Menstrual Disorders in the Athlete



Ovid: 5-Minute Sports Medicine Consult, The


Menstrual Disorders in the Athlete
Anastasia N. Fischer
Thomas L. Pommering
Basics
Description
  • Primary amenorrhea is the lack of spontaneous uterine bleeding:
    • By the age of 14 yrs without development of secondary sexual characteristics OR
    • By the age of 16 yrs with otherwise normal development.
  • Secondary amenorrhea is as a 3-mo absence of menstrual bleeding in a woman with previous regular menses or a 9-mo absence with previous oligomenorrhea.
  • Suspect Female Athlete Triad.
Epidemiology
  • Amenorrhea occurs in 3–64% of female college athletes compared with 2–5% of the general population.
Commonly Associated Conditions
  • Female Athlete Triad
Diagnosis
History
  • With amenorrhea, history is directed toward other causes besides hypothalamic amenorrhea: Thyroid disease, androgen excess, anabolic steroids, and autoimmune and pituitary disorders.
  • Menstrual history:
    • Age of menarche
    • Last menstrual period
    • Frequency and duration of menses
    • Longest time between menses
    • Physical signs of ovulation (cervical mucous change or menstrual cramps)
    • Previous or current hormonal therapy
  • Diet history
  • Exercise history
  • Sexual history
Physical Exam
  • Tanner stage
  • Acne
  • External genitalia abnormalities
  • Lanugo, or hirsutism
  • Bradycardia
  • Behavioral signs of disordered eating: Preoccupation with food and weight, self-criticism, eating alone, excessive water/soda drinking, compulsive and excessive exercise, poor self-image, frequent bathroom trips during and after meals
  • If anorexia nervosa is present, cachexia, hypotension, alopecia, pruritus, cold intolerance, and yellow skin (hypercarotenemia) also may be observed.
  • Any other findings consistent with differential diagnosis
Diagnostic Tests & Interpretation
  • Initial: Pregnancy test, follicle-stimulating hormone, luteinizing hormone, thyroid-stimulating hormone, prolactin
  • If patient is hirsute, has acne, or polycystic ovary syndrome is suspected, add free testosterone and dehydroepiandrosterone sulfate to the list of studies.
  • If TSH/prolactin is normal, consider progesterone challenge.
Imaging
  • Pelvic US if suspect anatomic abnormality
  • MRI Sella turcica if suspect pituitary problem
Differential Diagnosis
  • Pregnancy
  • Hypothalamic dysfunction:
    • Gonadotropin-releasing hormone (GnRH) deficiency
    • Hypogonadotropic hypogonadism (psychogenic, stress, weight loss, or exercise-induced)
    • Eating disorder/Female Athlete Triad
    • Drugs (GnRH analogues, medroxyprogesterone acetate, danazol, or oral contraceptives) or systemic illness
    • Kallmann syndrome
    • Idiopathic (eg, head trauma)
    • Space-occupying lesion or infection
  • Pituitary dysfunction:
    • Pituitary neoplasm or prolactin-secreting tumor
    • Sheehan syndrome
    • Empty-sella syndrome
    • Granulomatous disease (eg, sarcoidosis)
    • Lawrence-Moon-Biedl syndrome
    • Thalassemia major
    • Mumps encephalitis
  • P.387


  • Ovarian dysfunction:
    • Menopause or premature ovarian failure
    • Polycystic ovary syndrome
    • Ovarian neoplasm
    • Turner syndrome (45,X)
    • Gonadal dysgenesis
    • Autoimmune disease
  • Uterine dysfunction:
    • Asherman syndrome
    • Absence of uterus or transverse vaginal septum:
      • Androgen insensitivity
      • Imperforate hymen
      • Mayer-Rokitansky-Kuster-Hauser syndrome (müllerian agenesis)
  • Endocrine disease:
    • Hypothyroidism
    • Cushing syndrome
    • Adrenal hyperplasia
    • Adrenal tumors
Codes
ICD9
  • 307.50 Eating disorder, unspecified
  • 626.0 Absence of menstruation
  • 626.1 Scanty or infrequent menstruation


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