Amenorrhea

Amenorrhea – Treatment Overview

Introduction
Amenorrhea is defined as the absence of menstrual periods and is classified into:

• Primary amenorrhea: No menstruation by age 15 with normal secondary sexual characteristics, or by age 13 without them.

• Secondary amenorrhea: Absence of menstruation for ≥3 months in women with previously regular cycles, or ≥6 months in women with irregular cycles.

Causes range from physiological (pregnancy, menopause) to pathological (hormonal disorders, structural abnormalities, systemic diseases). Treatment focuses on the underlying cause, alongside symptom control and prevention of complications such as infertility, osteoporosis, or endometrial hyperplasia.

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Treatment Options (Based on Etiology)

1. Physiological Causes

• Pregnancy, lactation, menopause: Reassurance; no treatment required.

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2. Hypothalamic / Functional Causes (stress, weight loss, excessive exercise, chronic illness)

• Nutritional rehabilitation and weight optimization.

• Stress management and lifestyle modification.

• If persistent:

  • Combined oral contraceptives (COCs) or cyclic progestins to induce withdrawal bleeding and protect endometrium.

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3. Pituitary Causes

• Hyperprolactinemia (prolactinoma):

  • Cabergoline: 0.25–1 mg orally twice weekly.

  • Bromocriptine: 2.5 mg orally 2–3 times daily.

• Pituitary insufficiency: Hormone replacement therapy (thyroxine, hydrocortisone, estrogen/progestin depending on deficiencies).

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4. Ovarian Causes

• Premature ovarian insufficiency (POI):

  • Hormone replacement therapy (HRT) with estrogen + progestin until average age of menopause (~50 years).

• Polycystic Ovary Syndrome (PCOS):

  • Lifestyle modification (diet, exercise, weight loss).

  • COCs for cycle regulation and endometrial protection.

  • Metformin: 500–850 mg orally 2–3 times daily (for insulin resistance).

  • Clomiphene citrate or letrozole (for ovulation induction if fertility desired).

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5. Uterine / Outflow Tract Causes

• Asherman’s syndrome (intrauterine adhesions): Hysteroscopic adhesiolysis + estrogen therapy to promote endometrial regrowth.

• Congenital anomalies (e.g., Müllerian agenesis): Surgical correction or vaginal dilation procedures; counseling and reproductive assistance as needed.

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6. Thyroid Disorders

• Hypothyroidism: Levothyroxine replacement (starting dose ~1.6 mcg/kg/day, adjusted by TSH).

• Hyperthyroidism: Antithyroid drugs, radioiodine, or surgery depending on cause.

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Supportive Measures

• Calcium + Vitamin D supplementation to prevent osteoporosis in hypoestrogenic states.

• Psychological support for stress-related amenorrhea or infertility-related distress.

• Fertility counseling in women desiring pregnancy.