Patients with hypothalamic amenorrhea should be evaluated for eating disorders and are at risk for decreased bone density.Patients with polycystic ovary syndrome are at risk for glucose intolerance, dyslipidemia, and other aspects of metabolic syndrome.For information about the SORT evidence rating system, go to https://org/It is helpful to consider the possible causes of amenorrhea categorically.These include anatomic defects in the outflow tract; primary dysfunction of the ovary; disruption of hypothalamic or pituitary function; systemic disease affecting the hypothalamic-pituitary-gonadal axis; and pathology of other endocrine glands2 Print Figure 2. (DHEA-S = dehydroepiandrosterone sulfate; FSH = follicle-stimulating hormone; LH = luteinizing hormone; MRI = magnetic resonance imaging; TSH = thyroid-stimulating hormone.)Figure 2. (DHEA-S = dehydroepiandrosterone sulfate; FSH = follicle-stimulating hormone; LH = luteinizing hormone; MRI = magnetic resonance imaging; TSH = thyroid-stimulating hormone.)Patients should be asked about eating and exercise patterns, changes in weight, previous menses (if any), medication use, chronic illness, presence of galactorrhea, and symptoms of androgen excess, abnormal thyroid function, or vasomotor instability.Zika virus and complications: Questions and answers, from the World Health Organization (Mar 2017)Zika, from the Center for Infectious Disease Research and Policy, Univeristy of Minnesota (Mar 2017)Infographic on DEET use from the Pediatric Environmental Health Speciality Unit (Nov 2016)Zika articles published in Obstetrics & Gynecology May 2016 - Volume 127 - Supplement 1 Abstracts of Papers and Posters to be Presented at the 64th Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists, May 14-17, Washington, DC. Supplement sponsored by: Published May 2016 “Letzko Extraperitoneal Cesarean Section” (artist: F. Laboratory tests usually reveal low or low-normal levels of serum follicle-stimulating hormone, luteinizing hormone, and estradiol; however, these levels can fluctuate, and the clinical context is the discriminating factor.17 Patients with functional amenorrhea may demonstrate the features of the female athlete triad, which consists of insufficient caloric intake with or without an eating disorder, amenorrhea, and low bone density or osteoporosis.31 These patients should be screened for eating disorders, diets, and malabsorption syndromes (e.g., celiac disease).1Treatment of functional hypothalamic amenorrhea involves nutritional rehabilitation as well as reductions in stress and exercise levels.7 Menses typically return after correction of the underlying nutritional deficit.32 Bone loss is best treated by reversal of the underlying process, and the patient should undergo bone density evaluation and take calcium and vitamin D supplements.7 Although the bone loss is partly secondary to estrogen deficiency, estrogen replacement without nutritional rehabilitation does not reverse the bone loss. Metformin effects on clinical features, endocrine and metabolic profiles, and insulin sensitivity in polycystic ovary syndrome: a randomized, double-blind, placebo-controlled 6-month trial, followed by open, long-term clinical evaluation. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
Glucose intolerance should be assessed with a fasting glucose and two-hour glucose tolerance test, because patients may have insulin resistance and beta-cell dysfunction.144 In patients with PCOS who are overweight, weight loss combined with exercise is the first-line treatment.44 Chronic anovulation with resultant unopposed estrogen secretion is a risk factor for endometrial cancer, and low-dose combined OCs are more frequently prescribed to reduce this risk than higher-dose pills or progestin-only methods.4447 Metformin (Glucophage) can increase insulin sensitivity, thereby improving glucose tolerance. Banaszewska B, Pawelczyk L, Spaczynski RZ, Dziura J, Duleba AJ. Patients with Turner syndrome (or variant) should be treated by a physician familiar with the appropriate screening and treatment measures.Treatment goals for patients with amenorrhea may vary considerably, and depend on the patient and the specific diagnosis. Each of these conditions is associated with varying clinical sequelae; thus, it is important to consider a broad differential diagnosis to avoid missing rare or emergent pathology.Most pathologic cases of secondary amenorrhea can be attributed to polycystic ovary syndrome (PCOS), hypothalamic amenorrhea, hyperprolactinemia, or primary ovarian insufficiency.1A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series.For information about the SORT evidence rating system, go to https://org/A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series.This condition differs from menopause, in which the average age is 50 years, because of age and less long-term predictability in ovarian function.623 More than 90% of cases unrelated to a syndrome are idiopathic, but they can be attributed to radiation, chemotherapeutic agents, infection, tumor, empty sella syndrome, or an autoimmune or infiltrative process.6Patients with primary ovarian insufficiency should be counseled about possible fertility, because up to 10% of such patients may achieve temporary and unpredictable remission.24 [ corrected] Hormone therapy (e.g., 100 mcg of daily transdermal estradiol or 0.625 mg of daily conjugated equine estrogen [Premarin] on days 1 through 26 of the menstrual cycle, and 10 mg of cyclic medroxyprogesterone acetate for 12 days [e.g., days 14 through 26] of the menstrual cycle)6 until the average age of natural menopause is usually recommended to decrease the likelihood of osteoporosis, ischemic heart disease, and vasomotor symptoms.9 Combined oral contraceptives (OCs) deliver higher concentrations of estrogen and progesterone than necessary for hormone therapy, may confer thromboembolic risk, and may theoretically be ineffective at suppressing follicle-stimulating hormone for contraceptive purposes in this population; thus, a barrier method or intrauterine device is appropriate in sexually active patients.627There is evidence of genetic predisposition to primary ovarian insufficiency, and patients without evidence of a syndrome should be tested for FMR1 gene premutation (confers risk of fragile X syndrome in their offspring) and thyroid and adrenal autoantibodies.630Turner syndrome, a condition characterized by a chromosomal pattern of 45, X or a variant, can present with a classic phenotype including a webbed neck, a low hairline, cardiac defects, and lymphedema.1315 Thus, all patients with short stature and amenorrhea should have a karyotype analysis.15 Because patients require screening for a number of systemic problems, including coarctation of the aorta, other cardiac lesions, renal abnormalities, hearing problems, and hypothyroidism, and because they may require human growth hormone treatment and hormone replacement therapy, physicians inexperienced with Turner syndrome should consult an endocrinologist.1315The ovaries require physiologic stimulation by pituitary gonadotropins for appropriate follicular development and estrogen production.Functional hypothalamic amenorrhea occurs when the hypothalamic-pituitary-ovarian axis is suppressed due to an energy deficit stemming from stress, weight loss (independent of original weight), excessive exercise, or disordered eating.17 It is characterized by a low estrogen state without other organic or structural disease. Copyright © 2013 by the American Academy of Family Physicians. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.Primary amenorrhea is defined as the failure to reach menarche.Evaluation should be undertaken if there is no pubertal development by 13 years of age, if menarche has not occurred five years after initial breast development, or if the patient is 15 years or older.12 In contrast, a normal menstrual cycle typically occurs every 21 to 35 days.2Primary amenorrhea is often, but not exclusively, the result of chromosomal irregularities that lead to primary ovarian insufficiency (e.g., Turner syndrome) or anatomic abnormalities (e.g., Müllerian agenesis). In the accompanying legend, De Lee observes: “Trendelenburg again. Bay Jacobs, MD, Library for the History of Obstetrics and Gynecology in America. Now draw the peritoneum down, bring the bladder into position. Abdominal suture.”Podcasts featuring the editors discussing current and past issues are available. ABOG MOC II: The January 2018 ABOG MOC II article list is now available.