Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Amenorrhea
N91.2 – Amenorrhea, unspecified
I. DEFINITION
a. Primary amenorrhea: failure of the menses to occur by age 15
B. secondary amenorrhea: cessation of the menses for longer than 6 months in a woman who has established menses at least 1 year after menarche
II. ETIOLOGY
a. Primary amenorrhea
1. Gonadal failure
2. Congenital absence of uterus and vagina
3. Constitutional delay
B. secondary amenorrhea
1. Pregnancy, breastfeeding
2. Pituitary disease or tumor, disruption of hypothalamic-pituitary axis
3. Menopause
4. too little body fat (about 22% required for menses)
5. excessive exercise (e.g., long-distance running, ballet dancing, gymnastics, figure skating)
6. rapid weight loss
7. Following use of hormonal contraception
8. recent change in lifestyle (e.g., increase in stress, travel)
9. thyroid disease
10. Polycystic ovary syndrome
11. anorexia nervosa or other eating disorders
12. Premature ovarian failure, ovarian dysgenesis, infection, hemor- rhage, necrosis, neoplasm
13. asherman’s syndrome
14. Cervical stenosis—outflow tract anomaly
15. Medications, including psychotropics
16. Chronic illness
17. tuberculosis (tB)
III. HISTORY
a. What the patient presents with
1. absence of menstruation
2. Possible breast discharge
3. other symptoms secondary to underlying etiology
B. additional information to be considered
1. Careful menstrual history, pregnancy history
2. sexual history
3. Contraceptive history
4. Medications—over the counter (otC), prescription, homeopathic, herbal
5. sources of emotional stress
6. symptoms of climacteric
7. any current acute illness
8. History of chronic illness
9. Present weight, weight 1 year ago
10. amount of daily exercise
11. recent D&C or abortion
12. History of tuberculosis
13. eating disorder—current or history of
aMenorrHea 183
IV. PHYSICAL EXAMINATION
a. Weigh patient
B. neck: thyroid gland (look for nodes: palpable, enlarged)
C. Breast: discharge
1. Breast examination
2. Milky, clear, dark, light, bloody, thick, thin, color
D. Vaginal examination (speculum): Vagina may be atrophic, and there may be no cervical mucus.
e. Bimanual examination
1. uterus: may be enlarged
2. Cervix: scarring, stenosis
3. adnexa: ovaries may be enlarged—cystic
4. rectovaginal examination
F. Measure ratio of body fat to lean mass, body mass index (BMi)
V. LABORATORY EXAMINATION
(May include)
a. hCG qualitative, quantitative
B. Prolactin level
C. thyroid-stimulating hormone
D. FsH, lH, dehydroepiandrosterone sulfate (DHeas), and serum tes- tosterone (if patient is hirsute); hemoglobin, erythrocyte sedimenta- tion rate
e. Pap smear
F. Microscopic examination of cervical mucus
G. tB test if no history
H. Consider pituitary function assessment, GnrH stimulation test, ultra- sound, Ct scan, Mri, hysterosalpingography, hysteroscopy after con- sultation with a physician
VI. DIFFERENTIAL DIAGNOSIS
See Etiology, II.
VII. TREATMENT
a. if breast discharge is present, do not wait: do workup per breast dis- charge protocol.
B. if hCG and prolactin levels are within normal limits, pregnancy test is negative—may use a progesterone preparation: Prometrium, Provera, aygestin
1. if no withdrawal bleeding in 3 to 7 days after progestin, consider FsH and lH assays 2 weeks after Provera. try oral estrogen 1.25 to 2.5 mg to prime the endometrium (estropipate) daily for 21 to 25 days; if no bleeding, add progestin during last 5 to 10 days of estrogen. if no withdrawal bleeding, refer to physician.
2. if a woman wishes to start oral or other hormonal contraceptive and has no withdrawal bleeding from Provera, repeat hCG if indicated
and start oCs or other hormonal method. if no withdrawal bleeding after first cycle, consult with physician.
3. if a woman wishes to start oCs or other hormonal contraceptives and has withdrawal bleeding from Provera, start contraceptive after start of bleed; if Provera is not completed by that time, discontinue and discard remainder (some clinicians have woman complete Provera).
4. if withdrawal bleeding occurs with Provera, then no menses for 2 months following the bleeding, consult with physician, then give Provera 10 mg for 10 days every 2 months. if sexually active, an hCG level must be run prior to taking medication each time.
5. if a woman has a history of uterine infection or trauma to the uterus through multiple curettages (postpartum or postabortion) or if the workup is negative and there is no response to Provera, referral for further evaluation (hysterosalpingography, hysteroscopy to lyse adhesions, estrogen to restore endometrium)
6. instruct woman to complete 10 days of Provera even if withdrawal bleeding begins, unless starting oral or other hormonal contracep- tive as indicated in Treatment VII, 3
VIII. COMPLICATIONS
a. inability to conceive
B. sequellae of underlying cause
IX. CONSULTATION/REFERRAL
a. as outlined under Treatment, VII.B.5
B. after workup for hirsutism is completed (see Laboratory Examination, V.D)
C. For all primary amenorrhea cases
X. FOLLOW-UP
a. as deemed necessary with physician consult
B. Yearly
C. When necessary if unsatisfactory response to treatment
See Bibliographies.