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Evaluation and management of a patient with amenorrhea is common in gynecology, and the prevalence of pathologic amenorrhea ranges from 3 to 4 percent in reproductive-aged populations (Bachmann, 1982; Pettersson, 1973). Amenorrhea is diagnosed in a female: (1) who has not menstruated by age 14 years and who lacks other evidence of pubertal development; (2) who has not menstruated by age 16, even in the presence of other pubertal signs; or (3) who has previously menstruated but has been without menses for a time equivalent to a total of three previous cycles or 6 months. Although amenorrhea has classically been defined as primary (no prior menses) or secondary (cessation of menses), this distinction may lead to diagnostic error and should be avoided.

In some circumstances, evaluation reasonably may be initiated despite the absence of these strict criteria. Examples include a patient with the stigmata of Turner syndrome, obvious virilization, or a history of uterine curettage. An evaluation for delayed puberty should also be considered before the ages just listed if the patient or her parents are concerned.

Although the list of possible etiologies is extensive, most causes will fall into a limited number of categories (Tables 16-1 and 16-2). Of course, amenorrhea is a normal state prior to puberty, during pregnancy and lactation, and following the menopause.

Table 16-1. Primary Amenorrhea: Frequency of Etiologies
Table 16-2. Secondary Amenorrhea: Frequency of Etiologiesa

A differential diagnosis for amenorrhea can be developed based on requirements for normal menses. Generation of a cyclic, controlled pattern of uterine ...

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