Amenorrhea medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

• Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
• Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
• Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated [therapy 2].

Amenorrhea

• 1 - Hypothalamic causes
  • 1.1.1 Adult
    • Preferred regimen (1): Alora 0.05, 0.075, and 0.1 mg transdermal daily, applied twice weekly
    • Preferred regimen (2): Climara 0.025, 0.05, 0.075, and 0.1 mg transdermal daily, applied once weekly
    • Preferred regimen (3): Esclim 0.025, 0.0375, 0.05, 0.075, 0.1 mg transdermal daily, applied twice weekly
    • Preferred regimen (4): Vivelle-dot 0.037, 0.05, 0.075, 0.1 mg transdermal daily, applied twice weekly
    • Preferred regimen (5): Premarin 0.625-1.25 mg PO daily
    • Preferred regimen (6): Medroxyprogesterone acetate 10 mg PO for 12 days each month
    • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
    • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
    • Alternative regimen (3): drug name 500 mg PO q6h for 14–21 days
  • 1.1.2 Pediatric
    • Preferred regimen (1): drug name 50 mg/kg PO per day q8h (maximum, 500 mg per dose)
    • Preferred regimen (2): drug name 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
    • Alternative regimen (1): drug name10 mg/kg PO q6h (maximum, 500 mg per day)
    • Alternative regimen (2): drug name 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
    • Alternative regimen (3): drug name 12.5 mg/kg PO q6h (maximum, 500 mg per dose)

• 2 - Pituitary causes
  • 1.1.1 Adult
    • Preferred regimen (1): drug name 100 mg PO q12h for 10-21 days (Contraindications/specific instructions)
    • Preferred regimen (2): drug name 500 mg PO q8h for 14-21 days
    • Preferred regimen (3): drug name 500 mg q12h for 14-21 days
    • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
    • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
    • Alternative regimen (3): drug name 500 mg PO q6h for 14–21 days

• • 1.1.2 Pediatric
    • Preferred regimen (1): drug name 50 mg/kg PO per day q8h (maximum, 500 mg per dose)
    • Preferred regimen (2): drug name 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
    • Alternative regimen (1): drug name10 mg/kg PO q6h (maximum, 500 mg per day)
    • Alternative regimen (2): drug name 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
    • Alternative regimen (3): drug name 12.5 mg/kg PO q6h (maximum, 500 mg per dose)

• 3 - Ovary insufficiency
  • 3.1 Premature ovarian insufficiency
    • 3.1.1 Adult
      • Preferred regimen (1): Micronized 17-β estradiol 1-2 mg PO daily PLUS medroxyprogesterone acetate 2.5-5.0 mg PO daily (continuous)
      • Preferred regimen (2): Micronized 17-β estradiol 1-2 mg PO daily PLUS medroxyprogesterone acetate 10 mg PO for 12 days each month (sequential)
      • Preferred regimen (3): 17-β estradiol 1-2 mg transdermal daily PLUS micronized progesterone 100 mg PO daily (continuous)
      • Preferred regimen (4): 17-β estradiol 1-2 mg transdermal daily PLUS micronized progesterone 200 mg PO for 12 days each month (sequential)
      • Alternative regimen (1): Conjugated equine estrogen 0.625-1.25 mg PO daily PLUS micronized progesterone 100 mg PO daily (continuous)
      • Alternative regimen (2): Conjugated equine estrogen 0.625-1.25 mg PO daily PLUS micronized progesterone 200 mg PO for 12 days each month (sequential)
  • 3.2 Turner syndrome
    • 3.2.1 12-13 years old
      • Preferred regimen (1): Depot 17-β estradiol 0.2–0.4 mg IM every month
      • Alternative regimen (1): 17-β estradiol 6.25 μg transdermal daily
      • Alternative regimen (2): Micronized 17-β estradiol 0.25 mg PO daily
    • 3.2.2 12.5-15 years old
      • Gradually increase 17-β estradiol dose over about 2 years (e.g., 14, 25, 37, 50, 75, 100, 200 μg daily via patch) to adult dose, as following:
        • Preferred regimen (1): 17-β estradiol 100–200 μg transdermal daily
        • Preferred regimen (2): Micronized estradiol 2–4 mg PO daily
        • Preferred regimen (3): Ethinyl estradiol 20 μg PO daily
        • Preferred regimen (4): Conjugated equine estrogen 1.25–2.5 mg PO daily
    • 3.2.3 14-16 years old
      • Preferred regimen (1): Micronized progesterone 200 mg PO daily on the 20th–30th days of monthly cycle
      • Preferred regimen (2): Micronized progesterone 200 mg PO daily on the 100th–120th days of 3-month cycle 

• 4 - Chronic anovulation
  • 4.1 Polycystic ovary syndrome (PCOS)
    • 4.1.1 Adult
      • Preferred regimen (1): Clomiphene citrate 50 mg PO daily for 5 days (starting on day 2–5 following a spontaneous or progestin-induced withdrawal bleeding)
      • Preferred regimen (2): Metformin 500 mg PO q8h (lactic acidosis in renal impairment)
      • Preferred regimen (3): Follicle stimulating hormone (FSH) 37.5–75 IU SC or IM daily
      • Alternative regimen (1): Tamoxifen 20 to 80 mg PO daily during the cycle
      • Alternative regimen (2): Sibutramine 10 mg PO daily
      • Alternative regimen (3): Orlistat 120 mg PO q8h
      • Alternative regimen (4): Troglitazone 300-600 mg PO daily (weight gain)
      • Alternative regimen (5): Follicle stimulating hormone (FSH) 150 IU SC or IM daily [cause ovarian hyperstimulation syndrome (OHSS)]
    • 4.1.2 Pediatric
      • Preferred regimen (1): Metformin 1.50–2.55 g PO per day

Lifestyle Changes

The best way to treat 'athletic' amenorrhoea is to decrease the amount and intensity of exercise. Weight gain may be helpful as well. To prevent osteoporosis, consider oral contraceptives. Pulsatile gonadotropin-releasing hormone (GnRH) or exogenous gonadotropins may be necessary.

Pharmacotherapy

Hormone replacement therapy should be considered for ovarian failure. Unless receiving eggs from an egg donor or invitro fertilization, a woman is unable to conceive while she is amenorrhoeic. On the other hand, 'athletic' and drug-induced amenorrhoea has no effect on long term fertility as long as menstruation can recommence. Similarly, to treat drug-induced amenorrhea, stopping the medication on the advice of a doctor is the usual course of action.

In polycystic ovarian disease the following may be helpful:

• To decrease peripheral estrogen, reduce weight
• To decrease ovarian androgen secretion, consider oral contraceptives
• Clomiphene enhances fertility
• Endometrial hyperplasia is prevented by cyclic progesterone

Psychological Counseling

Psychological counseling may be helpful if there is the presence of a Y chromosome or absent mullerian organs.

References

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