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PubMed1999

The World Health Organization multinational study of breast-feeding and lactational amenorrhea. III. Pregnancy during breast-feeding. World Health Organization Task Force on Methods for the Natural Regulation of Fertility.

OBJECTIVE: To determine the risk of pregnancy during lactational amenorrhea relative to infant feeding status. DESIGN: Prospective longitudinal study. SETTING: Five developing and two developed countries. PATIENT(S): Four thousand one hundred eighteen breast-feeding mother-infant pairs. INTERVENTION(S): Infant feeding practices, menstrual status, and pregnancy were measured. MAIN OUTCOME MEASURE(S): Life-table rates of pregnancy. RESULT(S): In the first 6 months after childbirth, cumulative pregnancy rates during amenorrhea, depending on how the end of amenorrhea was defined, ranged from 0.9% (95% confidence interval [CI] = 0%-2%) to 1.2% (95% CI = 0%-2.4%) during full breast-feeding, and from 0.7% (95% CI = 0.1%-1.3%) to 0.8% (95% CI = 0.2%-1.4%) up to the end of partial breast-feeding. At 12 months, the rates ranged from 6.6% (95% CI = 1.9%-11.2%) to 7.4% (95% CI = 2.5%-12.3%) during full breast-feeding, and from 3.7% (95% CI = 1.9%-5.5%) to 5.2% (95% CI = 3.1%-7.4%) up to the end of partial breast-feeding. CONCLUSION(S): These results support the Bellagio Consensus on the use of lactational amenorrhea for family planning, and confirm that the lactational amenorrhea method is a viable approach to postpartum contraception.

Adult↗
PubMed1997

Low leptin levels predict amenorrhea in underweight and eating disordered females.

Evidence that leptin plays an important role in reproductive function is accumulating rapidly. We hypothesized that low leptin synthesis is associated with amenorrhea. We therefore determined serum leptin levels in 43 underweight female students, who were screened for lifetime occurrence of amenorrhea. We assessed the predictive value of leptin, body mass index (BMI), fat mass and percent body fat, respectively, for lifetime occurrence of amenorrea. Factors predicting amenorrhea were tested for their capability to predict current amenorrhea in a second cohort of 63 inpatients with anorexia nervosa (AN) or bulimia nervosa (BN). Furthermore, the relationships between serum leptin levels and of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol and progesterone, respectively, were evaluated. Only leptin predicted lifetime occurrence of amenorrhea in the student cohort. The critical leptin level was in the range of 1.85 micrograms L-1. This level served to largely separate anorectic from bulimic patients. In patients with AN mean serum log10 leptin levels over the first 4 weeks of inpatient treatment were correlated with mean FSH, LH and estradiol levels, respectively. Evidently, a critical leptin level is needed to maintain menstruation. In affluent populations eating disorders are likely to be a major cause of a low leptin synthesis.

Adolescent↗
PubMed1995

Osteopenia in primary and secondary amenorrhea.

This study aimed at investigating the prevalence of osteopenia among a hypoestrogenic group of patients with primary or secondary amenorrhea. Twenty-seven patients with amenorrhea were examined. Sixteen of them presented with secondary amenorrhea (mean age 27.8 +/- 1.9 yrs), and 11 with primary amenorrhea (mean age 21.3 +/- 1.6 yrs). Ten regularly menstruating women (mean age 28.9 +/- 1.4 yrs) served as controls. Estradiol serum levels as well as lumbar spine bone mineral density were measured. All 11 patients with primary amenorrhea showed osteopenia with a mean bone mineral density Z-score of 71 +/- 2% and mean estradiol levels of 30.6 +/- 5.9 pg/ml. The secondary amenorrheic patients were significantly demineralized with a mean Z-score of 82 +/- 3%; 10 of them had osteopenia. Their mean estradiol levels were 34.3 +/- 2.9 pg/ml. The bone density in the primary amenorrheic patients was significantly lower as compared with the secondary amenorrheic women. In comparison, lumbar spine bone density in all control women was normal with a mean Z-score of 104 +/- 3%. In summary, 21 of the 27 patients had osteopenia, higher than that reported in post-menopausal women. Since it is not proven whether the bone mineral deficit of amenorrheic patients can ever be compensated, early diagnostic steps and estrogen-progestogen replacement for the prevention of further bone loss and subsequent fractures are recommended.

Adolescent↗
PubMed1987

[Endocrine profile of patients with post-pill amenorrhea].

"Post-pill amenorrhea" is still a much-debated subject in gynecological endocrinology. The authors therefore studied the reproductive history and endocrinological parameters of 145 patients with the presumptive diagnosis of post-pill amenorrhea, seen in their department during the last two years; 166 cases of secondary amenorrhea served as a control group. The incidence of late menarche (20%), previous oligomenorrhea, and elevated androgen serum levels was high in both groups. There were no significant differences between the two collectives. These findings suggest that although oral contraceptives may have an unfavorable influence on the menstrual cycle, there is no causal relationship between such agents and the development of secondary amenorrhea. It seems that in many cases of presumptive post-pill amenorrhea the common condition of juvenile hyperandrogenemic ovarian insufficiency might be the underlying problem.

Adolescent↗
PubMed2004

Recombinant human leptin in women with hypothalamic amenorrhea.

BACKGROUND: Disruptions in hypothalamic-gonadal and other endocrine axes due to energy deficits are associated with low levels of the adipocyte-secreted hormone leptin and may result in hypothalamic amenorrhea. We hypothesized that exogenous recombinant leptin replacement would improve reproductive and neuroendocrine function in women with hypothalamic amenorrhea. METHODS: Eight women with hypothalamic amenorrhea due to strenuous exercise or low weight were studied for one month before receiving recombinant human leptin and then while receiving treatment for up to three months. Six control subjects with hypothalamic amenorrhea received no treatment and were studied for a mean (+/-SD) of 8.5+/-8.1 months. RESULTS: Luteinizing hormone (LH) pulsatility, body weight, ovarian variables, and hormone levels did not change significantly over time in the controls and during a one-month control period before recombinant leptin therapy in the treated subjects. In contrast, recombinant leptin treatment increased mean LH levels and LH pulse frequency after two weeks and increased maximal follicular diameter, the number of dominant follicles, ovarian volume, and estradiol levels over a period of three months. Three patients had an ovulatory menstrual cycle (P<0.05 for the comparison with an expected rate of spontaneous ovulation of 10 percent); two others had preovulatory follicular development and withdrawal bleeding during treatment (P<0.05). Recombinant leptin significantly increased levels of free triiodothyronine, free thyroxine, insulin-like growth factor 1, insulin-like growth factor-binding protein 3, bone alkaline phosphatase, and osteocalcin but not cortisol, corticotropin, or urinary N-telopeptide. CONCLUSIONS: Leptin administration for the relative leptin deficiency in women with hypothalamic amenorrhea appears to improve reproductive, thyroid, and growth hormone axes and markers of bone formation, suggesting that leptin, a peripheral signal reflecting the adequacy of energy stores, is required for normal reproductive and neuroendocrine function.

Adult↗
PubMed2006

Clinical evaluation of patients with weight loss-related amenorrhea: neuropeptide Y and luteinizing hormone pulsatility.

AIM: To characterize patients with weight loss-related amenorrhea and controls with respect to the pulsatility of neuropeptide Y (NPY) and luteinizing hormone (LH). SUBJECTS: Nine young women (aged 20.23+/-2.11 years) diagnosed with weight loss-related amenorrhea (body mass index (BMI) 17.52+/-2.43 kg/m2) and five age-matched (age 21.88+/-3.12 years) normally menstruating (every 28-33 days) controls with normal BMI (23.62+/-3.11 kg/m2) (mean value+/-standard deviation). METHODS: Basal hormonal evaluation included serum follicle-stimulating hormone (FSH), LH, estradiol (E2) and NPY. A pulsatility study investigated NPY and LH episodic release. Patients from control the group were studied during the mid-follicular phase (days 6-8) of the menstrual cycle. RESULTS: Patients with weight loss-related amenorrhea had lower FSH, LH and E2 levels than controls (p < 0.01). Basal serum NPY levels were lower in amenorrheic patients than in menstruating women (p < 0.01). The numbers of NPY and LH peaks were higher in patients with weigh loss-related amenorrhea than in controls (p < 0.01 and p < 0.05, respectively). CONCLUSION: Increased NPY pulsatility may have pathophysiological significance in weight loss-related hypothalamic amenorrhea.

Adult↗
PubMed1981

The fallacy of the postpill amenorrhea syndrome.

In conclusion, although there are changes in the hypothalamic pituitary axis in terms of release of FSH and LH resulting in anovulation in women on oral contraceptives, the evidence to date does not support a cause and effect phenomenon. On the basis of both epidemiologic as well as biochemical studies, the etiology of secondary amenorrhea is diverse. This serves only to indicate that amenorrhea is a symptom, not a diagnosis. It appears at the present time that amenorrhea following the use of oral contraceptives should indicate only the preceding temporal use of exogenous steroids without implication as to a cause of the amenorrhea. Investigation should be aimed at determining the underlying cause of the amenorrhea.

Amenorrhea↗
PubMed1975

The significance of weight loss in the evaluation of pituitary response to LH-RH in women with secondary amenorrhea.

Sixteen women with amenorrhea occurring in the setting of severe self-imposed weight loss and 18 women with secondary amenorrhea due to other causes were given LH-RH (luteinizing hormone-releasing hormone). Women with weight loss were found to be unresponsive to LH-RH when severely underweight. FSH responsiveness returned in a linear fashion as weight gain occurred and was not related to estrogen levels. LH responsiveness also returned with weight gain although the relationship was not linear but exponential and a sudden increase in responsiveness occurred at 15% below ideal weight. No relationship to estrogen levels could be found. Women who experienced amenorrhea in a setting other than weight loss did not demonstrate responsiveness to LH-RH which could be correlated with body mass, even when underweight. Women who experienced amenorrhea with weight loss had a consistently lower LH response to LH-RH than the second group and their LH response was always lower than the FSH response. On the other hand, a variety of patterns was found in women with amenorrhea due to other causes.

Adolescent↗
PubMed1991

Lack of bone accretion and amenorrhea: evidence for a relative osteopenia in weight-bearing bones.

Bone mineral density (BMD) was studied in young exercising amenorrheic girls to determine if density was compromised and the change related to injury. Ninety-eight volunteers (professional ballet dancers and controls) were studied in a cross-sectional study. Dancers and controls were further subdivided into normally cycling and amenorrheic subjects. Amenorrhea significantly lowered bone density of the spine (P less than 0.0001), wrist (P less than 0.03), and metatarsal (P less than 0.01); effects on the wrist were eliminated by controlling for age while controlling for weight eliminated all effects of amenorrhea at three sites. BMD of the metatarsal, a weight-bearing bone, showed an interaction between amenorrhea and dancing (exercising) P less than 0.035); surprisingly, dancing was associated with a further lowering of bone density. This interaction was eliminated when controlling for age, but not when controlling for weight. With multiple comparisons of the groups, spine, wrist, and metatarsal bone density was significantly lower in amenorrheic dancers when compared to normal dancers (P less than 0.05), even when controlling for age and weight in the metatarsal (P less than 0.05), and age in the spine (P less than 0.05). Estradiol levels correlated with bone density of both the wrist and the spine (r = 0.25, r = 0.23, P less than 0.02). Metatarsal density correlated with estradiol levels only in the dancers (r = 0.34, P less than 0.02). The only variable found to correlate with the occurrence of stress fractures was age of menarche. This was also the only variable of 9 (BMD of the wrist, spine or foot, calories ingested and expended, amount of calcium ingested, involvement in high energy activity, age of menarche or presence of amenorrhea) to predict stress fractures. Thus, BMD is significantly affected by the presence of amenorrhea but the effects are generally weight dependent. The compensatory increase in bone density generally seen in stressed bones, such as the metatarsal in ballet dancers, is deficient in amenorrheic premenopausal women even when controlling for weight but this effect may be age and estrogen dependent. Bone mass may not accumulate in the same manner in adolescents as in the mature women, thus putting them at risk for injury.

Adolescent↗
PubMed1999

Severity of osteopenia in estrogen-deficient women with anorexia nervosa and hypothalamic amenorrhea.

Reduced bone density is observed in over half of women with anorexia nervosa (AN), in whom the risk of fracture is significantly increased even at a young age. It is unknown to what extent low bone density in AN differs from other conditions of premenopausal osteoporosis and is related to estrogen deficiency and/or other factors, such as nutritional status. We therefore investigated bone loss in nutritionally replete and nutritionally deplete amenorrheic women by comparing patients with AN (n = 30) to age-matched subjects with hypothalamic amenorrhea (HA; n = 19) in whom duration of amenorrhea, prior estrogen use, and age of menarche were comparable. Healthy, age-matched, eumenorrheic women were studied as a control group (NL; n = 30). Weight and nutritionally dependent factors including (body mass index, 20.7 +/- 0.3 vs. 16.7 +/- 0.3 kg/m2; P < 0.0001), insulin-like growth factor I (270 +/- 18 vs. 203 +/- 17 ng/mL; P < 0.01), percent body fat (26% vs. 19%; P < 0.0001), and lean body mass (38.7 +/- 1.1 vs. 34.3 +/- 0.8, P < 0.01) were significantly different between the HA and AN groups, respectively. The bone densities of the anterior-posterior (AP) spine, total hip, and total body measured by dual energy x-ray absortiometry were reduced in both amenorrheic groups compared to those in control subjects, but were significantly lower in women with AN than in those with HA. The t scores for AP spine and hip were -1.80 +/- 0.15 (AN), -0.80 +/- 0.22 (HA), and 0.28 +/- 0.19 SD (NL) for the AP spine and -1.62 +/- 0.17 (AN), -0.51 +/- 0.21 (HA), and 0.25 +/- 0.16 (NL) for the total hip, respectively (P < 0.01 for all comparisons). Among the amenorrheic subjects, duration of amenorrhea, age of menarche, and N-telopeptide were inversely correlated with bone density at all sites, whereas body mass index, insulin-like growth factor I, lean body mass, and fat intake were positively correlated with bone density at all sites measured. In multivariate regression analyses, bone density was most significantly related to lean body mass (P = 0.05 and P = 0.03 for the spine and hip, respectively), but not to the duration of amenorrhea or other indexes of estrogen status among patients with AN. In contrast, bone density of the lumbar spine was significantly related to weight and duration of amenorrhea among patients with HA. These data demonstrate that the severity of osteopenia in AN is greater than that in patients with HA and is critically dependent upon nutritional factors in addition to the degree or duration of estrogen deficiency itself. Lean body mass, independent of the duration or severity of estrogen deficiency, is an important predictor of bone loss among women with AN.

Absorptiometry, Photon↗
PubMed2002

Bone density and amenorrhea in ballet dancers are related to a decreased resting metabolic rate and lower leptin levels.

Osteopenia, which is correlated with amenorrhea and poor nutritional habits, has been well documented in elite ballet dancers. Estrogen replacement therapy and recovery from amenorrhea have not been associated with normalization of bone density. Thus, the osteopenia may be related to changes brought about by chronic dieting or other factors, such as a hypometabolic state induced by poor nutrition. The purpose of this study was to investigate the relationship of chronic dieting and resting metabolic rate (RMR) to amenorrhea and bone density. RMR, bone density, eating disorder assessments, leptin levels, and complete menstrual and medical histories were determined in 21 elite ballet dancers and in 27 nondancers (age, 20-30 yr). No significant correlations were found between high EAT26 scores, a measure of disordered eating, and RMR, bone densities, body weight, body fat, or fat-free mass. However, when RMR was adjusted for fat-free mass (FFM), a significant positive correlation was found between RMR/FFM and bone density in both the arms (P < 0.001) and spine (P < 0.05) in ballet dancers, but not in the normal controls. The dancers also demonstrated significantly higher EAT scores (22.9 +/- 10.3 vs. 4.1 +/- 2.4; P < 0.001) and lower RMR/FFM ratios (30.0 +/- 2.2 vs. 32.05 +/- 2.8; P < 0.01). The only variable to predict lower RMR/FFM in the entire sample was ever having had amenorrhea; this group had significantly higher EAT scores (18.0 +/- 13.5 vs. 10.3 +/- 10.2; P < 0.05), lower leptin levels (4.03 +/- 0.625 vs. 7.10 +/- 4.052; P < 0.05), and lower bone mineral density in the spine (0.984 +/- 0.11 vs. 1.10 +/- 0.13; P < 0.05) and arm (0.773 +/- 0.99 vs. 0.818 +/- 0.01; P < 0.05). We hypothesize that the correlation between low RMR and lower leptin levels and bone density may be more strongly related to nutritional habits in ballet dancers, causing significant depression of RMR, particularly for those with a history of amenorrhea.

Adult↗
PubMed1999

Induction of ovulation with clomiphene citrate in combination with metoclopramide in patients with amenorrhea of hypothalamic origin.

Literature data have demonstrated that the chronic use of metoclopramide (MCP), a dopamine antagonist, causes increased gonadotropin secretion in patients with hypothalamic amenorrhea but without triggering ovulation. It has also been observed that women with hypothalamic amenorrhea respond poorly to ovulation induction with clomiphene citrate (CC). On this basis, the objective of the present study was to determine the effect of MCP on the response to CC in patients with hypothalamic amenorrhea in order to evaluate the validity of the simultaneous use of these drugs as ovulation inducers in this type of chronic anovulation. Twenty-two patients with amenorrhea of hypothalamic origin were submitted to a randomized double blind study in which one tablet of 5 mg MCP or placebo was administered every 8 hours for 2 months. After the 30th day of medication (MCP or placebo), CC, 100 mg orally, was additionally administered to both groups for 5 days. Blood samples were collected on days 1, 15 and 30 during the first month of the study and on days 7, 14 and 21 after the last CC tablet during the second month, for later measurement of follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, estradiol and progesterone by radioimmunoassay. The group that received MCP showed a significant increase in LH and FSH during the first month of the study, as well as a slighter increase in estradiol. Prolactin increased only during the second stage of treatment. No significant increases in gonadotropins, prolactin or estradiol occurred in the placebo group. In the group treated with MCP, 40% of the patients ovulated after CC, with menstruation occurring in 60% of them. In the placebo group, 33.3% of the women ovulated after CC and 44.4% menstruated at the end of the study. We conclude that MCP increases the circulating levels of LH, FSH, estradiol and prolactin in patients with hypothalamic amenorrhea and low estrogen levels, supporting the hypothesis that an increase in hypothalamic dopaminergic tonus occurs in these patients. On the other hand, the combination of MCP and CC does not improve the rate of ovulation compared to placebo.

Adult↗
PubMed2001

[Clinical study on women with amenorrhea after levonorgestrel intrauterine system].

OBJECTIVE: To study the 5 years contraceptive efficacy of levonorgestrel intrauterine system (LNG-IUS) and the ovarian functions in amenorrhea women. METHODS: LNG-IUS and TCu 380A IUD were randomly inserted in 2 groups of women, 50 each. Women were followed annually for 5 years. Serum follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), estradiol (E2), and T levels in 14 women with amenorrhea, and endometrial biopsies were obtained in 9 cases. RESULTS: By the end of 5 years, there were 2 pregnancies in TCu 380A group, but none in LNG-IUS group; and 24 amenorrhea cases in LNG-IUS. The 5 year cumulative continuation rates were 24% for LNG-IUS and 78% for TCu 380A (P < 0.001). In the 14 women with amenorrhea, the average serum concentrations were not significantly different from that of the normal controls. Histological study showed endometrial atrophy or a few secretory glands. CONCLUSIONS: LNG-IUS is a highly effective and safe contraceptive measure. Oligomenorrhea and amenorrhea caused by the local effects of LNG were reversible and did no harm to women's health. However, comprehensive consultation provided to women before insertion is of utmost importance for continuation use.

Adult↗
PubMed2002

[Spatial organization of bioelectrical brain activity in epilepsy and amenorrhea of central genesis].

The study aimed at modification of co-herent analysis (CA), as a mathematical method for EEG data processing for objective evaluation of bioelectric brain activity spatial organization in women with epilepsy and secondary amenorrhea of central genesis. One hundred sixty one women (30 with epilepsy, 116 with amenorrhea and 115 controls aged 15 to 41 years) have been examined. Characteristic changes of cortico-cortical inter- and intra-hemisphere relations for patients with catamenial (CTM) and noncatamenial (NCTM) epilepsy in different menstrual cycle terms were found. The most distinct changes were detected in theta-activity analysis. In the beginning of menstrual cycle, the patients with CTM epilepsy exhibited higher CA indices in theta-rhythm range in all right hemisphere pairs studied. On the contrary, patients with NCTM epilepsy exhibited lower CA indices mainly in the right brain hemisphere. alpha-rhythm spatial organization analysis in the same patients showed similar correlations, but they were better expressed in alpha-rhythm generation zone: in the beginning of menstrual cycle CA indices were high in patients with CTM epilepsy and low in those with NCTM epilepsy. Comparing to controls, patients with secondary amenorrhea of central genesis showed most distinct changes in theta-activity towards the CA indices increase in the majority of the leads. In patients with epilepsy and amenorrhea, CA indices of right brain hemisphere and intra-central temporal lead pairs were lower than in patients with amenorrhea without epilepsy by both alpha- and theta-rhythms.

Adolescent↗
PubMed1982

Management of amenorrhea due to contraceptive injectables by temporary IUD insertion.

Amenorrhea is a common side effect of injectable contraceptive. Lippes loops were inserted in 22 amenorrheic women who continued injectable contraception, and in 6 cases with prolonged postinjectable amenorrhea. The occurrence and rhythm of subsequent bleeding was recorded. IUD insertion induced bleeding in most cases of continued injectable users but it was usually irregular and unpredictable. It was regular in 6 subjects only while the IUD was in situ. After the removal of the IUD, the majority regained the state of amenorrhea within 3 months. Temporary IUD insertion had a positive impact on continuation (a mean additional rate of 18 months of use) among subjects who had wished to terminate the method because of amenorrhea. This procedure of temporary IUD insertion may serve to provide these women with an alternative contractive approach. In the postinjectable amenorrhea group, temporary IUD insertion induced bleeding during IUD application as well as after its removal, which was more predictable than that in the continued users. IUD insertion may facilitate return of regular menses and resumption of fertility in amenorrheic women who stop injectable contraception.

Age Factors↗
PubMed1992

[General and ethnic factors associated with the duration of lactation amenorrhea].

114 women in fully nursing, were studied, according to the length of lactational amenorrhea and their relation with general characteristics and ethnic group. Of the 114 mothers, 66 (58%) recovery their menses before the 6th postpartum month. The length of lactation was 100.7 +/- 5.2 and 277.9 +/- 10.5 days, for those mothers who were with menses and amenorrhea until the 6th postpartum month, respectively. A group of Mapuche women had a higher length of lactational amenorrhea and we found differences in the frequency of suckling episodes at night. This study corroborate, that short length of lactational amenorrhea is a condition highly frequent in Chilean population and it does not have a relation the nursing pattern in general population. However, the difference in the length of lactational amenorrhea in specific ethnic group, can include some general or behavioral factors of breast-feeding.

Adolescent↗
PubMedDate not supplied

[Impulse secretion of gonadotropins in patients with various forms of amenorrhea].

Circahoral variations of gonadotropin secretion were investigated in 5 healthy women in the follicular phase of the menstrual cycle, in 8 patients with normogonadotropic amenorrhea, in 6 patients with hyperprolactinemic amenorrhea, in 4 patients with hypogonadotropic amenorrhea, and in 10 patients with amenorrhea associated with body mass deficiency. The levels of LH, FSH, prolactin, estradiol and progesterone were determined by radioimmunoassay every 20 min for 4 hours. The results suggest that the blood levels of gonadotropins in different types of amenorrhea are determined mainly by an amplitude of their impulses.

Adolescent↗
PubMed1989

Secondary amenorrhea at Maharaj Nakhon Chiang Mai Hospital.

One hundred and thirty-seven patients attending the gynaecological endocrine clinic at Maharaj Nakhon Chiang Mai hospital between April 1, 1982 and July 31, 1987 were studied. Detailed history, physical and pelvic examination were obtained on all patients, followed by progesterone withdrawal test and other appropriate laboratory studies including thyroid and reproductive hormone profiles. The most common cause of secondary amenorrhea in this study was hypothalamic-pituitary dysfunction (54.7%), not unlike those reports from other foreign series. However, it was notable that nearly 40 per cent of our patients in this group experienced amenorrhea after discontinuation of contraceptive steroids. Premature ovarian failure was the second leading cause of amenorrhea in our patients (13.9%) and, perhaps, deserve future detailed studies. The other causes of amenorrhea in decreasing frequency were: hyperprolactinemia (11.7%), hypothalamic-pituitary failure (8.0%), Asherman's syndrome (5.1%) and androgen excess (2.9%). Primary hypothyroidism was a rare cause of amenorrhea in this study.

Adolescent↗