Amenorrhea

Disease Description (Causes and Symptoms)

• Definition summary
  Amenorrhea is a condition in which menstruation is absent. Primary amenorrhea applies when menstruation has not started by age 14 in the absence of secondary sexual characteristics, or by age 16 when secondary sexual characteristics are already present. Secondary amenorrhea refers to a woman who previously menstruated missing three consecutive menstrual cycles or having no menstruation for 6 months or more.
• Major causes (pathophysiology summary)
  • Anatomical abnormalities of the reproductive organs: imperforate hymen, congenital absence of the uterus or vagina (e.g., uterine agenesis), structural abnormalities of the uterus or fallopian tubes
  • Ovarian dysfunction: primary ovarian insufficiency (POI), polycystic ovary syndrome (PCOS)
  • Central causes: hypothalamic or pituitary dysfunction (pituitary tumors, Nelson syndrome, etc.), hyperprolactinemia
  • Endocrine disorders: hyperthyroidism or hypothyroidism, etc.
  • Functional and environmental causes: severe weight loss (anorexia), excessive exercise, stress, obesity
  • Chromosomal abnormalities (e.g., Turner syndrome), genetic abnormalities
• Main symptoms
  • Absence of menstruation (main symptom)
  • Infertility, menopausal symptoms (when ovarian function is reduced), abdominal pain or abdominal bloating (with obstructive lesions), abnormal vaginal bleeding, or weight changes and vasomotor symptoms accompanying amenorrhea, etc.
  • Additional symptoms depending on the cause, such as virilization (with androgen excess) and galactorrhea (with hyperprolactinemia)

Treatment Methods

• General treatment principles by diagnostic cause
  • Confirming pregnancy is the priority (separate management is required if pregnant)
  • Structural obstruction (e.g., imperforate hymen): surgical correction (simple hymen incision or removal, etc.)
  • Hyperprolactinemia (prolactin): dopamine agonists (cabergoline preferred, bromocriptine as an alternative)
  • Hypothalamic amenorrhea (nutritional deficiency or excessive exercise): restoration of weight and energy intake, adjustment of exercise levels, and treatment of mental health conditions or eating disorders
  • Polycystic ovary syndrome (PCOS): weight loss and lifestyle improvement, oral contraceptives (menstrual regulation), ovulation induction (letrozole recommended when fertility is desired), and metformin in some cases
  • Primary ovarian insufficiency (POI): consider hormone replacement therapy (HRT) for symptom relief and preservation of bone mineral density; counseling for fertility preservation (including egg donation, etc.)
  • Pituitary tumors: medication (dopamine agonists), surgery (transsphenoidal surgery), radiation therapy, etc., depending on size and function
  • Chromosomal abnormalities (e.g., gonadal dysgenesis): consider removal of the gonads if there is a risk of malignant transformation (determined according to age and risk level)
• Main medications
  • Dopamine agonists: cabergoline, bromocriptine (for hyperprolactinemia)
  • Ovulation induction: letrozole preferred (when pregnancy is desired in PCOS), clomiphene (alternative)
  • Hormone replacement therapy: oral contraceptives (menstrual regulation), estrogen + progestin (HRT for POI)
  • Treatment for thyroid dysfunction: antithyroid drugs or levothyroxine
• Lifestyle management
  • Maintain an appropriate weight (correct both underweight and overweight), eat regular meals, manage stress, and adjust exercise levels
  • Bone health management: calcium and vitamin D intake; bone mineral density testing and preventive treatment for osteoporosis when necessary
• Precautions / risk of complications
  • Taking hormones arbitrarily for a long period while the cause remains unidentified, particularly estrogen-based drugs, is dangerous because it may conceal an underlying lesion (e.g., a breast or endometrial problem)
  • Long-term amenorrhea (a low-estrogen state) increases the risk of osteoporosis
  • For certain diseases (e.g., pituitary tumors and hereditary diseases), early diagnosis and treatment are important for the prognosis
  • If emergency signs occur, such as severe abdominal pain, acute abdominal bloating, heavy bleeding, acute visual impairment, or severe headache, visit an emergency medical institution immediately

Checklist Before an Outpatient Visit (Including Sample Questions)

• Items and records to prepare
  • A list of all medications and supplements currently being taken (including dosage and duration of use)
  • Detailed menstrual history (date of the last menstrual period, when menstruation began and stopped, and previous cycle patterns)
  • Records of weight changes and changes in eating or exercise habits (including recent weight and BMI)
  • Records of accompanying symptoms (galactorrhea, headache, vision changes, signs of virilization, etc.)
  • Copies of previous test results (blood tests, ultrasound, MRI, etc.) or surgery and genetic testing results, if available
  • Pregnancy test results, if available
• Key information to provide to the doctor during the consultation
  • Previous reproductive-related diseases (ovarian surgery, uterine surgery, etc.) and family history (premature menopause, chromosomal abnormalities, etc.)
  • Amount of exercise (including whether exercise is occupational or competitive) and whether an eating disorder is suspected
• Tests that may be expected during the outpatient visit (whether advance preparation is required)
  • Urine pregnancy test; blood tests (FSH, LH, prolactin, TSH, total testosterone androgens, estrogen, etc.); blood glucose and lipids; karyotype and chromosomal tests when necessary; bone mineral density testing in some cases
  • Pelvic ultrasound, pituitary MRI when necessary, laparoscopy, etc.

General Sample Questions to Ask the Doctor

• "What is the most likely cause of my amenorrhea? What additional tests are needed?"
• "What treatment options are recommended, and what are the advantages and disadvantages of each?"
• "What are the main side effects of this medication or procedure?"
• "If I want to become pregnant in the future, what treatment and preparation will I need?"
• "What long-term effects can amenorrhea have on my health, such as my bones and cardiovascular system, and what should I do to prevent them?"
• "What should I expect regarding the treatment duration and prognosis, including recovery of normal menstruation and the possibility of pregnancy?"

Examples of Condition-Specific Questions

• When a structural cause is suspected: "Are the findings seen on the ultrasound or MRI definitely the cause of my menstrual failure? Is surgical correction necessary?"
• Regarding ovulation and fertility: "When I want to become pregnant, what is the most effective method of ovulation induction, and what are the success rate and risks of treatment?"

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