Treatment

The treatment of amenorrhoea is of the cause. Consider specialist referral (1).

Testicular feminisation (androgen insensitivity syndrome) requires gonadectomy to prevent the risk of malignancy with subsequent hormone replacement. The latter is also indicated in gonadal dysgenesis and uterine agenesis. These two conditions cannot be "cured" but hormone replacement may lessen their psychological impact considerably. An appropriate low dose combined oral contraceptive pill may be used.

Clomiphene is often effective in cases of polycystic ovarian syndrome but in extreme cases surgical intervention e.g. wedge resection or electrodiathermy may be needed.

In cases of hyperprolactinaemia, a repeat assay is advised as prolactin level may be raised temporarily by stress. Hyperprolactinaemia due to hypothyroidism or drugs resolves on correction of the underlying cause although in the case of phenothiazine, this may take several weeks. In other cases, bromocriptine may be necessary.

Patients with ovarian failure require oestradiol replacement up to the age of the expected menopause. Combined oestrogen and progestogen are advised in women with a uterus to ensure hormone replacement and avoid the risks of endometrial carcinoma.

If spontaneous menstruation does not resume following the attainment of a satisfactory body weight, or cessation of the pill or exercise, clomiphene citrate should be used if the patient wishes to become pregnant.

Exercise induced amenorrhoea is associated with increased risk for sequelae such as reduced bone mineral density, fractures, and dyslipidaemia. Appropriate advice on adequate calorie intake, weight gain and exercise modification should be provided. Adequate daily intake of calcium and vitamin D should be maintained to combat osteoporosis (2,3).

If the cause is uncertain and either the patient wishes to become pregnant or is anxious about the amenorrhoea, ovulation may be induced using clomiphene, pulsatile GnRH or human gonadotrophins.

Reference:

• (1) Maruthini D et al. Modern management of amenorrhoea. Trends Urol Gynaecol Sex Health 2008;13(2):24-28
• (2) Gamboa S et al. Clinical inquiries. What's the best way to manage athletes with amenorrhea? J Fam Pract. 2008 Nov;57(11):749-50.
• (3) Birch K. Female athlete triad. BMJ 2005;330(7485):244-6