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Menstrual disorders are a heterogeneous group of conditions that are both physically and psychologically debilitating. Although they were once considered nuisance problems, it is now recognized that menstrual disorders take a significant toll on society, in days lost from work, as well as the pain and suffering experienced by individual women. These disorders may arise from physiologic (eg, pregnancy), pathologic (eg, stress, excessive exercise, weight loss, endocrine or structural abnormalities), or iatrogenic (eg, secondary to contraceptive use) conditions.

Irregularities in menstruation may manifest as complete absence of menses, abnormal uterine bleeding, dysmenorrhea, or premenstrual syndrome. Vaginal bleeding is addressed in Chapter 34. Since it is essential to know what is normal in order to define that which is abnormal, normal menstrual parameters are listed in Table 13–1.

Table 13–1.Normal menstrual parameters.



  • Primary amenorrhea: the absence of menses by 16 years of age in a patient with or without secondary sex characteristics, or absence of menses by 14 years of age in a patient without secondary sex characteristics, or girls without onset of period after 2 years of onset of secondary sexual characteristics.

  • Secondary amenorrhea: absence of menses for at least 3 months in a woman with previously normal menses, or fewer than nine cycles in a year in a woman with previously irregular menses.

General Considerations

Amenorrhea is a symptom, not a diagnosis, and may occur secondary to a number of endocrine, physiologic, and anatomic abnormalities. Classifying amenorrhea into primary and secondary amenorrhea can aid in evaluation and simplify diagnosis.

Primary Amenorrhea

The clinician must be sensitive to the fact that the adolescent patient may be uncomfortable discussing her sexuality, especially in the presence of a parent. The most common causes of primary amenorrhea are gonadal dysgenesis, hypothalamic hypogonadism, pituitary disease, and anatomic abnormality.

Clinical Findings

A. Signs and Symptoms

The history and physical exam are the most important steps in diagnosing primary amenorrhea. Key elements of the history are listed in Table 13–2. This targeted history will help narrow the differential and eliminate unnecessary testing. Physical examination should focus on appearance of secondary sexual characteristics and pelvic examination findings—specifically the presence or absence of a uterus. Body mass index should also be calculated and compared with prior visits to assess both for rapid weight loss or weight gain. Presence or absence of breast development and presence or absence of the uterus and ...

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