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

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Irregularities in menstruation may manifest as complete absence of menses, dysfunctional uterine bleeding, dysmenorrhea, or premenstrual syndrome. 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.

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Table 13-1. Normal Menstrual Parameters.
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Essentials of Diagnosis

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  • Primary amenorrhea: the absence of menses by 16 years of age in patient with secondary sex characteristics, or absence of menses by 13 years of age in a patient without secondary sex characteristics.
  • Secondary amenorrhea: absence of menses for at least 6 months in a woman with previously normal mense, or at least 12 months or six cycles without a period in a woman with previously irregular menses.

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General Considerations

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

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Primary Amenorrhea

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The patient with primary amenorrhea is often brought to the physician by her mother who is concerned about the patient's delay in reaching developmental milestones. 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 are gonadal dysgenesis, hypothalamic hypogonadism, and anatomic abnormality.

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Prevention

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Amenorrhea may be prevented by maintaining an appropriate body weight and treating the underlying conditions.

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Clinical Findings

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Signs and Symptoms

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Key elements of the history are listed in Table 13-2. This targeted history will help to 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. The clinician should be careful to allay patient fears, as this will often be her first pelvic examination. BMI 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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