ntroduction Clinical Di--erentials /or0up 1reatment Medication 2ollo34up Miscellaneous 5 iblio'rap&%

Dopamine a'onists are t&e onl% medical t&erap% speci-icall% approved to reverse an underl%in' patcases! dopamine a'onists e--ectivel% reduce &%perprolactinemia (see Prolactinoma )=

$onadotropin t&erap% or pulsatile $nRH t&erap% is indicated in 3omen 3&o desire -ertilit% %et remai&%pot&alamic#pituitar% disorder=

2or some 3omen 3it& oli'omenorr&ea or amenorr&ea 3&o do not 3is& to become pre'nant! oral co

restore menstrual c%clicit% and provide estro'en replacement= Document t&e absence o- pre'nanc%be'un=

.n patients 3it& amenorr&ea or oli'omenorr&ea! induce 3it&dra3al bleedin' 3it& an in ection o- pro'm' o- medro;%pro'esterone -or + da%s= 1&erap% is t&en be'un 3it& an oral contraceptive containinas noret&indrone and levonor'estrel=

Hormone replacement t&erap%! consistin' o- an estro'en and a pro'estin! is needed -or 3omen in
http://www.emedicine.com/MED/topic1915.htmhttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliographyhttp://www.emedicine.com/MED/topic1915.htm


15/22

because ovarian -unction cannot be restored= 1&e role o- andro'en replacement is unclear at t&is tiinvesti'ation=

Dru' Cate'or%: Estrogens 44 Administered transdermall%! transva'inall%! or orall%= Appropriate d

&as not been establis&ed= 1&e aut&ors recommend -ull replacement doses -or %oun' 3omen= $eneas doses recommended -or &ormone replacement t&erap% in normall% postmenopausal 3omen= 1&b% s0in patc&= 1&is avoids t&e -irst4pass e--ect o- oral estro'en on t&e liver= 8o controlled studies aresa-et% o- one met&od over anot&er= 1&ere-ore! t&e c&oice o- t&erap% s&ould -ollo3 consideration o- tp&%sician7s e;perience=

-rug (ame

Estradiol (Alora! Climara! Esclim! Fivelle4dot! Estrace) 44 .ncreasess%nt&esis o- D8A! R8A! and man% proteins in tar'et tissues= 1D patavailable as Alora (+=+,! +=+ ,! and += m'#d! applied t3ice 3ee0l%)!Climara (+=+*,! +=+,! +=+ ,! and += m'#d! applied once 3ee0l%)!Esclim (+=+*,! +=+> ,! +=+,! +=+ ,! += m'#d! applied t3ice 3ee0l%)and Fivelle4dot (+=+> ! +=+,! +=+ ,! += m'#d! applied t3ice 3ee0l%)1D patc& not tolerated! P" -orm ma% be used=

Adult -ose ++ mc'#d 1D patc& or * m'#d P" in c%clic re'imen o- >30 on and30 o--ediatric -ose 8ot establis&ed

ContraindicationsDocumented &%persensitivit%9 t&rombop&lebitis9 neuroop&t&almolvascular disease9 undia'nosed va'inal bleedin'9 pre'nanc%9 breastcancer9 estro'en4dependent neoplasia9 c&ronic liver disease

Interactions

Ma% reduce &%poprot&rombinemic e--ects o- anticoa'ulantsevels ma% be reduced 3it& coadministration o- barbiturates! ri-ampi

and ot&er a'ents t&at induce &epatic microsomal en@%mesPossible increase in corticosteroid levels 3&en administeredconcurrentl%6se 3it& &%dantoins ma% cause spottin'! brea0t&rou'& bleedin'! anpre'nanc%.ncrease in -luid retention caused b% estro'en inta0e ma% reducesei@ure control.n isolated cases! ma% decrease e--ect o- 1CAs and t&ere-ore cause3orsenin' o- previousl% 3ell4controlled depression (p&enomenonseems to be dose4dependent and is reversible 3it& decrease ordiscontinuation o- estro'en)1&%roid replacement or suppressive t&erap% ma% need ad ustmentsbecause estro'en increases SH5$! t&us leavin' less -ree 1? (active&ormone) available1obacco smo0in' can &ave antiestro'enic e--ect b% increasin' t&e C&%dro;%lation o- estradiol molecule

regnancy I 4 Contraindicated in pre'nanc%recautions Reported endometrial cancer ris0 amon' t&ose on unopposed estro


16/22

is appro;imatel% *4 to *4-old 'reater t&an t&ose 3&o are not9 appeadependent on duration o- treatment and on estro'en dose9 'reatestappears associated 3it& prolon'ed use (increased ris0s o- ,4 to *?4-old -or ,4 + % or more)9 concurrent pro'estin t&erap% ma% o--set t&isris0 but overall &ealt& impact in premenopausal 3omen is un0no3n

Some studies su''est possible increased incidence o- breast cance3omen ta0in' estro'en t&erap% at &i'&er doses or -or prolon'edperiods9 t&ese studies &ave -ocused on postmenopausal 3omen9conclusions ma% not be applicable to %oun' 3omen 3it& ovarian -ailCounselin' s&ould &elp %oun' 3omen de-icient in estro'en to -eelcom-ortable ta0in' estro'ens9 estro'en t&erap% durin' pre'nanc% isassociated 3it& an increased ris0 o- -etal con'enital reproductive tradisorders and possibl% ot&er birt& de-ects13o studies &ave reported a *4 to ?4-old increase in ris0 o- 'allbladddisease re uirin' sur'er% in 3omen receivin' oral estro'enreplacement t&erap%! similar to t&e *4-old increase previousl% noted i

users o- oral contraceptives (ris0 -rom 1D estro'ens not establis&ed)"ccasional blood pressure increases durin' t&erap% &ave beenattributed to idios%ncratic reactions to estro'ens9 ot&er studies s&o3sli'&tl% lo3er blood pressure compared 3it& t&ose not on t&erap%9postmenopausal use does not increase ris0 o- stro0e9 nonet&eless!blood pressure s&ould be monitored at re'ular intervalsMa% lead to severe &%percalcemia in patients 3it& breast cancer anbone metastases9 i- &%percalcemia occurs! discontinue t&erap% andta0e appropriate measures to reduce serum calcium level

Addition o- a pro'estin to estro'ens ma% cause adverse e--ects onlipoprotein metabolism (lo3erin' HD and raisin' D )! 3&ic& could

diminis& cardioprotective e--ect o- t&erap%Possible en&ancement o- mitotic activit% in breast epit&elial tissue!alt&ou'& -e3 epidemiolo'ical data are available to address t&is pointta0e complete medical and -amil% &istor% be-ore initiation o- t&erap%a 'eneral rule! s&ould be prescribed -or no lon'er t&an % 3it&outanot&er p&%sical e;aminationSome studies &ave s&o3n t&at 3omen on t&erap% &ave&%percoa'ulabilit%! primaril% related to decreased antit&rombin activie--ect appears dose4 and duration4dependent and is less pronouncet&an t&at associated 3it& oral contraceptive use.nsu--icient in-ormation on &%percoa'ulabilit% in 3omen 3it& previou

t&romboembolic disease9 ma% be associated 3it& massive elevationplasma tri'l%cerides! leadin' to pancreatitis and ot&er complicationspatients 3it& -amilial de-ects o- lipoprotein metabolism9 because macause some de'ree o- -luid retention! care-ul observation re uired 3conditions t&at mi'&t be in-luenced b% t&is -actor are present (e'!ast&ma! epileps%! mi'raine! cardiac! renal d%s-unction)Certain patients ma% develop undesirable mani-estations o- estro'estimulation (e'! abnormal uterine bleedin'! mastod%nia)9 ma% be po


17/22

metaboli@ed in patients 3it& impaired liver -unction and s&ould beadministered 3it& caution9 accelerated P1! aP11! and plateleta''re'ation time9 increased platelet count9 increased -actors ..! F..anti'en! F... anti'en! F... coa'ulant activit%! .I! I! I..! F..4I comple;and beta4t&rombo'lobulin9 decreased levels o- anti-actor Ia andantit&rombin ...! decreased antit&rombin ... activit%9 increased levels-ibrino'en and -ibrino'en activit%9 increased plasmino'en anti'en anactivit%.ncreased t&%roid4bindin' 'lobulin leadin' to increased circulatin' tot&%roid &ormone! as measured b% protein4bound iodine! 1? levels (bcolumn or b% radioimmunoassa%)! or 1> levels b% radioimmunoassa-ree 1? and -ree 1> concentrations are unaltered"t&er bindin' proteins ma% be elevated in serum (e'! corticosteroid4bindin' 'lobulin and SH5$! leadin' to increased circulatin'corticosteroids and se; steroids! respectivel%)9 -ree or biolo'icall% ac&ormone concentrations are unc&an'ed9 ot&er plasma proteins ma%increased (e'! an'iotensino'en#renin substrate! alp&a 4antitr%psin!ceruloplasmin)9 increases plasma HD and HD 4* sub-ractionconcentrations! reduces D c&olesterol concentration! and increastri'l%ceride levels9 reduces response to metap%rone test9 reducesserum -olate concentration

on'4term continuous administration o- natural and s%nt&etic estro'in certain animal species increases -re uenc% o- carcinomas o- t&ebreast! uterus! cervi;! va'ina! testis! and liver $enerall%! an% dru' s&ould be administered to breast-eedin' 3omenonl% 3&en clearl% necessar% because man% dru's are e;creted in&uman mil09 administration to breast-eedin' 3omen &as been s&o3decrease uantit% and ualit% o- mil0

-rug (ame

Estro'ens! con u'ated (Premarin) 44 Some cannot tolerate 1D patc&=6se con u'ated e uine estro'ens to ac&ieve ade uate estro'eni@atio- va'inal epit&elium in %oun' 3omen and ade uatel% maintain bondensit%=

Adult -ose =*, m'#d P"ediatric -ose 8ot establis&ed

Contraindications

Documented &%persensitivit%9 0no3n or possible pre'nanc%9 breastcancer! undia'nosed abnormal 'enital bleedin'! active

t&rombop&lebitis! or t&romboembolic disorders9 &istor% o-t&rombop&lebitis! t&rombosis! or t&romboembolic disorders associat3it& previous estro'en use (e;cept 3&en used in treatment o- breastprostatic mali'nanc%)

Interactions Ma% reduce &%poprot&rombinemic e--ect o- anticoa'ulants9coadministration o- barbiturates! ri-ampin! and ot&er a'ents t&at indu&epatic microsomal en@%mes ma% reduce levels9 p&armacolo'ic andto;icolo'ic e--ects o- corticosteroids ma% occur as a result o- estro'e


18/22

induced inactivation o- &epatic P4?,+ en@%me9 loss o- sei@ure contro&as been noted 3&en administered concurrentl% 3it& &%dantoins

regnancy I 4 Contraindicated in pre'nanc%

recautions

Certain patients ma% develop undesirable mani-estations o- e;cessi

estro'enic stimulation (e'! abnormal or e;cessive uterine bleedin' omastod%nia)9 ma% cause some de'ree o- -luid retention (e;ercisecaution)9 prolon'ed unopposed estro'en t&erap% ma% increase ris0endometrial &%perplasia

Dru' Cate'or%: Progestins 44 Stop endometrial cell proli-eration! allo3in' or'ani@ed slou'&in' o-controlled studies compare e--icac% o- medro;%pro'esterone 3it& oral pro'esterone in protectin' t&doses o- estro'en 'enerall% re uired -or replacement in %oun' 3omen= 1&e aut&ors recommend ust&erap% because o- lon'er4term clinical e;perience 3it& t&is a'ent=

-rug (ame

Medro;%pro'esterone (Provera! C%crin! Depo4Provera! Amen) 44 Administer c%clicall% * d#mo to prevent endometrial &%perplasia t&unopposed estro'en ma% cause= .n %oun' 3omen! re'ular 3it&dra3bleedin' is pre-erable because even %oun' 3omen 3it& prematureovarian -ailure &ave a ,4 +B c&ance o- spontaneous pre'nanc% (unlpostmenopausal 3omen)= .- an e;pected 3it&dra3al bleedin' is absper-orm a pre'nanc% test (and a timel% dia'nosis o- pre'nanc% 3ill nbe missed)= "t&er causes o- amenorr&ea ma% also remit spontaneoand result in an une;pected pre'nanc%=

Adult -ose + m' P" d -or -irst * d o- menstrual c%cleediatric -ose 8ot establis&ed

ContraindicationsDocumented &%persensitivit%9 cerebral apople;%! va'inal bleedin' -r undia'nosed cause! t&rombop&lebitis! liver d%s-unction! pre'nanc%!missed abortion! breast or 'enital mali'nancies

InteractionsMa% decrease e--ects o- amino'lutet&imide9 sli'&tl% decreasesclearance o- di'o;in9 increases liver en@%mes 3&en coadministered3it& tamo;i-en9 increases &al-4li-e o- 3ar-arin

regnancy I 4 Contraindicated in pre'nanc%recautions 5e alert to earliest mani-estations o- t&rombotic disorders (e'!

t&rombop&lebitis! cerebrovascular disorders! pulmonar% embolism!retinal t&rombosis)9 i- t&ese occur or are suspected! discontinue druimmediatel%Discontinue medication pendin' e;amination 3it& sudden! partial! orcomplete loss o- vision or 3it& sudden onset o- proptosis! diplopia! omi'raine9 i- e;amination reveals papilledema or retinal vascular lesio3it&dra3 medicationPer-orm p&%sical e;amination (includin' special attention to breast!pelvic or'ans! and Papanicolaou smear)9 ma% cause some de'ree o-luid retention! and conditions t&at mi'&t be in-luenced b% t&is (e'!


19/22

epileps%! mi'raine! ast&ma! cardiac or renal d%s-unction) re uire car observation.n case o- brea0t&rou'& bleedin'! as in all cases o- irre'ular bleedinper va'ina! bear in mind non-unctional causes9 in cases o- va'inalbleedin' -rom an un0no3n cause! ade uate dia'nostic measures ar

indicatedCare-ull% observe patients 3it& &istor% o- depression and discontinudru' i- depression recurs to serious de'ree9 care-ull% observe diabetpatients receivin' pro'estin t&erap%9 advise pat&olo'ist o- pro'estint&erap% 3&en relevant specimens are submitted5ecause o- occurrence o- t&rombotic disorders (e'! t&rombop&lebitipulmonar% embolism! retinal t&rombosis! cerebrovascular disorders)patients ta0in' estro'en4pro'estin combinations and becausemec&anism is obscure! be alert to earliest mani-estation o- t&esedisorders

Administer an% dru' to breast-eedin' 3omen onl% 3&en clearl%

necessar% because man% dru's are e;creted in &uman mil09 detectaamounts o- pro'estin &ave been identi-ied in mil0

-rug (ame Pro'esterone (Prometrium) 44 6sed to prevent endometrial &%perpla

Adult -ose 2or 3omen 3it& a uterus receivin' estro'en t&erap%: *++ m'#d P" - d se uentiall% per * 4d c%cleediatric -ose 8ot establis&ed

Contraindications

Documented &%persensitivit%9 caps contain peanut oil and s&ould nebe used b% patients aller'ic to peanuts9 0no3n or suspected pre'nat&rombop&lebitis t&romboembolic disorders! cerebral apople;%! orpatient 3it& a &istor% o- t&ese conditions9 severe liver d%s-unction ordisease9 0no3n or suspected mali'nanc% o- breast and 'enital or'aundia'nosed va'inal bleedin'9 missed abortion9 as a dia'nostic testpre'nanc%

Interactions Getocona@ole in&ibits metabolism b% &uman liver microsomes (clinicrelevance un0no3n)regnancy 5 4 6suall% sa-e but bene-its must out3ei'& t&e ris0s=

recautions

Ma% cause some de'ree o- -luid retention9 t&us! conditions t&at mi'&be in-luenced b% t&is -actor (e'! epileps%! mi'raine! ast&ma! cardiacrenal d%s-unction) re uire care-ul observationPatients 3it& &istor% o- depression s&ould be care-ull% observed1ransient di@@iness ma% occur in some patients9 caution 3&en drivinmotor ve&icle or operatin' mac&iner%9 small percenta'e o- 3omene;perience e;treme di@@iness and#or dro3siness durin' initial t&erap-or t&ese 3omen! bedtime dosin' is advised

)& &8:" Aut&or .n-ormation .ntroduction Clinical Di--erentials /or0up 1reatment Medication 2ollo34up Miscellaneous 5iblio'rap&%
http://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliography


20/22

)urther &ut#atient Care$

1&e need -or on'oin' care is de-ined b% t&e mec&anism disruptin' t&e menstrual c%cle and tovarian insu--icienc% annuall% to monitor t&eir ovarian &ormone replacement and to detect t&

t&at ma% be related to t&e ori'inal pat&o'enic mec&anism t&at led to t&e disruption o- t&e me

Com#lications$

oss o- menstrual re'ularit% &as been associated 3it& an increased ris0 o- 3rist and &ip -racteven 3it&out t&e development o- amenorr&ea= A later menarc&e and menstrual c%cle intervalassociated 3it& increased -racture rates in later %ears= Youn' 3omen 3it& ovarian insu--icienre uire &ormone replacement to maintain bone densit%=

atient Education$

2or patients 3it& ovarian insu--icienc% t&at remains a-ter appropriate evaluation and treatmenstress t&e need -or on'oin' attention to t&e -actors t&at &elp maintain bone densit%= Hot&ese patients= "t&er -actors to consider are t&e need -or ade uate ca lcium inta0e ( *need -or *+4>+ min utes o- 3ei'&t4bearin' e;ercise eac& da%=

2or e;cellent patient education resources! visit eMedicine7s /omen7s Healt& Center ! ERepro duction Cent er = Also! see eMedi cine7s p atient education articles Amenorr&ea ! An5irt& Control 2AJs =

MISCE A(E&"S Aut&or .n-ormation .ntroduction Clinical Di--erentials /or0up 1reatment Medication 2ollo34up Miscellaneous 5iblio'rap&%

Medical3 egal it+alls$

Evidence is mountin' t&at loss o- menstrual re'ularit% is a ris0 -actor -or later development o-patients and clinicians need to vie3 t&e ovar% as an important endocrine or'an t&at &elps mat&e evaluation and treatment o- disordered menses can contribute to osteoporosis= At somepresence o- ovarian insu--icienc% could become a medicole'al pit-all=

S#ecial Concerns$

Havin' re'ular menses is a si'n o- 'ood &ealt&= 5lood pressure is reco'ni@ed as an importadetec tion o- a dise ase pro cess t &at ma % be silentl% a dvancin' = .n t&is sense! t&e menstrusi'n t&at can lead to earlier detection o- t&e silent disease process o- osteoporosis=

.I. I&1'A H; Aut&or .n-ormation .ntroduction Clinical Di--erentials /or0up 1reatment Medication 2ollo34up Miscellaneous 5iblio'rap&%

5er'a S ! Mortola K2! $irton ! et al: 8euroendocrine aberrations in 3omen 3it& -unctional &Endocrinol Metab 2eb9 < (*): >+ 4 LMedline =
http://www.emedicinehealth.com/collections/SU310.asphttp://www.emedicinehealth.com/collections/CO1589.asphttp://www.emedicinehealth.com/collections/CO1602.asphttp://www.emedicinehealth.com/articles/53430-1.asphttp://www.emedicinehealth.com/articles/12688-1.asphttp://www.emedicinehealth.com/articles/39063-1.asphttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliographyhttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliographyhttp://www.emedicinehealth.com/collections/SU310.asphttp://www.emedicinehealth.com/collections/CO1589.asphttp://www.emedicinehealth.com/collections/CO1602.asphttp://www.emedicinehealth.com/articles/53430-1.asphttp://www.emedicinehealth.com/articles/12688-1.asphttp://www.emedicinehealth.com/articles/39063-1.asphttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliographyhttp://www.emedicine.com/med/topic117.htm#section~author_information%23section~author_informationhttp://www.emedicine.com/med/topic117.htm#section~introduction%23section~introductionhttp://www.emedicine.com/med/topic117.htm#section~clinical%23section~clinicalhttp://www.emedicine.com/med/topic117.htm#section~differentials%23section~differentialshttp://www.emedicine.com/med/topic117.htm#section~workup%23section~workuphttp://www.emedicine.com/med/topic117.htm#section~treatment%23section~treatmenthttp://www.emedicine.com/med/topic117.htm#section~medication%23section~medicationhttp://www.emedicine.com/med/topic117.htm#section~follow-up%23section~follow-uphttp://www.emedicine.com/med/topic117.htm#section~miscellaneous%23section~miscellaneoushttp://www.emedicine.com/med/topic117.htm#section~bibliography%23section~bibliographyhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=89139733http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=22919339


21/22

5er'a S ! Marcus MD! ouc0s 1 ! et al: Recover% o- ovarian activit% in 3omen 3it& -unctiontreated 3it& co'nitive be&avior t&erap%= 2e rtil Steril * ++> "ct9 +(?): 4 $arner DM: Eatin' Disorder .nventor%4* Pro-essional Manual= "dessa! 2la: Ps%c&olo'ical As $arner DM! "lmsted MP! Poliv% K: Development and validation o- a multidimensional eatin'

and bulimia= .nt K Eatin' Disorders >9 *: ,4> ?= $arner DM! "lmsted MP! Poliv% K: Development and validation o- a multidimensional eatin'

and bulimia= .nt K Eatin' Disor ders > 9 *: ,4>?= $ibson KH! Mitc&ell A! Harries M$! Reeve K: 8utritional and e;ercise4related determinants o-

"steoporos .nt *++? Au'9 ,( ): < 4 LMedline = $iles DE! 5er'a S : Co'nitive and ps%c&iatric correlates o- -unctional &%pot&alamic amenorr

Steril > Sep9 ): ? Dec9 > (LMedline =

Gris0a AM! Gno3ler /C! aPorte RE! et al: Development o- uestionnaire to e;amine relatioPima .ndians= Diabetes Care + Apr9 >(?): ?+ 4 LMedline =

au-er MR! 2loor AE! Parsons GE! et al: Hormone testin' in 3omen 3it& adult4onset amenorr *++4>LMedline =

au'&lin $A! Yen SS: 8utritional and endocrine4metabolic aberrations in amenorr&eic at&lete( *): ?>+ 4 LMedline =

ouc0s A5! Ferdun M! Heat& EM: o3 ener'% availabilit%! not stress o- e;ercise! alters H puP&%siol Kan9 ?( ): > 4?< LMedline =

Marcus MD! ouc0s 1 ! 5er'a S : Ps%c&olo'ical correlates o- -unctional &%pot&alamic amen> +4


22/22

Pettersson 2! 2ries H! 8illius SK: Epidemiolo'% o- secondar% amenorr&ea= .= .ncidence and pr > Sep 9 ( ): +4

Amenorrhea 2

Documents

Transcript of Amenorrhea 2