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The attainment of ovulatory menstrual cycles is one feature of maturation and synchronization of the hypothalamic-pituitary-gonadal axis. Despite frequent anovulatory cycles, the majority of menstrual cycles during adolescence range from 21 to 42 days with duration of menstrual flow lasting 2 to 8 days. Young women frequently complain of menstrual abnormality when their cycle falls within the expected range of normal. Charting cycles on a calendar is a useful tool to evaluate cycle irregularity.1 The most common menstrual disorders in adolescents, including amenorrhea, dysfunctional uterine bleeding, and dysmenorrhea, are discussed in this section.

Amenorrhea is traditionally divided into 2 categories: primary and secondary. Primary amenorrhea is defined as either (1) the failure to menstruate by age 16 (age of expected menarche) in the presence of breast development and normal growth or (2) delayed menarche by 14 years of age in the absence of secondary sexual characteristics. Despite evidence that puberty may be occurring earlier, no revision to the definition of delayed puberty and primary amenorrhea is uniformly endorsed. When significant delay in secondary sexual development and accompanying amenorrhea is detected, prompt evaluation rather than waiting for an adolescent to meet strict criteria should occur.2,3

Secondary amenorrhea is defined as either (1) cessation of menses for more than 3 cycle intervals or 6 consecutive months in females with previous regular menses or (2) cessation of menses for more than 12 months in females with previous irregular menses.1,2 The categorization of primary and secondary amenorrhea is retained; however, the clinical approach to primary and secondary amenorrhea in the female adolescent and young adult is similar. All causes of secondary amenorrhea may also present as primary amenorrhea. Oligomenorrhea, or infrequent menses, is considered as amenorrhea in this discussion. Amenorrhea is further discussed with delayed puberty in Chapter 541.

Differential Diagnosis

Pregnancy is the most common cause of secondary amenorrhea and must not be overlooked as a potential cause of primary amenorrhea. The diagnosis of pregnancy is reviewed in Chapter 77. Beyond pregnancy, the etiology of primary and secondary amenorrhea falls into 3 categories depending on the function of the pituitary gland in relation to the ovary: hypogonadotropic gonadism, hypergonadotropic hypogonadism, and eugonadotropic eugonadism.2,3

Hypogonadotropic Hypogonadism

Hypogonadotropic hypogonadism indicates inadequate hypothalamic-pituitary stimulation of the ovary and is characterized by low levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estrogen.2 Hypothalamic amenorrhea results from partial or complete inhibition of gonadotropin-releasing hormone (GnRH) release. It may be associated with constitutional delay of puberty; nutritional deficiencies secondary to chronic diseases such as regional enteritis, cystic fibrosis, and poorly controlled diabetes; anorexia nervosa; excessive exercise and accompanying alterations in body fat and weight as found in the female athlete triad (disordered eating, amenorrhea, osteoporosis); stress; isolated GnRH deficiency; endocrinopathies such as hypothyroidism, congenital adrenal hyperplasia, and Cushing disease; ...

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