L ARTICLE

Menstrual Disorders in the symptoms tend to accompany

tory cycles and, therefore,
ovula-
are more
Adolescent: Amenorrhea common in the older adolescent.
Regular ovulatory cycles usually
Margaret M. Polaneczky, MD* and Gail B. Slap, MDt are established within 1 to 2 years of
menarche. Although normal cycle
This is the first of a two-pan article about menstrual disorders in the length ranges from 21 to 45 days, the
adolescent. The second part, on dysmenorrhea and dysfunctional uterine length for a given individual is fairly
bleeding, will appear in the March 1992 issue of Pediatrics in Review. constant. Normal menstrual flow
R.J.H. lasts 2 to 7 days and usually is heavi-
est on the first and second days. The
average blood loss during a normal
menstrual period is 30 to 40 mL.
ties of the genital tract. Most impor.
FOCUS QUESTIONS tantly, any abnormality in menstru- Primary Amenorrhea
1. What is the difference between ation should alert the clinician to the
primary and secondary
Primary amenorrhea, or delayed
possibility of pregnancy.
amenorrhea? menarche, is defined as any one of
2. What are the symptoms of the following: 1) the absence of men-
hypothalamic amenorrhea and
Normal Menstrual Cycle
arche by 16 years of age in the pres-
how are they treated? The average age of menarche in the
3. What is the appropriate
ence of normal pubertal growth and
United States is 12.8 years and development; 2) the absence of men-
laboratory evaluation of secondary
amenorrhea?
ranges from 9 to 16 years. Menarche arche by 14 years of age in the ab-
4. What is the diagnostic approach to usually occurs 2 to 2.5 years after sence of normal pubertal growth and
patients who have primary breast budding and 1 year after the development; or 3) the absence of
amenorrhea? growth spurt. Consequently, the ab- menarche 2 years after completed
sence of menarche at 15 years of age sexual maturation.
may be normal in an adolescent who
The menstrual history is an integral just passed her growth spurt but ab- INITIAL EVALUATION
part of the evaluation of the adoles. normal in an adolescent who com- A complete history and physical ex-
cent female. Abnormal menstrual pleted puberty 2 years earlier. Most amination is the most important step
flow or timing may be the first sign early menstrual cycles are anovula. in evaluating the adolescent who has
of systemic illness or sexually trans- tory. As a result, menses in the primary amenorrhea. Particular atten-
mitted disease. Amenorrhea may sig- young adolescent often are irregular tion should be focused on pubertal
nal an endocrine or genetic disorder and may be prolonged or heavy. milestones. The history should in-
or may suggest structural abnormali- Dysmenorrhea and premenstrual elude questioning about maternal age

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Pediatrics is accredited by the the American Academy of credit on the 1992 annual credit
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Pediatrics iii Review Vol. 13 No. 2 Februa,y 1992 43

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 ADOLESCENT

at menarche,
Menstrual

gestational
MEDICHIE
Disorders

complica- ify the degree of estrogen stim- mal steroid production from those
J
tions and medications, childhood de- ulation. Bimanual examination, who have hypothalamic or pituitary
velopment, chronic systemic illness, followed by ultrasonographic exami- disorders. Chromosomal analysis is
nutrition, and family history of ge- nation of the pelvis, if necessary, indicated when FSH and LH levels
netic anomalies. Physical examina- will establish the presence or absence are high.
tion should be meticulous and of a uterus and ovaries. Gonadal dysgenesis is the most
include charting of height, weight, common cause of primary amenor-
and sexual maturation rating; com- DIFFERENTIAL DIAGNOSIS AND rhea. It usually is due to Turner syn-
MANAGEMENT
plete neurologic examination, includ- drome (45,XO kaiyotype) or some
ing the cranial nerves; examination Patients who have primary amenor- other abnormality in X chromosome
of the skin, hair, and genitalia for rhea can be divided into four groups, structure or number. The ovaries fail
signs of hirsutism or virilization; pal- depending on pubertal maturation and to develop, leaving remnant fibrous
pation of the thyroid; and palpation internal genitalia (Figure 1). bands called gonadal streaks. Patients
of the abdomen and groin for who have gonadal dysgenesis are
No breast development-Intact uterus
masses. sexually immature, amenorrheic, and
Pelvic examination, if done in a These individuals lack ovarian estro- have high FSH and LH levels (hyper-
sensitive manner, need not be a trau- gen but have normal development of gonadotropic hypogonadism). Indi-
matic experience. At absolute mini- the Mullerian system during fetal viduals who have Turner syndrome
mum, a careful examination of the life. The differential diagnosis in- often have other stigmata, such as
external genitalia must be performed. cludes gonadal dysgenesis, hypothal- short stature, webbed neck, or chest
Use of the speculum should be pre- amic-pituitary disorder, and genetic and limb abnormalities. Patients who
ceded by digital vaginal examination defects in ovarian steroid production. have mosaic Turner syndrome or
to avoid injuring the patient with an Measurement of the serum levels of other X chromosome abnormalities
absent vagina or an outflow obstruc- follicle stimulating hormone (FSH) may be phenotypically normal except
tion. If a normal vagina and cervix and luteinizing hormone (LH) will for sexual immaturity.
are present, microscopic examination differentiate patients who have gona- Gonadal dysgenesis also may oc-
of the cervical mucus may help clar- dal (ovarian) dysgenesis and abnor- cur in individuals who have normal

Breasts (-)
Breasts (-)
Uterus (+)
Uterus (-)

Follicle Stimulating Hormone (FSH)

Karoytype (XY)

High

Hypogonadotropic
Lesions
T hypogonadism
of the central nervous system
Gonadal
45,XO
I
dysgenesis
(Turner syndrome)
Gonadal enzyme deficiency Agonadism
(testicular regression)

Kailman syndrome Other X chromosome variants

Pituitary gonadotropic deficiencies Pure XX or XY
(eg, chronic disease, anorexia nervosa) gonadal dygenesis Breasts (+)
Gonadal enzyme deficiency

Breasts (+)
Uterus (-) Uterus (+)

TestosteronelKaryotype Cyclic pain

Female Male Present Absent

Mullerian
ti agenesis Androgen
insensitivity (testicular obstruction
Rule
ft
out vaginal
(eg, imperforate
outlet
hymen,
Hypothalmic-pituitary-ovarian
disturbance
1
(evaluate as
axis

feminization) transverse vaginal septum) secondary amenorrhea)

FIGURE 1. Diagnostic approach to patients who have primaty amenorrhea. Adapted from Maschak CA, Kletzky OA, Davajan V. Mishell DR
Jr. Clinical and laboratoty evaluation of patients with primaty amenorrhea. Obstet Gynecol. 1981;5 7: 71 9. Reprinted with pennission from the
American College of Obstetrics and Gynecology.

44 Pediatrics in Review Vol. 13 No. 2 February 1992

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 ----=

ADOLESCENT MEDICINE
Menstrual Disorders

Hauser syndrome). These patients are

Any abnormality in menstruation chromosomally and phenotypically
female but have anomalous develop-
should alert the clinician to the ment of the Mullerian
sequently,
system.
the vagina and uterus fail
Con-

possibility of pregnancy. to develop

present;
normally.
breast development,
Ovaries are
steroid
production, axillary hair, and pubic
hair are normal. Renal anomalies oc-
karyotypes. Genetic males and fe- duction resulting in hypertension and cur in 15% to 40% of patients, and
males who have gonadal dysgenesis hypokalemia. The diagnosis should skeletal abnormalities occur in 12%.
will be phenotypically female be- be considered in patients who have Cardiac and other congenital abnor-
cause, in the absence of testosterone, hypergonadotropic hypogonadism, malities also are increased in fre-
gender development is female. In the normal female karyotypes, and nor- quency. Chromosomal studies should
genetic male, the gonadal streaks mal female genitalia. be performed to confirm the normal
must be removed because of the risk xx chromosomal complement and to
of malignancy. Normal breast development-Absent exclude rare forms of incomplete
Individuals who have gonadal dys- uterus
androgen insensitivity or pseudoher-
genesis are almost universally sterile, Individuals in this category are phe- maphroditism. Once the diagnosis is
and hormonal replacement should be notypically female. Pelvic examina- made, a functioning vagina usually
initiated during early adolescence. tion, however, reveals an absent or can be created by the use of vaginal
However, these patients do have in- shortened vagina and an absent dilators or by vaginoplasty. Hor-
tact uteri and may be able to bear uterus. The diagnosis at this point is monal therapy is not necessary.
children after donor oocyte implanta- either androgen insensitivity (testicu-
No breast development-Absent uterus
tion and hormonal support. lar feminization) or Mullerian
Patients who have primary amen- agenesis. This rare combination occurs in ge-
orrhea due to hypogonadotropic hy- Patients who have testicular femin- netic males (XY) whose gonads pro-
pogonadism have normal ovaries but ization are chromosomally male (XY) duce Mullerian inhibiting factor but
lack hypothalamic or pituitary stim- and have normal male gonads that insufficient testosterone to induce the
ulation of the ovaries. FSH and LH produce normal male levels of testos- development of male internal and ex-
levels will be low or low-normal. terone, yet they appear phenotypi- ternal genitalia. Phenotypic gender,
These patients are genetically and cally female. This is due to a genetic therefore, is female. The lack of tes-
phenotypically female but are sex- X-linked defect in androgen-receptor tosterone is due to a gonadal enzyme
ually immature. Care must be taken function with resultant end-organ in- deficiency or to early gonadal regres-
to exclude both tumors of the central sensitivity to androgen. The Wolifian sion (vanishing testes). Laboratory
nervous system (CNS) and congenital ducts fail to develop, and the exter- evaluation reveals a male karyotype,
defects in the production of gonado- nal genitalia develop as female in the low androgen levels, and high gonad-
tropin releasing hormone (GnRH). absence of testosterone stimulation. otropin levels. Treatment includes
The most common CNS tumors pro- Because the male gonad is still able surgical removal of the gonads and
ducing primary amenorrhea are pitui- to produce Mullerian inhibiting fac- estrogen replacement.
tary adenomas and tor, the Mullerian ducts regress and Normal breast development-Intact
craniopharyngiomas. Hypothalamic female internal genitalia do not de- uterus
defects in GnRH production may oc- velop. Internally, these individuals Individuals in this category are phe-
cur as the result of abnormal hypo- have normal male gonads and fibrous notypically normal females who
thalamic development. When this Mullerian remnants. The low levels undergo normal Mullerian develop-
occurs in association with anosmia of endogenous gonadal and adrenal ment and normal pubertal progres-
and facial abnormalities, it is called estrogens, unopposed by androgen, sion. They can be presumed to have
Kallmann syndrome. Hypogonado- result in breast development. Because normal female kaiyotypes. The
tropic hypogonadism also may be as- of target end-organ androgen insensi- causes of the amenorrhea include va-
sociated with systemic disease, tivity, axillary and pubic hair is ginal outlet obstruction (eg, imperfor-
exercise, psychological stress, or an- sparse or absent. Confirmatory labo- ate hymen, transverse vaginal
orexia nervosa. (These diagnoses are ratory studies include male levels of septum) and disturbances in the hy-
discussed in detail in the section on serum testosterone and male chromo- pothalamic-pituitary-ovarian axis.
secondary amenorrhea.) somes. The gonads, which may be The management of patients in this
Abnormal steroidogenesis due to either intraabdominal or inguinal, latter group is identical to that of pa-
17-aipha-hydroxylase deficiency is a should be removed because there is a tients who have secondary amenor-
rare disorder that results in the inabil- 20% incidence of malignancy. Estro- rhea.
ity of the ovary to produce estrogen. gen replacement should be initiated
It occurs in chromosomally normal following surgery. Secondary Amenorrhea
females with structurally normal ova- Approximately 15% of cases of Secondary amenorrhea is defined as
ries and uterus. These patients also primary amenorrhea are due to Mul- the absence of menstruation for at
have a defect in adrenal steroid pro- lerian agenesis (Rokintansky-Kuster- least three cycles or at least 6 months

Pediatrics in Review Vol. 13 No. 2 February 1992 45

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 ADOLESCENT MEDICINE
Menstrual DIsorders

in females who have already estab- amenorrhea focuses on the hypothala- ing, weight fluctuation, bowel habits,
lished menstruation. Although men- mic-pituitary-ovarian axis. This be- exercise, medication and drug use,
ses often are irregular in young gins with a complete history and headache, visual change, and galac-
adolescents, they should stabilize physical examination (Figure 2). torrhea. Family history of menstrual
within 1 to 2 years of menarche. irregularities, eating disorders, diabe-
Amenorrhea occurring more than 18 INITIAL EVALUATION tes, and thyroid disease also may be
months after menarche should be Maintenance of normal menses re- helpful.
considered abnormal and warrants quires adequate body fat composi- The physical examination should
investigation. tion. Because weight loss or failure begin with measurement of height
Pregnancy always must be in- to gain weight is a common sign of and weight and an assessment of
cluded in the differential diagnosis of illness during adolescence, secondary body habitus. Common stigmata of
secondary amenorrhea. Sensitive amenorrhea may be an indication of anorexia nervosa include cachexia,
questioning need not imply inherent poor nutrition, stress, or systemic ill- lanugo, parotid enlargement, brady-
distrust or disbelief of the adolescent ness. Common diseases presenting cardia, hypotension, and hypother-
who denies sexual activity. Instead, during adolescence that may be asso- mia. Fundoscopic examination, gross
it acknowledges the strong sociocul- ciated with secondary amenorrhea in- visual fields, and examination of the
tural pressures that may lead an ado- clude anorexia nervosa, inflammatory cranial nerves should be done as part
lescent to give an inaccurate sexual bowel disease, diabetes mellitus, thy- of an initial screening for a pituitary
history. roid disease, and pituitary adenomas. lesion. Breast examination should in-
Once pregnancy has been ex- The history,therefore,should include clude an attempt to elicit galactor-
cluded, evaluation of secondary questioning about caloric intake, diet- rhea. If light microscopy of the

Rule out
Ashermann
syndrome

Abnormal

Lesion of1
I central nervous
system

FIGURE 2. Evaluation of secondary amenorrhea. CT, computed tomography; DHEA-S, dehydroepiandrosterone sulfate; LH, luteinizing
hormone; MRI, magnetic resonance imaging; TEST, testosterone; TSH, thyroid stimulating hormone. Modified from Speroff L, Glass RH,
Kase NG. Clinical Gynecologic Endocrinology and Infertility. 4th ed. Baltimore, MD: Williams and Wilkins; 1989:178

46 Pediatrics in Review Vol. 13 No. 2 February 1992

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 ADOLESCENT MEDICINE
Menstrual Disorders

expressed fluid reveals fat lobules, it

confirms that the discharge is breast Menses often are irregular during
milk and suggests stimulation of the
breast by high prolactin levels. The early adolescence but should
hair, skin, and external genitalia
should be inspected for evidence of stabilize within 2 years of
androgen excess (eg, hirsutism, clito-
romegaly, male escutcheon). The ab- menarche.
domen should be palpated for ten-
derness, masses, or signs of preg-
nancy. A rectal examination for fis- norrhea includes polycystic ovarian secondary amenorrhea is variable in
sures, fistulae, skin tags, or occult syndrome (PCOS), ovarian tumors, its onset and duration.
blood also should be done. congenital adrenal hyperplasia (C-21 The fundamental defect character-
On pelvic examination, the vaginal hydroxylase deficiency), adrenal tu- izing PCOS probably is not located
mucosa and cervical mucus may help mors, and Cushing syndrome. in the ovary. Instead, it is probably
define the degree of estrogen stim- DHEA-S levels > 700 ng/mL and tes- the result of inappropriate signals
ulation. Estrogenic mucus is clear, tosterone levels > 90 p.g/mL require along the hypothalamic-pituitary-
watery, distensible, and reveals fern- further investigation. This may in- ovarian axis. It has been suggested
ing on light microscopy. Bimanual dude measurement of a serum 17- that exaggerated adrenarche and
and rectovaginal examination should hydroxyprogesterone level, adrenal obesity, resulting in high levels of
be done in all patients presenting suppression testing, and computed to- extraglandular estrogen, lead to pos-
with unexplained secondary amenor- mography or magnetic resonance im- itive feedback on LH secretion and
rhea to evaluate uterine and ovarian aging of the abdomen and pelvis. negative feedback on FSH secretion.
size and to screen for pelvic masses. This is reflected in a high LH-to-FSH
The minimum laboratory evalua- PROGESTERONE CHALLENGE ratio ( > 2). The elevated LH level
tion of secondary amenorrhea in- leads to hyperplasia of the ovarian
After excluding pregnancy, hypothy-
cludes a pregnancy test (serum or stroma and theca cells and increased
roidism, and pituitary adenoma as the
urine level of human chorionic go- ovarian production of androgens. Pe-
cause of secondary amenorrhea, the
nadotropin), thyroid function studies, ripheral aromatization of the andro-
next step in the evaluation is admin-
and serum prolactin level. Prolactin gens to estrogens then perpetuate the
istration of a progesterone challenge.
should be measured even in the ab- anovulation.
The purpose of this is twofold. First,
sence of galactorrhea because only Treatment of PCOS attempts to in-
withdrawal bleeding following expo-
one third of patients who have ele- terrupt this cycle. Use of a combined
sure to exogenous progesterone es-
vated levels will have galactorrhea. It estrogen-progestin oral contraceptive
tablishes the presence of a normal
is estimated that 5% to 10% of pa- helps control hirsutism, regulates
uterus. Second, withdrawal bleeding
tients who have both amenorrhea and menses, and is well-tolerated by most
indicates that the endometrium has
elevated serum prolactin levels have adolescents. Although a strong oral
been primed by endogenous estrogen
pituitary adenomas, while 25% of progestin formulation (ie, levonorges-
and, thus, implies ovarian function.
those with amenorrhea, galactorrhea, trol) is useful in controlling dysfunc-
Oral medroxyprogesterone acetate is
and high prolactin levels have adeno- tional uterine bleeding, a lower
administered in a dose of 5 to 10 mg
mas. It should be remembered that strength, nonandrogenic progestin
daily for 5 to 10 days. If compliance
mild elevations in the serum prolactin formulation (ie, norothindrone)
is of concern, 200 mg of progester-
level usually are due to medication, should be considered for long-term
one suspended in oil can be given as
breast stimulation, stress, hypothy- use in the hirsute patient. If the ado-
a single intramuscular injection.
roidism (due to stimulation of the pi- lescent prefers not to use an oral con-
tuitary by thyroid releasing traceptive, progesterone should be
Positive withdrawal bleeding
hormone), or other extraneous fac- administered every 3 months in the
tors. The first elevation should be The occurrence of bleeding, however absence of spontaneous menses to
evaluated by comparison with a sec- minimal, 2 to 7 days after concluding protect against the long-term risk of
ond sample drawn in a relaxed, fast- the progesterone regimen constitutes endometrial hyperplasia.
ing state. Persistently high prolactin positive withdrawal bleeding and es- The hirsutism associated with
levels (>100 ng/mL) are associated tablishes the presence of anovulation. PCOS also may respond to anti-an-
with tumors and mandate radiologic The most common cause of anovula- drogens such as spironolactone. The
evaluation of the pituitary via com- tion in a postmenarchal adolescent is effectiveness of spironolactone is re-
puted tomography or magnetic reso- PCOS. This disorder is characterized lated to dosage. An initial dose of
nance imaging. by amenorrhea or oligomenorrhea, 150 to 200 mg daily is recom-
If the physical examination reveals hirsutism, infertility, and often obes- mended, with subsequent tapering to
signs of androgen excess, serum lev- ity. When spontaneous bleeding oc- a maintenance dose of 25 to 50 mg.
els of dehydroepiandrosterone sulfate curs in association with PCOS, it Oral contraceptives containing ges-
(DHEA-S) and testosterone should be tends to be unpredictable and often is todene and norgestimate are expected
measured. The differential diagnosis prolonged or heavy (ie, dysfunctional to be approved by the FDA in 1992.
of hirsutism-virilization and oligome- uterine bleeding). Oligomenorrhea or These nonandrogenic, potent proges-

Pediatrics in Review Vol. 13 No. 2 February 1992 47

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r ADOLESCENT
Menstrual
MEDICINE
Disorders
L
tins may prove to be the optimal for- vated beta-endorphin levels. Short- SUGGESTED READING
mulation for the hirsute patient with term treatment includes reassurance, American College of Obstetrics and
PCO. counseling, and watchful waiting. If Gynecology. Amenorrhea. Technical
Bulletin. 1989;128:1-7
the amenorrhea persists, estrogen re-
Negative withdrawal bleeding Chihul Hi, London SN. Menstrual cycle
placement is indicated. This is best disorders. Obstet Gynecol Clin North Am.
If the patient fails to bleed after the accomplished with a combined estro- 1990;17:275-481
progestin challenge, either the uterus gen-progestin oral contraceptive. An Coupey SM. Common menstrual disorders.
is abnormal or there has been insuffi- alternative regimen for the adolescent Pediatr Clin North Am. 1989;36:551-571
Droegemueller W, Herbst AL, Mishell DR,
cient endogenous estrogen to prime who is not sexually active is a conju- Stenchever MA. Comprehensive
the endometrium. A combined oral gated estrogen (0.625 to 1 .25 mg Gynecology. 1st ed. St. Louis, MO: CV
estrogen-progestin regimen should re- daily on days 1 to 25) and medroxy- Mosby Co; 1987
sult in bleeding if the endometrium is progesterone acetate (10 mg daily on Emans SJH, Goldstein DP. Pediatric and
Adolescent Gynecology. 3rd ed. Boston,
normal. days 16 to 25). Menses usually oc-
MA: Little, Brown and Company; 1990
If no bleeding occurs after the es- curs at the end of each cycle. Farber M, ed. Congenital anomalies of the
trogen-progestin regimen, Asherman Exercise-induced amenorrhea prob- paramesonephric ducts. Semin Repro
syndrome may have occurred as a re- ably is due to a complex interplay of Endocrinol. 1986;4:1-73
sult of uterine instrumentation, decreased body fat and stress. Ath- Herzog DB, Copeland PM. Eating disorders.
N Engi J Med. 1985 ;313:295-303
trauma, or infection. The resulting letes who have body fat below the Mansfield Mi, Emans Si. Anorexia nervosa,
formation of intrauterine scarring tenth percentile for age are likely to athletics, and amenorrhea. Pediatr Clin
(synechiae) causes amenorrhea. develop amenorrhea. High-energy North Am. 1989;36:533-549
In the adolescent who has a nor- output and stress may act indepen- Maschchak CA, Kletzky OA, Davajan V.
Mishell DR. Clinical and laboratory
mal vagina and uterus and no risk dently of body fat in inducing amen-
evaluation of patients with primary
factors for intrauterine scarring, the orrhea because menses often return amenorrhea. Obstet GynecoL 1981;57:715-
estrogen-progestin challenge can be during nontraining intervals, even 721
eliminated and a hypoestrogenic state when body fat remains unchanged. Shangold MM. Causes, evaluation and
can be presumed to exist. Serum go- Elevated prolactin levels also have management of athletic olig-/amenorrhea.
Med Clin North Am. 1985 ;69:83-95
nadotropin levels then should be been observed in some amenorrheic Speroff L, Glass RH, Kase NG. Clinical
measured. High serum levels of go- athletes during peroids of intense ex- Gynecologic Endocrinology and Infertility.
nadotropins (FSH and LH) indicate ercise. The simplest way to treat ex- 4th ed. Baltimore, MD: Williams and
ovarian failure (hypergonadotropic ercise-induced amenorrhea is to Wilkins; 1989
hypogonadism). Karyotype testing decrease the amount of exercise. If
should be performed on patients with the amenorrhea persists, estrogen Asssstant Professor of Obstetrics-Gynecology,

presumed ovarian failure to rule out replacement therapy should be University of Pennsylvania School of Medi-
cute.
Turner mosaicism or other chromo- instituted.
somal abnormalities. The presence of Anorexia nervosa is a special case tAssociate Professor of Medicine and Pediat-
rics, University of Pennsylvania School of
any portion of a Y chromosome man- of hypothalamic amenorrhea. Al- Medicine, and Director, Craig-Dulcimer Pro-
dates gonadectomy to eliminate the though the mechanisms of amenor- grunt in Adolescent Medicine, Hospital of the
risk of malignant transformation of rhea are similar to those of exercise- University of Pennsylvania, Childrens Hospi-
the gonad. Ovarian failure also may induced amenorrhea (ie, low body tal of Philadelphia.

result from autoimmune disease, fat, stress, beta-endorphin release), Correspondence and reprint requests should be
chemotherapy, or radiation. the complex psychological and mcdi- addressed to Dr Polaneczky, Department of
Obstetrics and Gynecology, University of
Low serum levels of gonadotropins cal problems associated with anorexia Pennsylvania, 5 Penn Tower, 34th Street and
point to a defect in the hypothalamus nervosa are difficult to manage. A Civic Center Boulevard Philadelpia, PA 19104-
or pituitary (hypogonadotropic hypo- team approach employing psychiatric 4283.
gonadism or hypothalamic amenor- counseling, close medical supervi-
rhea). Although the incidence of sion, nutritional consultation, and
pituitary tumors is low in the absence hormonal replacement provides the
of galactorrhea or an elevated serum best outcome.
prolactin, radiologic evaluation There is increasing evidence that
should be considered in cases where osteoporosis associated with chronic
no obvious cause for hypothalamic estrogen deficiency may begin during
dysfunction can be found. Hypothala- the adolescent years. For this reason,
mic amenorrhea comprises a hetero- estrogen replacement therapy should
geneous group of disorders as not be delayed until adulthood in the
discussed previously, including sys- patient who has well-established hy-
temic illness, anorexia nervosa, exer- pogonadism. Progesterone should be
cise-induced amenorrhea, and administered with the estrogen to
stressful situations (eg, going away minimize the risk of endometrial car-
to school). It is believed that stress cinoma. When such a combined regi-
leads to alterations in hypothalamic men is used, the benefits appear to
GnRh secretion, possibly due to ele- far outweigh the risks.

48 Pediatrics in Review VoL 13 No. 2 February 1992

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 Menstrual Disorders in the Adolescent: Amenorrhea
Margaret M. Polaneczky and Gail B. Slap
Pediatrics in Review 1992;13;43
DOI: 10.1542/pir.13-2-43

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 Menstrual Disorders in the Adolescent: Amenorrhea
Margaret M. Polaneczky and Gail B. Slap
Pediatrics in Review 1992;13;43
DOI: 10.1542/pir.13-2-43

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pedsinreview.aappublications.org/content/13/2/43

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and
trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove
Village, Illinois, 60007. Copyright 1992 by the American Academy of Pediatrics. All rights reserved.
Print ISSN: 0191-9601.

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