18.3 Amenorrhea

The absence of menstruation in women of reproductive age who have ovaries and a uterus is called amenorrhea. There are two types of amenorrhea called primary and secondary amenorrhea. Primary amenorrhea is the absence of menarche by the age of 16 years. Secondary amenorrhea is the absence of menstruation for three or more consecutive cycles in women who previously experienced regular menstrual cycles.^[1] There are several common causes of primary and secondary amenorrhea as listed in Table 18.3.

Table 18.3. Causes of Primary and Secondary Amenorrhea^[2]

Signs and symptoms of amenorrhea caused by hormonal imbalances may include the following^[3]:

• Hirsutism (excessive hair growth on unexpected areas)
• Hair loss
• Headache
• Galactorrhea (milk production not related to pregnancy or breastfeeding)
• Visual changes

Assessment of a client with amenorrhea begins with a detailed history and physical examination by the provider to determine primary or secondary amenorrhea. If primary amenorrhea is confirmed, the provider will assess for chromosomal abnormalities. If the client has secondary amenorrhea, focused assessment includes questions about menstrual and reproductive history, as well as symptoms of hormonal changes. Diagnostic testing is ordered based on the suspected etiology and may include the following tests^[4]:

• Beta–human chorionic gonadotropin (beta-hCG) to rule out pregnancy
• Testosterone and dehydroepiandrosterone sulfate (DHEAS) to assess for hyperandrogenism
• Follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen, thyroid function, and prolactin to evaluate for hormonal imbalances
• Imaging tests, such as pelvic ultrasound or computed tomography (CT), to evaluate for adrenal tumors, pituitary tumors, or anatomic variations (such as a transverse vaginal septum or the absence of ovaries, uterus, or cervix)

Treatment of amenorrhea is based on the underlying cause. Medical management may include hormonal therapies, such as combined oral contraceptives or progestin therapy, to induce withdrawal bleeding, regulate menstrual cycles, and correct hormonal imbalances. For specific causes of amenorrhea such as hyperprolactinemia, targeted medications such as dopamine agonists may be prescribed. Clients with chronic amenorrhea may be at risk for osteoporosis due to bone loss associated with estrogen deficiency and may require bone density monitoring or treatment with calcium and vitamin D replacement and/or bisphosphonate therapy to reduce bone loss. For clients with eating disorders or excessive exercise-induced amenorrhea, a multidisciplinary approach involving dieticians, therapists, and exercise specialists is crucial.^[5]

Nurses provide health teaching about amenorrhea and treatment options, as well as offer emotional support by addressing client concerns or anxieties related to the condition. Nonpharmacologic approaches to managing amenorrhea include lifestyle modifications, such as maintaining a healthy weight, managing stress levels, and ensuring adequate nutrition and exercise.^[6]