Therapy for the amenorrhea should be directed at the cause. Anovulation can be managed with either cyclic progesterone withdrawal or combined hormonal contraceptives (CHCs). In hypothalamic amenorrhea and ovarian failure, there is an associated hypoestrogenism; therapy is directed at replacing estrogen and progesterone, usually with a CHC. PCOS usually can be treated effectively with weight loss, exercise, progesterone withdrawal, or CHC. If there is evidence of androgen excess, CHCs reduce androgen production from the ovaries and increases sex hormone–binding globulin to reduce the amount of available androgen. Spironolactone helps treat hirsutism, and when there is evidence of insulin insensitivity, metformin can restore ovulatory cycles. Contraception should be prescribed, if applicable.
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Normal, ovulatory menses can occur 21 to 45 days apart, measuring from the first day of menstruation to the first day ofthe next menstruation. The average duration of flow is 3 to 7days, with more than 7 days considered prolonged. More than8 well-soaked pads or 12 tampons per day may be consideredexcessive, although classically blood loss is difficult to estimate. Table 69-1 defines menstrual disorders according to thenew International Federation of Gynecology and Obstetricsnomenclature and classification of abnormal uterine bleeding (AUB). If the menstrual problem is unclear and nonacute,observation and charting on a menstrual calendar are warranted. Excessively heavy, prolonged, or infrequent bleedingin the first year after menarche is often physiologic but shouldbe investigated, especially if there is associated iron deficiencyanemia.
Approximately 20% of adolescents with heavy or prolonged menses, especially those presenting in early menarche, have a coagulation disorder and 10% have other pathology. If an underlying pathology is discovered, treatment should be directed at the primary disorder and the secondary menstrual dysfunction.
Duration Prolonged menstrual >8 days of flow bleeding Shortened menstrual <2 days of flow bleeding
The differential diagnosis of AUB is found in Table 69-2. Anovulation is the most common etiology of AUB in adolescents. Without progesterone from the corpus luteum, unopposed estrogen causes endometrial hyperplasia and irregularendometrial shedding, which can be prolonged and heavy,sometimes life threatening. Progesterone induces a secretoryendometrium. When progesterone is withdrawn, the endometrium sheds in a synchronous fashion with myometrial and vascular contractions (causing dysmenorrhea but limiting bloodloss). For the first 1 to 2 years post-menarche, the majority ofadolescent cycles are anovulatory. After 1 year of regular cycles,irregular bleeding usually indicates an organic abnormality.
A thorough history with a menstrual calendar indicating the amount of flow and associated symptoms is followed by physical examination, including a pelvic examination in a nonvirginal adolescent or an ultrasound in a virginal adolescent. Physical examination should also assess for signs of anemia, bruising or petechia, signs of hyperandrogenism or thyroid disease. A complete blood count, pregnancy test, thyroid function tests, and coagulation screen should be performed. In sexually active adolescents, sexually transmitted infections (STIs) should be ruled out.