The patient’s history of weight changes, exercise, eating habits, and body image is an important factor in determining whether anorexia nervosa, malnutrition, obesity, exercise, or stress may be responsible for amenorrhea.
Patients with certain specific clinical findings should undergo screening for other hormonal alterations: 1.
Androgen levels should be assessed in any hirsute patient to ensure that adrenal and ovarian tumors are not present and to aid in the diagnosis of PCOS.
2.
Acromegaly is suggested by coarse facial features, large doughy hands, and hyperhidrosis and may be confirmed by measuring IGF-1 levels.
3.
In patients with truncal obesity, hirsutism, hypertension, and erythematous striae, Cushing syndrome should be ruled out by assessing 24-hour urinary cortisol levels or performing a 1-mg overnight dexamethasone suppression test or late night salivary cortisol (126). It is important to confirm that the patient is not taking exogenous glucocorticoid.
Treatment for Women with Amenorrhea in the Presence of Normal Pelvic Anatomy and Normal Secondary Sexual Characteristics
The treatment of nonanatomic causes of amenorrhea associated with normal secondary sexual characteristics varies widely according to the cause. The underlying disorder should be treated whenever possible. Patients who are pregnant may be counseled regarding the options for continued care. When thyroid abnormalities are detected, thyroid hormone, radioactive iodine, or antithyroid drugs may be administered as appropriate. When hyperprolactinemia is present, treatment may include discontinuation of contributing medications, treatment with dopamine agonists such as bromocriptine or cabergoline, and, rarely, surgery for particularly large pituitary tumors. When POI causes amenorrhea, hormone replacement may be considered to diminish symptoms and to prevent osteoporosis. Counseling regarding the risks and benefits of hormone replacement therapy is indicated. Gonadectomy is required when a Y cell line is present.
Surgical removal, radiation therapy, or a combination of both is advocated for treatment of CNS tumors other than prolactinomas. It may be necessary to treat individuals who have panhypopituitarism with various replacement regimens after all the deficits are elucidated. These regimens include estrogen and progestogen replacement for lack of gonadotropins, corticosteroid replacement for lack of ACTH, thyroid hormone for lack of TSH, and desmopressin acetate (1-deamino-8-D-AVP [DDAVP]) to replace vasopressin.
The treatment of amenorrhea associated with hypothalamic dysfunction depends on the underlying cause: 1.
Hormonally active ovarian tumors are surgically removed (rare).
2.
Obesity, malnutrition or chronic disease, Cushing syndrome, and acromegaly should be specifically treated.
3.
Stress-induced amenorrhea may respond to psychotherapy.
4.
Exercise-induced amenorrhea may improve with moderation of activity and weight gain, when appropriate. If hypoestrogenism persists, higher doses of estrogen may be needed in these women than in older menopausal women to maintain bone density. In addition, 1,200 to 1,500 mg of calcium and 400 to 800 IU of vitamin D daily are advised. Bisphosphonates do not improve bone density in amenorrheic athletes because it is lack of bone formation rather than increased resorption that causes the osteopenia. In addition, the use of bisphosphonates is not advised because they can be deposited into the bone, and long-term effects, especially during pregnancy, are unknown.
5.
Treatment of eating disorders such as anorexia nervosa generally demands a multidisciplinary approach, with severe cases requiring hospitalization (127).