eMedicine Specialties > Obstetrics and Gynecology > Reproductive Endocrinology and Infertility

Amenorrhea, Primary: Follow-up

Author: Vaishali Popat, MD, MPH, Clinical Investigator, Intramural Research Program on Reproductive and Adult Endocrinology, National Institutes of Child Health and Human Development, National Institutes of Health
Coauthor(s): Tamara Prodanov, MD, Research Assistant, National Institute of Health/National Institute of Child Health and Human Development; Karim Anton Calis, PharmD, MPH, FASHP, FCCP, Professor, Medical College of Virginia, Virginia Commonwealth University, Clinical Professor, University of Maryland; Clinical Specialist, Endocrinology and Women's Health, Director, Drug Information Service, Mark O Hatfield Clinical Research Center, National Institutes of Health; Somya Verma, MD, Fellow in Pediatric Endocrinology, National Institutes of Child Health and Human Development; Officer of United States Public Health Service Commissioned Corps; Sharon N Covington, LCSW-C, BCD, Clinical Assistant Professor, Department of Obstetrics and Gynecology, Georgetown University School of Medicine; Associate Investigator, Integrative Reproductive Medicine Unit, Reproductive Biology and Medicine Branch, National Institutes of Child Health and Human Development, National Institutes of Health; Private Practice, Covington and Hafkin and Associates; Director of Psychological Support Services, Shady Grove Fertility Reproductive Science Center; Lawrence M Nelson, MD, MBA, Head of Integrative Reproductive Medicine Unit, Investigator, Intramural Research Program on Reproductive and Adult Endocrinology, National Institutes of Child Health and Human Development, National Institutes of Health
Contributor Information and Disclosures

Updated: Aug 14, 2008

Follow-up

Further Outpatient Care

The need for ongoing care is defined by the mechanism disrupting the menstrual cycle and the patient's desires. See patient every 3-6 months for the first 2 years to monitor ovarian hormone replacement and to detect the development of associated conditions that may be related to the original pathogenic mechanism that led to the disruption of the menstrual cycle.

Complications

Loss of menstrual regularity has been associated with an increased risk of wrist and hip fractures related to reduced bone density. A later menarche has been associated with increased fracture rates in later years. Young women with ovarian insufficiency that is unresponsive to therapy require hormone replacement to achieve the peak and maintain bone density. Adolescence is a critical period for bone accretion as over half of peak bone mass is achieved during the teenage years.20  Hormones such as estrogen and androgens are important along with modifiable risk factors such as vitamin D deficiency, calcium intake, nutrition, exercise, and smoking. Adolescents who maximize their bone mass will have an advantage when their bone density declines as they age or due to illness or menopause.

Patient Education

  • For patients with ovarian insufficiency that remains after appropriate evaluation and treatment, careful counseling is warranted to stress the need for ongoing attention to the factors that help maintain bone density. Hormone replacement therapy is important for these patients. Other factors to consider are the need for adequate calcium intake (1200-1500 mg/d of elemental calcium) and the need for 20-30 minutes of weight-bearing exercise each day.
  • For excellent patient education resources, visit eMedicine's Women's Health Center, Eating Disorders Center, and Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Amenorrhea, Anorexia Nervosa, Birth Control Overview, and Birth Control FAQs.

Miscellaneous

Medicolegal Pitfalls

Evidence is mounting that amenorrhea is a risk factor for later development of osteoporosis and hip fractures. Both patients and clinicians need to view the ovary as an important endocrine organ that helps maintain healthy bones. Excessive delay in the evaluation and treatment of disordered menses can contribute to osteoporosis. At some point, failure to promptly evaluate for the presence of ovarian insufficiency could become a medicolegal pitfall.

Special Concerns

Having regular menses is a sign of good health. Blood pressure is recognized as an important vital sign that can lead to earlier detection of a disease process that may be silently advancing. In this sense, the menstrual cycle should also be viewed as a vital sign that can lead to earlier detection of the silent disease process of osteoporosis.

Emotional health concerns

Primary amenorrhea and the potential for impaired fertility affect the emotional health of the adolescent and her family. Adolescence encompasses a broad spectrum of emotional maturity, which needs to be considered in assessment and treatment. For the adolescent girl, a reproductive disorder impacts her developing sense of self, body-image, and sexuality, which, in turn, can affect her self-esteem and relationships with others. Because of the sexual nature of a reproductive disorder, feelings of embarrassment, inadequacy, or protectiveness can make it difficult for families. Families should be encouraged to be open and honest regarding the condition and discouraged from keeping the diagnosis a secret.

The family is an emotional unit and a family systems approach to deal with health issues is most appropriate. Parents must first deal with their own feelings about the condition before they can help their child. They must also be provided with tools to build an ongoing conversation with their child. Physicians need to be culturally sensitive because in some cultures a woman's identity in adulthood as a mother could play a crucial role in her life. The objective is to help the adolescent girl formulate positive self-esteem and body image, despite impaired fertility.

 
Acknowledgments

This work was supported by the Intramural Research Program of the National Institutes of Health.



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References
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Further Reading

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Keywords

amenorrhea, primary amenorrhea, secondary amenorrhea, hypothalamic amenorrhea, pituitary amenorrhea, menstruation, absence of menstruation, gonadotropin-releasing hormone, GnRH, follicle-stimulating hormone, FSH, luteinizing hormone, LH, hypothalamus-pituitary-ovarian axis, HPO, gonadal dysgenesis, Turn syndrome, spontaneous primary ovarian insufficiency, POI, premature ovarian failure, POF, premature menopause, Swyer syndrome, 46,XY gonadal dysgenesis, 46,XX gonadal dysgenesis, polycystic ovarian syndrome, vaginal agenesis, mullerian dysgenesis, Mayer-Rokitansky-Kuster-Hauser syndrome, MRKH

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Contributor Information and Disclosures

Author

Vaishali Popat, MD, MPH, Clinical Investigator, Intramural Research Program on Reproductive and Adult Endocrinology, National Institutes of Child Health and Human Development, National Institutes of Health
Vaishali Popat, MD, MPH is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, and Endocrine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Tamara Prodanov, MD, Research Assistant, National Institute of Health/National Institute of Child Health and Human Development
Disclosure: Nothing to disclose.

Karim Anton Calis, PharmD, MPH, FASHP, FCCP, Professor, Medical College of Virginia, Virginia Commonwealth University, Clinical Professor, University of Maryland; Clinical Specialist, Endocrinology and Women's Health, Director, Drug Information Service, Mark O Hatfield Clinical Research Center, National Institutes of Health
Karim Anton Calis, PharmD, MPH, FASHP, FCCP is a member of the following medical societies: American College of Clinical Pharmacy, American Society of Health-System Pharmacists, and Endocrine Society
Disclosure: Nothing to disclose.

Somya Verma, MD, Fellow in Pediatric Endocrinology, National Institutes of Child Health and Human Development; Officer of United States Public Health Service Commissioned Corps
Disclosure: Nothing to disclose.

Sharon N Covington, LCSW-C, BCD, Clinical Assistant Professor, Department of Obstetrics and Gynecology, Georgetown University School of Medicine; Associate Investigator, Integrative Reproductive Medicine Unit, Reproductive Biology and Medicine Branch, National Institutes of Child Health and Human Development, National Institutes of Health; Private Practice, Covington and Hafkin and Associates; Director of Psychological Support Services, Shady Grove Fertility Reproductive Science Center
Sharon N Covington, LCSW-C, BCD is a member of the following medical societies: Academy of Certified Social Workers, American Orthopsychiatric Association, American Society for Reproductive Medicine, National Association of Social Workers, and Society for Assisted Reproductive Technologies
Disclosure: Nothing to disclose.

Lawrence M Nelson, MD, MBA, Head of Integrative Reproductive Medicine Unit, Investigator, Intramural Research Program on Reproductive and Adult Endocrinology, National Institutes of Child Health and Human Development, National Institutes of Health
Lawrence M Nelson, MD, MBA is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Endocrine Society, and Society for Experimental Biology and Medicine
Disclosure: Nothing to disclose.

Medical Editor

Thomas Michael Price, MD, Associate Professor of Reproductive Endocrinology, Director of Reproductive Fellowship Training Program, Duke University Medical Center
Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Phi Beta Kappa, and Society for Gynecologic Investigation
Disclosure: Clinical Advisors Group Consulting fee Consulting; MEDA Corp Consulting Consulting fee Consulting; Gerson Lehrman Group Advisor  Consulting fee Consulting; Roche/GSK Spokesperson  Consulting fee Consulting; Abbott Pharmaceuticals Grant/research funds PI; Adiana Grant/research funds PI

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)
A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Bryan D Cowan, MD, Professor and Chairman, Department of Obstetrics and Gynecology, University of Mississippi College of Medicine; Consulting Staff, Department of Obstetrics and Gynecology, Veterans Affairs Medical Center; Medical Director, Wiser Hospital for Women, University of Mississippi Medical Center
Bryan D Cowan, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Gynecological and Obstetrical Society, American Medical Association, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Endocrine Society, Sigma Xi, Society for Assisted Reproductive Technologies, Society for Gynecologic Investigation, Society for the Study of Reproduction, and Society of Laparoendoscopic Surgeons
Disclosure: Wyeth None Speaking and teaching

 
 
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