Escolar Documentos
Profissional Documentos
Cultura Documentos
If patients have had no menstrual periods by age 13 and have no signs of puberty (eg, any
type of breast development), they should be evaluated for primary amenorrhea.
Secondary amenorrhea is cessation of menses after they have begun. Usually, patients
should be evaluated for secondary amenorrhea if menses have been absent for ≥ 3 mo or ≥ 3
typical cycles because from menarche until perimenopause, a menstrual cycle lasting > 90
days is unusual.
Pathophysiology
Normally, the hypothalamus generates pulses of gonadotropin-releasing hormone (GnRH).
GnRH stimulates the pituitary to produce gonadotropins (follicle-stimulating hormone [FSH]
and luteinizing hormone [LH]—see Female Reproductive Endocrinology : Menstrual Cycle),
which are released into the bloodstream. Gonadotropins stimulate the ovaries to produce
estrogen (mainly estradiol ), androgens (mainly testosterone ), and progesterone. These
hormones do the following:
If pregnancy does not occur, estrogen and progesterone production decreases, and the
endometrium breaks down and is sloughed during menses. Menstruation occurs 14 days after
ovulation in typical cycles.
When part of this system malfunctions, ovulatory dysfunction occurs; the cycle of
gonadotropin-stimulated estrogen production and cyclic endometrial changes is disrupted,
and menstrual flow does not occur, resulting in anovulatory amenorrhea. Most amenorrhea,
particularly secondary amenorrhea, is anovulatory.
However, amenorrhea can occur when ovulation is normal, as occurs when genital anatomic
abnormalities (eg, congenital anomalies causing outflow obstruction, intrauterine adhesions
[Asherman syndrome]) prevent normal menstrual flow despite normal hormonal stimulation.
Etiology
Amenorrhea is usually classified as anovulatory (see Some Causes of Anovulatory
Amenorrhea) or ovulatory (see Some Causes of Ovulatory Amenorrhea). Each type has many
causes, but overall, the most common causes of amenorrhea include
Anovulatory amenorrhea
The most common causes (see Some Causes of Anovulatory Amenorrhea) involve a
disruption of the hypothalamic-pituitary-ovarian axis. Thus, causes include
Cause Examples
Genetic disorders (eg, congenital gonadotropin-releasing hormone
deficiency, GnRH receptor gene mutations that result in low FSH and
Hypothalamic estradiol levels and a high LH level, Prader-Willi syndrome)
dysfunction,
structural Infiltrative disorders of the hypothalamus (eg, Langerhans cell
granulomatosis, lymphoma, sarcoidosis, TB)
Cause Examples
Irradiation to the hypothalamus
Dieting
Immunodeficiency
Psychoactive drugs
Undernutrition
Aneurysms of the pituitary
Hyperprolactinemia*
Hyperthyroidism
Other endocrine
dysfunction
Hypothyroidism
True hermaphroditism †
Ovulatory amenorrhea
The most common causes (see Some Causes of Ovulatory Amenorrhea) include
Chromosomal abnormalities
Congenital anatomic genital abnormalities that obstruct menstrual flow
Cause Examples
Cervical stenosis (rare)
Imperforate hymen
Some acquired anatomic abnormalities, such as endometrial scarring after instrumentation for
postpartum hemorrhage or infection (Asherman syndrome), cause secondary ovulatory
amenorrhea.
Evaluation
Girls are evaluated if
They have no signs of puberty (eg, breast development, growth spurt) by age 13.
Pubic hair is absent at age 14.
Menarche has not occurred by age 16 or by 2 yr after the onset of puberty
(development of secondary sexual characteristics).
Women of reproductive age should have a pregnancy test after missing one menses. They are
evaluated for amenorrhea if
They are not pregnant and have missed menstrual cycles for ≥ 3 mo or ≥ 3 typical
cycles.
They have < 9 menses a year.
They have a sudden change in menstrual pattern.
History
History of present illness includes whether menses have ever occurred (to distinguish
primary from secondary amenorrhea) and, if so, how old patients were at menarche, whether
periods have ever been regular, and when the last normal menstrual period occurred. History
should also include duration and flow of menses; presence or absence of cyclic breast
tenderness and mood changes; and growth, development, and age at thelarche (development
of breasts at puberty).
Past medical history should note risk factors for functional hypothalamic anovulation, such
as stress; chronic illness; new drugs; a recent change in weight, diet, or exercise intensity;
and, in patients with secondary amenorrhea, risk factors for Asherman syndrome (eg, D & C,
endometrial ablation, endometritis, obstetric injury, uterine surgery).
Drug history should include specific questions about use of drugs that affect dopamine (eg,
antihypertensives, antipsychotics, opioids, tricyclic antidepressants), cancer chemotherapy
drugs (eg, busulfan, chlorambucil, cyclophosphamide), and sex hormones that can cause
virilization (eg, androgens, estrogens , high-dose progestins) and questions about recent use
of contraceptives.
Family history should include height of family members and any cases of delayed puberty or
genetic disorders in family members.
Physical examination
Clinicians should note vital signs and body composition and build, including height and
weight, and should calculate body mass index (BMI). Secondary sexual characteristics are
evaluated; breast and pubic hair development are staged using Tanner’s method. If axillary
and pubic hair is present, adrenarche has occurred.
With the patient seated, clinicians should check for breast secretion by applying pressure to
all sections of the breast, beginning at the base and moving toward the nipple. Galactorrhea
(breast milk secretion not temporally associated with childbirth) may be observed; it can be
distinguished from other types of nipple discharge by finding fat globules in the fluid using a
low-power microscope.
Pelvic examination is done to detect anatomic genital abnormalities; a bulging hymen may be
caused by hematocolpos, which suggests genital outflow obstruction. Pelvic examination
findings also help determine whether estrogen has been deficient. In postpubertal females,
thin, pale vaginal mucosa without rugae and pH > 6.0 indicate estrogen deficiency. The
presence of cervical mucus with spinnbarkeit (a stringy, stretchy quality) usually indicates
adequate estrogen .
Red flags
Delayed puberty
Virilization
Visual field defects
Interpretation of findings
Other Possible
Finding Possible Cause
Findings
Use of certain drugs
Drugs that affect dopamine (which
helps regulate prolactin secretion):
Antihypertensives (eg,
methyldopa, reserpine,
verapamil)
Antipsychotics, 2nd
generation (eg, molindone,
olanzapine, risperidone)
Antipsychotics,
conventional (eg,
haloperidol,
Galactorrhea Hyperprolactinemia
phenothiazines, pimozide)
Cocaine
Estrogens
GI drugs (eg, cimetidine,
metoclopramide)
Hallucinogens
Opioids (eg, codeine,
morphine)
Tricyclic antidepressants
(eg, clomipramine,
desipramine)
Moon facies,
buffalo hump,
truncal obesity,
Striae Cushing syndrome
thin extremities,
virilization,
hypertension
Obesity,
Acanthosis nigricans Polycystic ovary syndrome
virilization
Vitiligo or hyperpigmentation of Orthostatic
Addison’s disease
the palm hypotension
General findings suggesting estrogenic or androgenic abnormalities
Symptoms of estrogen deficiency Risk factors such
(eg, hot flushes, night sweats, as oophorectomy, Premature ovarian failure
particularly with vaginal dryness or chemotherapy, or
Other Possible
Finding Possible Cause
Findings
atrophy) pelvic irradiation
Androgen excess due to
True hermaphroditism
Hirsutism with virilization
Pseudohermaphroditism
Primary
An androgen-secreting tumor
amenorrhea
Adrenal virilism
Gonadal dysgenesis
A genetic disorder
17-Hydroxylase deficiency
Enlarged ovaries Polycystic ovary syndrome
An androgen-secreting
ovarian tumor
Virilization
Androgen exposure during the 1st
trimester, possibly indicating
Fused labia, clitoral enlargement at
― Congenital adrenal virilism
birth
True hermaphroditism
Drug-induced virilization
Testing
If girls have secondary sexual characteristics, a pregnancy test should be done to exclude
pregnancy and gestational trophoblastic disease as a cause of amenorrhea. Women of
reproductive age should have a pregnancy test after missing one menses.
The approach to primary amenorrhea (see see Figure: Evaluation of primary amenorrhea. a)
differs from that to secondary amenorrhea (see see Figure: Evaluation of secondary
amenorrhea.), although no specific general approaches or algorithms are universally
accepted.
Evaluation of primary amenorrhea. a
a
Normal values are
b
Some clinicians measure LH levels when they measure FSH levels or when FSH levels are
equivocal.
c
Constitutional delay of growth and puberty is possible.
d
Possible diagnoses include functional hypothalamic chronic anovulation and genetic
disorders (eg, congenital gonadotropin-releasing hormone deficiency, Prader-Willi
syndrome).
e
Possible diagnoses include Cushing syndrome, exogenous androgens, congenital adrenal
virilism, and polycystic ovary syndrome.
f
Possible diagnoses include Turner syndrome and disorders characterized by Y chromosome
material.
g
Pubic hair may be sparse.
DHEAS = dehydroepiandrosterone sulfate; FSH = follicle-stimulating hormone; LH =
luteinizing hormone; TSH = thyroid-stimulating hormone.
If clinical evaluation suggests a chronic disease, liver and kidney function tests are done, and
ESR is determined.
If patients have secondary amenorrhea without virilization and have normal prolactin and
FSH levels and normal thyroid function, a trial of estrogen and a progestin to try to stimulate
withdrawal bleeding can be done (progesterone challenge test). The trial begins by giving
medroxyprogesterone 5 to 10 mg po once/day or another progestin for 7 to 10 days.
However, because this trial takes weeks and results can be inaccurate, diagnosis of some
serious disorders may be delayed significantly; thus, brain MRI should be considered before
or during the trial.
Mildly elevated levels of testosterone or DHEAS suggest polycystic ovary syndrome, but
levels can be elevated in women with hypothalamic or pituitary dysfunction and are
sometimes normal in hirsute women with polycystic ovary syndrome. The cause of elevated
levels can sometimes be determined by measuring serum LH. In polycystic ovary syndrome,
circulating LH levels are often increased, increasing the ratio of LH to FSH.
Treatment
Treatment is directed at the underlying disorder; with such treatment, menses sometimes
resume. For example, most abnormalities obstructing the genital outflow tract are surgically
repaired.
Jika gejala atau tanda menyarankan gangguan tertentu, tes khusus dapat diindikasikan terlepas dari
apa algoritma merekomendasikan. Sebagai contoh, pasien dengan striae abdomen, facies bulan,
punuk kerbau, obesitas trunkal, dan ekstremitas tipis harus diuji untuk sindrom Cushing (lihat
Cushing Syndrome). Pasien dengan sakit kepala dan cacat bidang visual atau bukti disfungsi hipofisis
memerlukan MRI otak.
Jika evaluasi klinis menunjukkan penyakit kronis, hati dan ginjal tes fungsi dilakukan, dan ESR
ditentukan.
Seringkali, pengujian meliputi pengukuran kadar hormon; testosteron total serum atau
dehydroepiandrosterone sulfate (DHEAS) tingkat diukur hanya jika tanda-tanda virilisasi yang hadir.
Kadar hormon tertentu harus diukur kembali untuk mengkonfirmasi hasil. Sebagai contoh, jika
serum prolaktin tinggi, harus diukur kembali; jika serum FSH tinggi, harus diukur kembali bulanan
setidaknya dua kali. Amenore dengan tingkat FSH tinggi (hipergonadotropik hipogonadisme)
menunjukkan disfungsi ovarium; amenore dengan tingkat FSH rendah (hipogonadisme
hipogonadisme) menunjukkan hipotalamus atau hipofisis disfungsi.
Jika pasien memiliki amenore sekunder tanpa virilisasi dan memiliki prolaktin dan FSH yang normal
tingkat dan fungsi tiroid normal, percobaan estrogen dan progestin untuk mencoba untuk
merangsang perdarahan penarikan bisa dilakukan (progesteron tantangan test). Sidang dimulai
dengan memberikan medroxyprogesterone 5 sampai 10 mg po sekali / hari atau progestin lain
selama 7 sampai 10 hari.
• Jika perdarahan terjadi, amenore mungkin tidak disebabkan oleh lesi endometrium (misalnya,
sindrom Asherman) atau obstruksi saluran keluar, dan penyebabnya mungkin disfungsi hipotalamus-
hipofisis, kegagalan ovarium, atau kelebihan estrogen.
• Jika perdarahan tidak terjadi, sebuah estrogen (misalnya, conjugated equine estrogen 1,25 mg,
estradiol 2 mg) sekali / hari diberikan selama 21 hari, diikuti oleh medroxyprogesterone 10 mg po
sekali / hari atau progestin lain selama 7 sampai 10 hari. Jika perdarahan tidak terjadi setelah
estrogen diberikan, pasien mungkin memiliki lesi endometrium atau obstruksi saluran keluar.
Namun, perdarahan mungkin tidak terjadi pada pasien yang tidak memiliki kelainan tersebut
(misalnya, karena rahim tidak sensitif terhadap estrogen); dengan demikian, sidang menggunakan
estrogen dan progestin dapat diulang untuk konfirmasi.
Namun, karena percobaan ini mengambil minggu dan hasilnya bisa tidak akurat, diagnosis beberapa
gangguan serius mungkin tertunda secara signifikan; dengan demikian, MRI otak harus
dipertimbangkan sebelum atau selama persidangan.
Tingkat sedikit meningkat dari testosteron atau DHEAS menyarankan sindrom ovarium polikistik,
tetapi tingkat dapat meningkat pada wanita dengan disfungsi hipotalamus atau hipofisis dan kadang-
kadang normal pada wanita berbulu dengan sindrom ovarium polikistik. Penyebab peningkatan
kadar kadang-kadang dapat ditentukan dengan mengukur serum LH. Dalam sindrom ovarium
polikistik, tingkat sirkulasi LH sering meningkat, peningkatan rasio LH untuk FSH.
Pengobatan
Pengobatan diarahkan pada gangguan yang mendasarinya; dengan pengobatan tersebut, menstruasi
terkadang melanjutkan. Sebagai contoh, sebagian besar kelainan menghalangi saluran keluar
kelamin pembedahan diperbaiki.
Jika kromosom Y hadir, ooforektomi bilateral dianjurkan karena risiko kanker sel germinal ovarium
meningkat.
Masalah yang terkait dengan amenore juga mungkin memerlukan pengobatan, termasuk
• Mendorong ovulasi jika kehamilan diinginkan
• Mengobati gejala dan efek jangka panjang defisiensi estrogen (misalnya osteoporosis)
• Mengobati gejala dan mengelola efek jangka panjang dari kelebihan estrogen (misalnya,
perdarahan berkepanjangan, persisten atau ditandai nyeri payudara, risiko hiperplasia endometrium
dan kanker)
• Meminimalkan hirsutisme dan jangka panjang efek androgen yang berlebihan (misalnya, gangguan
kardiovaskular, hipertensi)