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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.

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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.

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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.

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