Management of Primary Amenorrhea
Treatment of amenorrhea depends upon the identified cause. The following is a brief description of treatment options.
In cases of müllerian agenesis, counseling is warranted to discuss the diagnosis with the patient and the family; this should include a discussion of future fertility options, including use of a gestational carrier, and sexual relationships. Treatment includes nonsurgical and surgical creation of a neovagina, as well as general gynecologic examinations to evaluate for vaginal stricture and stenosis. 
For androgen insensitivity syndrome, complete gonadectomy may be performed after the patient has completed puberty to prevent gonadal neoplasia, for which the patient is at increased risk.  In this case, use of a donor egg versus use of a gestational carrier may be discussed.
Anatomic defects, such as imperforate hymen or transverse vaginal septum, are treated with a surgical procedure to create a patent outflow tract. Usually, a successful, normal pregnancy and delivery can be anticipated.
For primary hypogonadism, if it is due to premature ovarian failure, treatment should include a discussion of hormone therapy, and additional assessment may be required, including testing for a premutation in the FMR1 gene.  A donor egg can be utilized, with normal delivery expected.
In cases of functional hypothalamic amenorrhea, gaining weight and reducing exercise levels will likely result in resumption of menses.
Polycystic ovary syndrome (PCOS) is treated essentially as it would be in the context of abnormal uterine bleeding (AUB; see below).
Management of Abnormal Uterine Bleeding
Polycystic ovary syndrome
Treatment of PCOS depends on the patient’s goals, as follows:
For patients who wish to conceive, clomiphene citrate is the first-line treatment, followed by gonadotropins 
For those who are not attempting to conceive, a combined oral contraceptive pill (COCP) is usually the first line of treatment, provided that there are no contraindications; COCPs are therapeutic for multiple reasons, including regulating menstrual cycles, suppressing ovarian and adrenal androgen production and increasing circulating levels of sex hormone binding globulin, thus lowering the levels of free testosterone in the serum 
In addition to these treatment options, lifestyle modifications are recommended for overweight and obese PCOS patients so as to decrease their risk for cardiovascular disease, diabetes, and metabolic syndrome. [18, 44, 19]
Metformin has also been demonstrated to decrease ovarian androgen production and insulin levels, and it may improve ovulation rates; however, it is not currently approved for treatment of PCOS-related menstrual dysfunction. It may be used to delay the development of diabetes in those with impaired glucose tolerance, but is not as effective as lifestyle modifications. 
For patients with hirsutism, multiple treatment options are available. A multitiered approach is often necessary, combining cosmetic procedures with medications such as COCPs and antiandrogens (eg, spironolactone, flutamide and finasteride).  When antiandrogen medications are being used, it is important to use contraceptives as well because the antiandrogens are teratogenic.
Heavy menstrual bleeding
First-line therapy for AUB – heavy menstrual bleeding (HMB) often includes nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, and mefenamic acid. They have been demonstrated to decrease menstrual blood loss in comparison with placebo; they decrease prostaglandin levels, which are increased in women with AUB-HMB. 
Additional treatment options include hormone therapy with COCPs, as well as the use of progestin-only medications, including pills, medroxyprogesterone acetate, and the etonogestrel implant (especially if there are contraindications to COCPs). 
Another progestin-only option is the levonorgestrel-releasing intrauterine device (IUD), [47, 48] which has been demonstrated to decrease menstrual blood loss to a greater extent than NSAIDs, COCPs, or antifibrinolytic agents do.  Although most of the studies on IUDs have been performed in women at least 18 years of age, this is an appropriate form of contraception in adolescents  and thus may be an option for treatment of AUB-HMB.
A nonhormonal pharmacologic option that has been demonstrated to decrease HMB in adults is the use of antifibrinolytic drugs, such as tranexamic acid  ; however, these agents are not currently approved for use in adolescents.
If a patient is diagnosed with von Willebrand disease, one should seek consultation with a hematologist in order to optimize the treatment regimen. Possible medical options include antifibrinolytic agents, COCPs, and progestin-only contraceptives.  Additional nonhormonal treatment options include desmopressin acetate and recombinant factor VIII. 
If a patient is taking a short-acting hormone, it is important to counsel her about proper administration of the medication. It is also important to provide counseling about what she may expect in terms of bleeding patterns, especially during the first few months of use. If a patient was recently started on contraceptives, unscheduled bleeding is common in the first 3 months, and in many cases, all that is needed is reassurance.
If irregular bleeding persists and the adolescent is taking a low-dose COCP (eg, < 20 µg ethinyl estradiol), the intermenstrual bleeding (IMB) may resolve if the estrogen dose is increased.  Depending on when the bleeding occurs during the cycle, she may benefit from increasing either the progestin level or the estrogen support in her formulation. 
For patients who are taking progestin-only formulations, bothersome unscheduled bleeding can often be treated by administering NSAIDS or by providing brief estrogen supplementation with COCPs, provided that no contraindications exist. 
Management of Dysmenorrhea
First-line therapy for primary dysmenorrhea consists of NSAIDs, which inhibit prostaglandin synthesis and lead to less vigorous uterine contractions.  Improvement may occur if regularly scheduled doses are started 1-2 days before anticipated menses. If improvement is not seen after three menstrual cycles, a trial of oral contraceptive pills for three menstrual cycles may be offered.
Secondary dysmenorrhea is less likely to respond to NSAIDs than primary dysmenorrhea is. 
NSAIDs are a common first-line treatment for endometriosis, though there is no current evidence that these agents reduce endometriosis-related pain.  Oral contraceptives, progestins, androgens, and gonadotropin-releasing hormone (GnRH) agonists are the mainstays of medical therapy.
COCPs decrease pain as compared with placebo, and in patients who experience pain during withdrawal bleeding, pain reduction has been demonstrated with continuous oral contraceptives.  Progestins, administered orally and subcutaneously, provide pain relief and offer benefit equivalent to that of GnRH agonists, with fewer side effects. 
GnRH agonists do provide effective relief of endometriosis-related pain, but they have significant side effects, including osteopenia, vaginal dryness and hot flashes. If these agents are used for longer than 6 months, add-back therapy should be initiated. 
Pelvic inflammatory disease
Treatment of pelvic inflammatory disease (PID) consists of antibiotics (given orally or intravenously, depending on the patient’s clinical presentation and findings) and, potentially, drainage of an abscess or surgical intervention. In view of the known sequelae of untreated PID, it is recommended that all sexually active women presenting with lower abdominal or pelvic pain with no other identifiable etiology, or cervical motion, uterine or adnexal tenderness be empirically treated for PID. [59, 60]
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