Amenorrhea in adolescents

Amenorrhea in the adolescent population is of great importance because this is the time in the female life cycle when peak bone mass is achieved. The cause of amenor-rhea and appropriate treatment must be identified promptly in this population because hypoestrogenism contributes negatively to bone development. Estrogen replacement, typically via an OC, is important. In addition, ensuring that the patient is receiving adequate amounts of calcium and vitamin D is imperative.

Table 49-2 Therapeutic Agents for Selected Menstrual Disorders

Specific Menstrual n ¡iDTric n i)

Agr jirtst

Cm»r Hfltnm mended

Common Adifc™ Effrcti

Anienoi rliea Ipiinsy CEE or secondly!

Amcnon hra fceoonctaryh

Amenorrhea hypefpiofecimemla

ArcmjUlwy blwdin^

Etysinervsrlwa bthinyl -G-slr^Kdiol patch Combination ÛC Oil MR*

Biotnoci (Kins

ComtiirMtion OC

Combinai ion OC

Depo MPA USvunoittiStrel iuty-' NiAIDt—any us acceptable Ihe moil commonly jtmJusl/citrd .hp inchjdnd in thri Ml*.'

iitiîi-l.ïi ring by mouih daily on dayi 1-ffiDÎtfenrfi*1

50irtg/î4 l'ouït 3(M0 ^lcgfaí^HJlaloni, S 10 my byrrmulliyn d^yi 14 iSolthc cycle"

Oplirndl Joie unknown' frit aculc l^idirig, (icOutTCOnHinii^) nyr'i eiTiinytesirAdinl; takeon^ iabli?i by mouih l y. clailyx I wpA: then oik1 tablet by mauih dally * Iweefci" fi* O^Ulf tjklxJilig. 20 rri(j Yrf ninu'h 3 v Lkiily y t wetHt; [hen 10 irtj by mouih once dally X i wflek-;1, LtSjthjnÎj meg-fcf irulariof« i> nutyriticl or tCvOnwyfirrtl'^uit of ««ended-qvta tamiiljiaorri w*

IvivFe'i.jI foi thi*. indication ISO mg intramusciilarly evEfy 12 weaki 20 rtttiJiitMiiiidtliily Diclofenac 50 rrg by mouth 3 x daily ibuptolen 800 mg by muulh i x dally Mt^eitjmiC idd SCO roQ by rH^irth ij ,1 loading dc«e. then 250 mg by mouth, up to -1 x daily as reeded1' NdpttMun BO mg kidding dose try roulli l-2<Jiyit»kjr lu nx-niti, iuflOivLVi by 275 mg try mtOMlh evei y fi-li hours «needed" Itaimeni ihoukJ begirt l ? tiiyi prior to (ht luvefttdonKi of i^n«;"

Ihioirinynityjlrj-i, lïuun enlagenvom, bf=as.r tartanes, bbafcnç, nausea Gl upwL httKtatfie, pruf^vi^lftlrii^s

[denu. jrnjfl.'iikj.dl.'pn.'i^kjn. inMnniLi weiijhi galnor toss, Incieav* in wium total and LDL cMcili-tol. rrny rcdjot HIXihok.'Mi.-nLiI Hypertension. nausea eonitipalio^

Av iwt«J dtow la< C£t, rtKinyl liiii.-KloL JrxJit>mDiniliOH OC (riifiii^tpione '.ide filer ti with rlie OC. depend an agent ihmen)

Ai not«! above lot CEE, ethinyl r.'illjrlijl. :ir-(J iuiillliriiljiiln Ot (pfogeiiaw it jide flfftc rs with the

C£ depend on agent ihmen} Irregular inenseii amenorrhea Hfiifilir il'«'®, anienoffh« Gl upMt. st-nrnjch ukEf. nausea voniitmgt hefiittuia mdigetlion. lash, di/iirww-


PCOS-related amenorrhea and/ or anovulatory Weeding

Combination OC LewnorgotxH WD MPA (oral)



Depo MPA MPA (oral) Metformin


Optimal dose unknown 20 meg ««Heoyrvl

5-10 mg by mouth on days 5-26of the cycle ot<iurmg the luteal phase'' Doses as recommended for above; therapy should be initiated with the onset of menses" 50 mg by mouth daily x 5 days starting 3-5 days after the start of menses; doses up to 100 mg by mouth daily have been used in signrflcantty obese patients 150 mg intramuscularly every 12 weeks 10 mg by mouth x 10 days' t.500-2,000 mg by mouth daily in 2-3

dwded doses' FNoglltazone 15-45 mg by mouth daily, rosiglitaKXK* 4-8 mg by mouth daily

As noted above As rioted olXr.C As noted above

As noted above

Hot flashes, ovarian enlargement, thromboembolism, blurred vision, breast discomfort

As noted above As noted above

Anorexia, nausea, vomiting, diarrhea.

flatulence, lactic acidosis Weight gala increase m total. IDL and HDL cholesterol: edema; headache: fatigue; l>epatic injury (rare)

CEE. conjugated equine estrogerv HDL high-density lipoprotein: IUD, intrauterine device IDL low--density lipoprotein OC oral contraceptive: NSAIDs. nonsteroidal anti inflammatory drugs: MPA. medroxyprogesterone acetate.

From Roft 7 Q_M

j1Ragardlassof cause, adequate calcium and vitamin D intake must be ensured. FIGURE 49-3. Treatment algorithm for amenorrhea.

Patient Encounter 1, Part 2 Additional Workup of JK Reveals: PMH: Seasonal allergic rhinitis PSH: None

FH: Mother and father are alive and well. She has two younger siblings (ages 12 and 15) who are alive and well

SH: The patient works part-time as a waitress. She has participated in cross-country running throughout high school and now into college. She denies smoking cigarettes or drinking alcohol.

Meds: Loratadine 10 mg daily

Past Gynecologic Hx: Never pregnant and never on contraception; (-) history of abnormal pap smears; (-) history of sexually transmitted infections; (+) history of irregular menses each year during track season

ROS: (-) restrictive eating patterns or self-induced vomiting; (-) galactorrhea, headaches, change in vision; (-) abnormal hair growth; (-) acne

Gen: Thin appearing African American female, no acute distress VS: BP 118/62, P 74, RR 16, wt 56 kg (123 lb), ht 5'6" (168 cm), BMI: 19.9 kg/m2 HEENT: (-) hirsutism Breasts: (-) galactorrhea

Pelvic: Normal appearance of external genitalia and vagina, cervix without lesions, uterus midposition without masses, adnexa without masses


Urine HCG: Negative

TSH: 1.8 pIU/mL (1.8 mlU/L) (within normal limits) Prolactin: 10 ng/mL (10 mcg/L) (within normal limits) Progesterone challenge: No withdrawal bleeding FSH: 7.4 mlU/mL or mU/mL (7.4 U/L) (within normal limits) LH: 0.4 mlU/mL or mU/mL (0.4 U/L) (within normal limits) Head MRI: Normal

Given this information what is your assessment of this patient's condition? Identify your treatment goals for this patient.

What therapeutic options exist for this patient? Identify those that would be most appropriate.

What monitoring parameters are necessary to employ in assessing efficacy and safety of the therapeutic options?

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