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Amenorrhea Medication

  • Author: Kenneth M Bielak, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
 
Updated: Mar 02, 2016
 

Medication Summary

For primary amenorrhea, hormone therapy, consisting of an estrogen and a progestin, is recommended for women with estrogen deficiency.[74] Girls with primary amenorrhea typically do not have symptoms of estrogen deficiency. However, with inadequate estrogen exposure over time, these patients are at increased risk for developing osteoporosis and possibly other health issues.

Young women in whom secondary sex characteristics have failed to develop fully should be exposed initially to very low doses of estrogen in an attempt to mimic the gradual pubertal maturation process. A typical regimen consists of an estrogen with a dosage equivalent to 25 mcg/day of transdermal estradiol (approximately 0.3 mg of conjugated equine estrogen) given unopposed (ie, no progesterone) daily for 6 months with incremental dose increases at 6-month intervals until the required maintenance dose is achieved.

Gradual dose escalation allows time to balance estrogen supplementation with need to grow in height, develop secondary sexual characters, and often results in optimal breast development. It also allows time for the young woman to adjust psychologically to her physical maturation.[75]

Cyclic progesterone therapy, given 12-14 days per month, should be instituted once vaginal bleeding begins.

Parenteral estrogen (transdermal or vaginal) is the preferred route of administration because it avoids first-pass liver metabolism. Moreover, it is less likely to increase sex hormone–binding globulin (SHBG) and has little or no effect on circulating lipids, coagulation parameters, or C-reactive protein. However, no long-term controlled studies are available to compare the efficacy and safety of one method over another. Therefore, the choice of therapy should follow consideration of the patient's preferences and the physician's experience.

The role of androgen replacement is unclear at this time and is the subject of ongoing investigation.[76]

For secondary amenorrhea, dopamine agonists are the only medical therapy specifically approved to reverse an underlying pathology that leads to amenorrhea. In most cases, dopamine agonists effectively reduce hyperprolactinemia.

Gonadotropin therapy or pulsatile gonadotropin-releasing hormone (GnRH) therapy is indicated in women who desire fertility yet remain anovulatory because of an unresolved hypothalamic/pituitary disorder. GnRH pump therapy is available in Europe but not in the United States.

Once the diagnosis is established, for some women with oligomenorrhea or amenorrhea who do not wish to become pregnant, oral contraceptives may be a good choice to restore menstrual cyclicity and provide estrogen replacement. The absence of pregnancy should be documented before oral contraceptive therapy is begun.

In patients with amenorrhea or oligomenorrhea withdrawal bleeding should be induced with an injection of progesterone or the administration of 5-10 mg of medroxyprogesterone for 10 days.

Hormone therapy, consisting of an estrogen and a progestin, is needed for women in whom estrogen deficiency remains because ovarian function cannot be restored. The role of androgen replacement is unclear at this time and is the subject of ongoing investigation.

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Estrogens

Class Summary

Estrogens are administered transdermally, transvaginally, or orally. The appropriate dose for young women with ovarian failure or secondary amenorrhea has not been established. The authors recommend full replacement doses for young women. Generally, this is approximately twice as high as doses recommended for hormone therapy in normally postmenopausal women.

The authors prefer to administer estradiol by skin patch (100-mcg transdermal estradiol patch). This avoids the first-pass effect of oral estrogen on the liver. No controlled studies are available to compare the efficacy and safety of one method over another. Therefore, the choice of therapy should follow consideration of the patient's preferences and the physician's experience.

Estradiol (Alora, Climara, Esclim, Vivelle-dot, Estrace)

 

Estradiol increases synthesis of DNA, RNA, and many proteins in target tissues. Transdermal patch available as Alora (0.05, 0.075, and 0.1 mg/d, applied twice weekly), Climara (0.025, 0.05, 0.075, and 0.1 mg/d, applied once weekly), Esclim (0.025, 0.0375, 0.05, 0.075, 0.1 mg/d, applied twice weekly), and Vivelle-dot (0.037, 0.05, 0.075, 0.1 mg/d, applied twice weekly). If transdermal patch is not tolerated, oral form may be used.

Estrogens, conjugated (Premarin)

 

Use in patients who refuse or do not tolerate other forms of estrogen. Use oral estrogen to achieve adequate estrogenization of vaginal epithelium in young women and adequately maintain bone density.

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Progestins

Class Summary

Progestins stop endometrial cell proliferation, allowing organized sloughing of cells after withdrawal. No long-term controlled studies compare efficacy of medroxyprogesterone with oral progesterone in protecting the endometrium from neoplasia at the doses of estrogen generally required for replacement in young women. The authors recommend use medroxyprogesterone as first-line therapy because of longer-term clinical experience with this agent.

Medroxyprogesterone (Provera, Cycrin, Depo-Provera, Amen)

 

Administer cyclically 12 d/mo to prevent endometrial hyperplasia that unopposed estrogen may cause. In young women, regular withdrawal bleeding is preferable because even young women with premature ovarian failure have a 5-10% chance of spontaneous pregnancy (unlike postmenopausal women). If an expected withdrawal bleeding is absent, perform a pregnancy test (and a timely diagnosis of pregnancy will not be missed). Other causes of amenorrhea may also remit spontaneously and result in an unexpected pregnancy.

Progesterone (Prometrium)

 

This agent is used to prevent endometrial hyperplasia

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Contributor Information and Disclosures
Author

Kenneth M Bielak, MD Professor, Department of Family Medicine, University of Tennessee Health Science Center College of Medicine

Kenneth M Bielak, MD is a member of the following medical societies: American Academy of Family Physicians, American Society for Colposcopy and Cervical Pathology, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Gayla S Harris, MD Associate Professor, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center Graduate School of Medicine

Gayla S Harris, MD is a member of the following medical societies: American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Elizabeth Alderman, MD Director of Fellowship Training Program, Director of Adolescent Ambulatory Service, Professor of Clinical Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Children's Hospital at Montefiore

Elizabeth Alderman, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine

Disclosure: Merck Honoraria Speaking and teaching

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.

Karim Anton Calis, PharmD, MPH, FASHP, FCCP Adjunct Clinical Investigator, Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health; Clinical Professor, Medical College of Virginia, Virginia Commonwealth University School of Pharmacy; Clinical Professor, University of Maryland School of Pharmacy

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.

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 Group, 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.

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 College of Physicians and Endocrine Society

Disclosure: Nothing to disclose.

Thomas Michael Price, MD Associate Professor, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Director of Reproductive Endocrinology and Infertility Fellowship 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 Medical Association, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Endocrine Society, Phi Beta Kappa, Society for Gynecologic Investigation, Society for Reproductive Endocrinology and Infertility, and South Carolina Medical Association

Disclosure: Clinical Advisors Group Consulting fee Consulting; MEDA Corp Consulting Consulting fee Consulting; Gerson Lehrman Group Advisor Consulting fee Consulting; Adiana Grant/research funds PI

Tamara Prodanov, MD Research Assistant, National Institutes of Child Health and Human Development, National Institutes of Health

Disclosure: Nothing to disclose.

Shannon D Sullivan, MD, PhD Staff Physician, Department of Endocrinology, Washington Hospital Center

Shannon D Sullivan, MD, PhD is a member of the following medical societies: American Association of Clinical Endocrinologists, American Thyroid Association, and Endocrine Society

Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause 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.

Wayne Wolfram, MD, MPH Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Andrea L Zuckerman, MD Assistant Professor of Obstetrics/Gynecology and Pediatrics, Tufts University School of Medicine; Division Director, Pediatric and Adolescent Gynecology, Tufts Medical Center

Andrea L Zuckerman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine

Disclosure: Nothing to disclose.

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Hypothalamus, pituitary and ovaries form a functional endocrine axis, known as HPO axis with hormonal regulations and feedback loops.
Primary amenorrhea flowchart.
 
 
 
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