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Evaluation and management of a patient with amenorrhea is common in gynecology. Specifically, the prevalence of pathologic amenorrhea ranges from 3 to 4 percent in reproductive-aged populations (Bachmann, 1982; Pettersson, 1973). Amenorrhea has classically been defined as primary (no prior menses) or secondary (cessation of menses). Although this distinction does suggest a relative likelihood of finding a particular diagnosis, the approach to diagnosis and treatment is similar for either presentation (Tables 16-1 and 16-2). Of course, amenorrhea is a normal state prior to puberty, during pregnancy and lactation, with certain hormonal medications such as continuous administration of combination oral contraceptives (COCs), and following menopause. Evaluation is considered for an adolescent: (1) who by age 13 has not menstruated or shown other evidence of pubertal development, or (2) who has reached other pubertal milestones but has not menstruated by age 15 or within 3 years of thelarche (American College of Obstetrician and Gynecologists, 2009). Secondary amenorrhea for 3 months or oligomenorrhea involving fewer than nine cycles a year is also investigated (American Society for Reproductive Medicine, 2008). In some circumstances, testing 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 is also considered before the ages listed above if the patient or her parents are concerned.

TABLE 16-1Primary Amenorrhea: Frequency of Etiologies
TABLE 16-2aSecondary Amenorrhea: Frequency of Etiologiesa

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