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Home , Amenorrhea, Anovulation, Cervical agenesis, Hyperandrogenism, Hypogonadism, Imperforate hymen

Current evaluation of

The Practice Committee of the American Society for Birmingham, Alabama

Amenorrhea is the absence or abnormal cessation of the menses. Primary and secondary amenorrhea describe the occurrence of amenorrhea before and after , respectively. (Fertil Steril 2008;90:S219–25. 2008 by American Society for Reproductive Medicine.)

Amenorrhea is the absence or abnormal cessation of the men- complaint. The sexual ambiguity or should be ses (1). Primary and secondary amenorrhea describe the evaluated as separate disorders, mindful that amenorrhea is occurrence of amenorrhea before and after menarche, respec- an important component of their presentation (9). tively. The majority of the causes of primary and secondary amenorrhea are similar. Timing of the evaluation of primary EVALUATION OF THE PATIENT amenorrhea recognizes the trend to earlier age at menarche History, physical examination, and estimation of follicle and is therefore indicated when there has been a failure to stimulating (FSH), stimulating hormone menstruate by age 15 in the presence of normal secondary sex- (TSH), and will identify the most common causes ual development (two standard deviations above the mean of of amenorrhea (Fig. 1). The presence of 13 years), or within five years after breast development if means there has been previous action. Excessive tes- that occurs before age 10 (2). Failure to initiate breast develop- tosterone secretion is suggested most often by and ment by age 13 (two standard deviations above the mean of 10 rarely by increased muscle mass or other signs of virilization. years) also requires investigation (2). In women with regular The history and physical examination should include a thor- menstrual cycles, a delay of menses for as little as one week ough assessment of the external and internal genitalia. may require the exclusion of ; secondary amenor- rhea lasting three months and involving less The genital examination is abnormal in approximately than nine cycles a year require investigation. 15% of women with primary amenorrhea. A blind or absent with breast development usually indicates Mullerian The prevalence of amenorrhea not due to pregnancy, lacta- agenesis, transverse , or insensitiv- tion or is approximately 3% to 4% (3, 4). Al- ity syndrome. If a genital examination is not feasible, an though the list of potential causes of amenorrhea is long abdominal ultrasound may be useful to confirm the presence (Table 1), the majority of cases are accounted for by four con- or absence of the . ditions: polycystic syndrome, hypothalamic amenor- rhea, hyperprolactinemia, and ovarian failure. Other causes When the physical examination is normal (the majority of are seldom encountered in a typical reproductive medicine cases), the initial investigations should exclude pregnancy practice. In highly specialized referral centres, only 10 to and estimate FSH and prolactin concentrations. Estimation 15 patients per annum were seen with primary amenorrhea, of TSH is useful to rule out subclinical , and a similar number with secondary amenorrhea (5–7). even in the absence of thyroid-related symptoms. If there is The World Health Organization (WHO) has summarized gonadal failure, a karyotype should be done if the woman the causes: in WHO group I there is no evidence of endoge- is less than 30 years of age to identify chromosomal abnor- nous estrogen production, normal or low FSH levels, normal malities, including the presence of a Y chromosome as may prolactin levels, and no evidence of a lesion in the hypotha- be seen in mosaic or Swyer syndrome. If lamic-pituitary region; WHO group II is associated with ev- the serum prolactin is persistently elevated, and there is no idence of estrogen production and normal levels of prolactin history of medication or drug use that may elevate prolactin, and FSH; and WHO group III involves elevated serum FSH magnetic resonance imaging (MRI) is preferred to identify levels indicating gonadal failure (8). a pituitary tumor. When FSH values are normal or low, the problem is most often polycystic ovary syndrome or hypotha- Amenorrhea may occur with sexual ambiguity or viriliza- lamic amenorrhea. Tables 2 and 3 show the distribution of the tion, but usually in these cases amenorrhea is not the primary common causes of primary and secondary amenorrhea, respectively, in clinical practice (5–7). Educational Bulletin Reviewed June 2008. Received February 20, 2004; revised and accepted February 20, 2004. CAUSES OF AMENORRHEA No reprints will be available. Anatomical Defects Correspondence to: Practice Committee, American Society for Reproduc- tive Medicine, 1209 Montgomery Highway, Birmingham, Alabama When all or part of the uterus and vagina are absent in the 35216 . presence of otherwise normal female sexual characteristics,

0015-0282/08/$34.00 and Sterility Vol. 90, Suppl 3, November 2008 S219 doi:10.1016/j.fertnstert.2008.08.038 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc. TABLE 1 TABLE 1 Classification of amenorrhea (not including Continued. disorders of congenital sexual ambiguity). b. Syphilis I. Anatomic defects (outflow tract) c. Encephalitis/meningitis A. Mullerian€ agenesis (Mayer-Rokitansky- d. Kuster-Hauser syndrome) 3. Chronic debilitating B. Complete androgen resistance (testicular 4. Tumors feminization) a. Craniopharyngioma C. Intrauterine synechiae (Asherman b. Germinoma syndrome) c. Hamartoma D. Imperforate d. Langerhans cell histiocytosis E. Transverse vaginal septum e. Teratoma F. —isolated f. Endodermal sinus tumor G. Cervical stenosis—iatrogenic g. Metastatic carcinoma H. Vaginal agenesis—isolated IV. Pituitary causes I. Endometrial hypoplasia or A. Tumors aplasia—congenital 1. II. Primary 2. Other hormone-secreting pituitary tu- A. mor (ACTH, thyrotropin-stimulating hor- 1. Abnormal karyotype mone, growth hormone, ) a. Turner syndrome 45,X b. Mutations of FSH receptor b. Mosaicism c. Mutations of LH receptor 2. Normal karyotype d. Fragile X syndrome a. Pure gonadal dysgenesis 4. Autoimmune disease i. 46,XX 5. ii. 46,XY (Swyer syndrome) V. Other endocrine gland disorders B. Gonadal agenesis A. Adrenal disease C. Enzymatic deficiency 1. Adult-onset adrenal hyperplasia 1. 17a-Hydroxylase deficiency 2. Cushing syndrome 2. 17,20-Lyase deficiency B. 3. deficiency 1. Hypothyroidism D. Premature ovarian failure 2. 1. Idiopathic C. Ovarian tumors 2. Injury 1. Granulosa-theca cell tumors a. 2. Brenner tumors b. Radiation 3. Cystic teratomas c. 4. Mucinous/serous cystadenomas 3. Resistant ovary 5. Krukenberg tumors a. Idiopathic 3. Nonfunctional tumors III. Hypothalamic causes (craniopharyngioma) A. Dysfunctional 4. Metastatic carcinoma 1. B. Space-occupying lesions 2. Exercise 1. Empty sella 3. Nutrition-related 2. Arterial aneurysm a. , diet, malnutrition C. Necrosis b. Eating disorders (, 1. Sheehan syndrome bulimia) 2. Panhypopituitarism 4. Pseudocyesis D. Inflammatory/infiltrative B. Other disorders 1. Sarcoidosis 1. Isolated gonadotropin deficiency 2. Hemochromatosis a. 3. Lymphocytic b. Idiopathic hypogonadotropic E. Gonadotropin mutations (FSH) hypogonadism VI. Multifactorial causes 2. Infection A. Polycystic ovary syndrome a. ASRM Practice Committee. Amenorrhea. Fertil Steril 2008. ASRM Practice Committee. Amenorrhea. Fertil Steril 2008.

S220 ASRM Practice Committee Amenorrhea Vol. 90, Suppl 3, November 2008 FIGURE 1

Suggested flow diagram aiding in the evaluation of women with amenorrhea.

ASRM Practice Committee. Amenorrhea. Fertil Steril 2008.

the diagnosis is usually Mullerian agenesis, which accounts , is usually due to intrauterine synechiae. If the vag- for approximately 10% of cases of primary amenorrhea. Mul- inal opening is patent and the is visualized with a spec- lerian agenesis is associated with urogenital malformations ulum, a sound or probe can confirm the presence or the such as unilateral , pelvic kidney, horseshoe absence of cervical stenosis or scarring (9). To evaluate intra- kidney, hydronephrosis, and ureteral duplication. Mullerian uterine synechiae, an imaging procedure (hysterosalpingo- agenesis must be differentiated from complete androgen in- gram, sonohysterogram, or hysteroscopy) is indicated. sensitivity because the vagina may be absent or short in both disorders. Complete androgen insensitivity is rare, hav- ing an incidence as low as 1 in 60,000 (10), but it comprises Elevated FSH Levels approximately 5% of cases of primary amenorrhea (Table 2). Lack of gonadal function is marked by high FSH levels. Go- The simplest means of distinguishing between Mullerian nadal failure can occur at any age, even in utero, when it is agenesis and complete androgen insensitivity is by measuring usually the result of gonadal agenesis or gonadal dysgenesis. serum , which is in the normal male range or Gonadal failure in genetically XX individuals is ovarian fail- higher in the latter condition (11). Complete androgen insen- ure; when this occurs at any time before onset of sexual mat- sitivity is suggested by family history, the absence of pubic uration, there will be primary amenorrhea and incomplete hair, and the occasional presence of inguinal masses. The di- breast development. Genetically XY individuals with agnosis can be confirmed by a 46, XY karyotype. The inci- gonadal failure will have female genitalia because Mullerian dence of gonadal malignancy is 22%, but it rarely occurs inhibiting factor and testosterone will not be produced. before age 20 (12). A plan should be established for the Gonadal tumors occur in up to 25% of women with a Y chro- timely removal of the following breast development mosome; unlike complete androgen insensitivity, these and the attainment of adult stature. gonads do not secrete and should be removed at the time of diagnosis (14). Other anatomic defects include (1 in 1,000 women), transverse vaginal septum (1 in 80,000 Gonadal dysgenesis (streak gonads) can occur with normal women), and isolated absence of the vagina or cervix (13). XX and XY karyotypes and a variety of abnormal karyo- These conditions are more likely to present with cyclic types, most commonly 45,X (Turner syndrome), in which oo- pain and an accumulation of blood behind the obstruction cyte loss is accelerated after 18 weeks in utero (15, 16). which can lead to and pelvic adhesions. Amen- Turner syndrome is often diagnosed in early childhood be- orrhea after an episode of postpartum or an op- cause of the well-known phenotypic characteristics (short erative procedure involving the uterus, particularly curettage stature, webbed neck and low hairline), and therefore many for postpartum hemorrhage, elective abortion, or a missed patients do not present for assessment of primary

Fertility and Sterility S221 TABLE 2 sponsible for polyendocrinopathy-candidiasis-ectodermal dystrophy (25). A further indication for karyotype and genetic Common causes of primary amenorrhea (4, 6). investigation is that some patients with POF have children for Approximate whom the genetic information may be useful. Category frequency (%) Up to 40% of women with POF may have autoimmune ab- Breast development 30 normalities, most commonly autoimmune thyroiditis (26, Mullerian agenesis 10 27). POF is slightly more common in women with -de- Androgen insensitivity 9 pendent mellitus, myasthenia gravis, and parathy- Vaginal septum 2 roid disease than in healthy women (28). Autoimmune Imperforate hymen 1 lymphocytic oophoritis may be seen in Addison’s disease, Constitutional delay 8 in which 10% to 60% of cases may have ovarian failure, No breast development: high FSH 40 but this condition is extremely rare (1 per million women). 46 XX 15 Ovarian is not indicated in clinical practice, but be- 46 XY 5 cause autoimmune POF could be a component of a polygland- Abnormal 20 ular syndrome, patients can be screened for other No breast development: low FSH 30 abnormalities by means of TSH, thyroid autoantibodies, fast- Constitutional delay 10 ing , and electrolytes (29). Thyroid autoantibodies Prolactinomas 5 may increase the ability to identify individuals likely to de- Kallman syndrome 2 velop subsequent primary hypothyroidism. No currently Other CNS 3 available validated serum antibody marker can confirm a clin- Stress, weight loss, anorexia 3 ical diagnosis of autoimmune premature ovarian failure. PCOS 3 Also, at this time, no therapy for infertile patients with Congenital adrenal hyperplasia 3 autoimmune ovarian failure has been proven effective in Other 1 a prospective controlled study.

ASRM Practice Committee. Amenorrhea. Fertil Steril 2008. Patients with ovarian failure should be offered estrogen and progestin treatment to promote and maintain secondary sexual characteristics and reduce the risk of developing oste- oporosis. In adolescents with gonadal failure, the aim is to amenorrhea. Uncommon causes of ovarian failure include FSH or LH receptor mutations (17, 18), galactosemia, 17 a-hydroxylase or 17,20-lyase deficiency, and aromatase defi- TABLE 3 ciency (19–21). Common causes of secondary amenorrhea (5). In premature ovarian failure (POF), amenorrhea, persistent estrogen deficiency, and elevated FSH levels occur prior to Approximate the age of 40, and this condition affects 1% to 5% of women Category frequency (%) (22, 23). Iatrogenic causes of POF, such as chemotherapy and Low or normal FSH 66 radiation therapy for malignancy, have a potential for recov- Weight loss/anorexia ery. Ovarian function may fluctuate, with increasingly irreg- Non-specific hypothalamic ular menstrual cycles before the final depletion of oocytes Chronic and permanent ovarian failure. The resulting fluctuation in including PCOS gonadotropin levels accounts for the lack of accuracy associ- Hypothyroidism ated with a single FSH value (24). Cushing’s syndrome Ovarian failure is confirmed by documenting an FSH level Pituitary tumor, empty sella, persistently in the menopausal range. In women under 30 with Sheehan syndrome POF, a karyotype should be obtained to rule out sex chromo- Gonadal failure: high FSH 12 some translocation, short arm deletion, or the presence of an 46 XX occult Y chromosome, which is associated with an increased Abnormal karyotype risk of gonadal tumors. About 16% of women who are carriers High prolactin 13 of the premutation of Fragile X syndrome experience prema- Anatomic 7 ture menopause (19). A thorough family history should be Asherman syndrome obtained because several autosomal disorders have been Hyperandrogenic states 2 associated with ovarian failure, including mutations of the Ovarian tumor phosphomannomutase 2 (PMM2) gene, the galactose-1-phos- Non-classic CAH phate uridyltransferase (GALT) gene, the FSH receptor Undiagnosed (FSHR) gene, chromosome 3q containing the Blepharophi- ASRM Practice Committee. Amenorrhea. Fertil Steril 2008. mosis gene, and the autoimmune regulator (AIRE) gene, re-

S222 ASRM Practice Committee Amenorrhea Vol. 90, Suppl 3, November 2008 mimic pubertal development with low-dose , in- concentrations tend to fluctuate and each condition is associ- creasing gradually to augment breast development, avoiding ated with both normal and low estrogen production. As an in- progestin until the breast mound and areola have developed. dication of endogenous estrogen levels, the duration of the Rarely, some ovarian follicles remain in women with ovarian amenorrhea and clinical features are more important than failure so that spontaneous and conception are pos- measurement of , the challenge test, sible, even in women taking exogenous estrogen with or or presence of cervical mucus. Although the progesterone without a (29). challenge test might seem to characterize estrogen produc- tion, withdrawal bleeding correlates poorly with estrogen sta- Elevated Prolactin Levels tus and the test imposes a delay on the diagnostic process. The Hyperprolactinemia is associated with decreased estradiol false positive rate is high: up to 20% of women with oligome- concentrations and amenorrhea or oligomenorrhea. Prolactin norrhea or amenorrhea in whom estrogen is present have no concentrations are higher in women with amenorrhea than in withdrawal bleeding (35). The false negative rate is also those with oligomenorrhea (30). With persistent hyperprolac- high; withdrawal bleeding occurs in up to 40% of women tinemia, after ruling out primary hypothyroidism, MRI of the with amenorrhea due to stress, weight loss, exercise, or hyper- pituitary is indicated. Mildly elevated prolactin levels may be prolactinemia where estrogen production is usually reduced a sign of another organic lesion, such (36) and in up to 50% of women with ovarian failure (29). as congenital aqueductal stenosis, non-functioning adeno- Hypothalamic Amenorrhea mas, or any condition which causes pituitary stalk irritability. In women with hyperprolactinemia, the prevalence of a pitu- Functional disorders of the or higher centers itary tumor is 50% to 60% (31). The likelihood of a pituitary are the most common reason for chronic anovulation. Psy- tumor was unrelated to the level of prolactin (31), and only chogenic stress, weight changes, undernutrition, and exces- 16% of the variability in tumor size was associated with sive exercise are frequently associated with functional prolactin level (r¼0.40, p<.001) (32). hypothalamic amenorrhea, but the pathophysiologic mecha- nisms are unclear. More cases of amenorrhea are associated Usually, however, patients with amenorrhea have larger tu- with weight loss than with anorexia, which is rare (15 cases mors than patients with oligomenorrhea. The poor correlation per 100,000 women per year), but amenorrhea with anorexia between tumor presence and prolactin level indicates that nervosa is more severe (37, 38). Women involved in compet- MRI should be performed whenever prolactin levels are per- itive sports activities have a three-fold higher risk of primary sistently elevated. In most amenorrheic women with hyper- or secondary amenorrhea than others, and the highest preva- prolactinemia, prolactin levels do not decline without lence is among long-distance runners (39). Infrequently, hy- treatment, and the amenorrhea does not resolve as long as pothalamic dysfunction occurs before menarche and presents the prolactin levels remain elevated (30, 32). In the absence as primary amenorrhea in approximately 3% of adolescents; of another organic condition, dopamine agonists are the pre- usually secondary sexual characteristics will develop and ferred treatment of hyperprolactinemia with or without a pitu- menstrual cycles will evolve without therapy (40). itary tumor. Chronic debilitating , such as uncontrolled juve- Normal or Low FSH Levels nile diabetes, end-stage kidney disease, malignancy, acquired immune deficiency syndrome, or malabsorption, which are Amenorrhea associated with normal or low FSH values and uncommon in women of reproductive age, may lead to anov- chronic anovulation is frequently unexplained. The most ulation and amenorrhea through a central mechanism. common diagnostic categories are hypothalamic amenorrhea and polycystic ovary syndrome, and in each case similar but Other rare causes of hypothalamic amenorrhea include iso- less common conditions must be excluded. Hypothalamic lated gonadotropin deficiency. This is most often due to Kall- amenorrhea is characterized by inconsistent GnRH drive, mann syndrome, which is associated with defects in olfactory while in polycystic ovary syndrome GnRH pulses are persis- bulb development. Thus, these women may have anosmia as tently rapid or increased, leading to excessive LH synthesis, well as amenorrhea and low due to gonadotro- , and impaired follicular maturation (33). pin-releasing hormone (GnRH) deficiency (41). Mutations in Differentiating hypothalamic amenorrhea from polycystic gonadotropin-releasing hormone receptor genes also may ovary syndrome depends on clinical judgment aided by the be associated with hypogonadotropic hypogonadism (42). Pi- presence of and androgenization, which are typical tuitary disorders that cause anovulation include Sheehan syn- features of polycystic ovary syndrome. This judgment also drome, necrosis of the , and empty sella is relevant to the prognosis because obesity and androgeniza- syndrome (43). When amenorrhea persists and stress, exces- tion tend to reduce the likelihood of conception (34). sive exercise, or weight loss can be confidently excluded as causes, MRI may be indicated to rule out organic disease in Estradiol concentration does not effectively distinguish be- the central nervous system, hypothalamus, or pituitary gland. tween hypothalamic amenorrhea and polycystic ovary syn- drome. Although hypothalamic amenorrhea implies that Women with hypothalamic amenorrhea are susceptible to levels of estradiol should be low, while normal levels of estra- the development of (44). Unless the primary diol are expected with polycystic ovary syndrome, estradiol cause can be easily treated, cyclic estrogen-progestin therapy

Fertility and Sterility S223 or oral contraceptive pills should be initiated to prevent ex- on hormonal criteria. Serum androgen levels usually range cessive bone loss. If pregnancy is desired, good nutrition from upper normal to two-fold higher than normal in women and optimal body weight are important objectives but may with PCOS. Prolactin levels are mildly elevated in 10% to be difficult to achieve. with clomiphene 25% of women with PCOS. The LH/FSH ratio may be greater citrate, exogenous gonadotropins, or pulsatile GnRH therapy than 2, but gonadotropin values are not useful to confirm the should be offered (45). diagnosis (47, 49–51).

Polycystic Ovary Syndrome Women with PCOS are frequently insulin resistant; insulin sensitivity is reduced by 30% to 40%, leading to hyperinsuli- When amenorrhea is associated with evidence of androgen nemia, but the insulin response may be inadequate because of excess, the most common disorder is polycystic ovary syn- beta-cell dysfunction. Thus, PCOS patients are pre-disposed drome (PCOS). Less commonly, amenorrhea with hyperan- to glucose intolerance (52). Impaired glucose tolerance oc- drogenism arises from adrenal diseases, such as non- curs in 31% of PCOS patients, but fasting glucose is elevated classical adrenal hyperplasia and Cushing syndrome or in only 7.5%. It can be argued that women with PCOS should from androgen-producing tumors (46). Other disorders that be screened for (52, 53). Obesity further ex- may cause chronic anovulation (Table 1) are much less com- acerbates , and higher insulin concentra- mon than PCOS, and in each case special characteristics are tions are associated with higher androgen levels (34). likely to direct the investigation toward a specific diagnosis. PCOS is characterized by menstrual disturbances ranging CONCLUSIONS from dysfunctional uterine bleeding to oligomenorrhea and amenorrhea, hyperandrogenism, and . Seventy- Amenorrhea is an uncommon presentation in reproduc- five percent of North American women with PCOS are obese tive medicine. (47). PCOS patients are more likely to present with oligome- The four most common causes are polycystic ovary syn- norrhea (76%) than amenorrhea (24%) (34, 48). The symp- drome, hypothalamic amenorrhea, ovarian failure, and toms often occur first at menarche, but the signs of hyperprolactinemia. androgen excess may not become evident until several years The initial useful laboratory tests are FSH, TSH, and later and these signs increase over time. prolactin. Differentiating hypothalamic amenorrhea from poly- The 1990 National Institutes of Health/National Institute cystic ovary syndrome depends on clinical judgment, of Child Health and Development (NIH/NICHHD) aided by the presence or absence of androgenization. criteria for PCOS, although not a consensus, were as follows: (1) ovulatory dysfunction, (2) clinical evidence of hyperan- Acknowledgment: This report was developed under the direction of the Prac- drogenism (hirsutism, , androgenic alopecia) and/or hy- tice Committee of the American Society for Reproductive Medicine as a ser- perandrogenemia, and (3) exclusion of other related disorders vice to its members and other practicing clinicians. While this document such as hyperprolactinemia, thyroid abnormalities, and non- reflects appropriate management of a problem encountered in the practice classical adrenal hyperplasia (49). An international consen- of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of man- sus conference held in 2003 concluded that the syndrome agement may be appropriate, taking into account the needs of the individual ‘‘encompasses a broader spectrum of patient, available resources, and institutional or clinical practice limitations. of ovarian dysfunction than those defined by the original di- This report was approved by the Board of Directors of the American Society agnostic criteria’’ (50). Therefore, participants concluded for Reproductive Medicine in January 2004. that individuals must have two out of three of the following features to be classified as having PCOS: REFERENCES 1. Stedman’s Medical Dictionary. 27th ed. Philadelphia: Lippincott Wil- 1 Oligo- and/or anovulation. liams & Wilkins, 2000:56. 2 Clinical and/or biochemical signs of hyperandrogenism. 2. 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