Treatment of amenorrhea

Abstract

There are many different causes for amenorrhea. Having a systematic way to think about and work up the causes will help you diagnose the etiology. Causes of amenorrhea can be broken down into structural and endocrine categories. Structural causes are either due to congenital abnormalities such as those seen with primary amenorrhea or acquired, including cervical stenosis or Asherman syndrome. Endocrine causes are associated with dysfunction of the ovary, pituitary, or hypothalamus. Dysfunction of the ovary can be either due to chronic anovulation from polycystic ovary syndrome, obesity, thyroid dysfunction, or hyperprolactinemia. The other major cause of ovarian dysfunction is due to primary ovarian insufficiency/diminished ovarian reserve. Pituitary disorders can be endocrine or structural, with aberrant production of hormones or mass effect interrupting the normal hypothalamic-pituitary-ovarian (HPO) axis. Hypothalamic etiologies stem from congenital deficiencies such as Kallmann syndrome or dys- function/failure from weight loss, heavy exercise, or emotional/psychological stress. The first visit with a patient should include a thorough history and physical exam. Initial labs such as urine HCG, TSH, prolactin, FSH, and estradiol are important for screening for the most common etiologies of amenorrhea. In addition, these also are the first step in assessing the status of the HPO axis in order to discover the underlying reason for amenorrhea.