2025 – PAGE 69 – ADOLESCENT MEDICINE

PRIMARY AMENORRHEA

­Do a workup for primary amenorrhea if the patient has not had menses in the presence of ANY of the following:

• Puberty ended 2 years ago. For example, if puberty started at age 8 and finished at age 11 (patient is now SMR 5), a workup can be started at age 13.
• Patient is 13 years of age and lacks secondary sexual characteristics (no breast development or pubic hair).
• Patient has normal growth and secondary sex characteristics with SMR 2-5 pubic hair and breast development but is now 15 years of age and still with no menses.

* Lab workup as mentioned in the “amenorrhea workup” section. In other words, after HCG is checked, check LH, FSH, PRL, and/or TSH as per the algorithm. BUT if there are signs of ANDROGENIZATION, add TESTOSTERONE and DHEA.

* Possible causes of primary amenorrhea include the following:

• EXERCISE INDUCED AMENORRHEA: Look for DELAYED puberty + LOW LH and Treatment is to reduce exercise and increase calories.
• TURNER’S SYNDROME: No breasts (or just buds), no/scant hair → Get a Karyotype.
• ANDROGEN INSENSITIVITY (AKA TESTICULAR FEMINIZATION): Genetically XY = Breasts but no hair!

SECONDARY AMENORRHEA

Secondary amenorrhea is the absence of menses for more than 3 months in girls who previously had regular menstrual cycles, or the absence of menses for more than 6 months in girls with irregular menses. The differential includes ASHERMAN’S SYNDROME (intrauterine adhesions), CYSTIC FIBROSIS, SARCOIDOSIS, phenothiazines, nutrition, brain tumors, and tuberculosis.

ANOREXIA AS A CAUSE OF AMENORRHEA

Anorexia can cause amenorrhea. Suspect anorexia as the possible cause of secondary amenorrhea if the patient has not had a period for 3 months. Anorexia = low HR, orthostasis, hypothermia.

BULIMIA AS A CAUSE OF AMENORRHEA

Bulimia is often associated with irregular menses.

POLYCYSTIC OVARIAN SYNDROME (PCOS) AS A CAUSE OF AMENORRHEA

Polycystic ovarian syndrome is a clinical diagnosis. Labs are supportive. Look for an elevated free or total testosterone level in a patient with acne, irregular menses, excess hair on her body, and/or signs of insulin resistance. This can be caused by anything increasing androgens, including Cushing’s syndrome and exogenous steroids.