{ "schema_version": 1, "kind": "condition", "id": "amenorrhea", "name": "Amenorrhea (absent periods)", "category": "chronic", "sources": "Amenorrhea - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK482168/ · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class GS07.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care · Amenorrhea - disease-level clinical article (amenorrhea-full.txt) · Egyptian National Drug Formulary - Endocrine System 2024 (cabergoline monograph, Indications and Dosage Regimen, Hyperprolactinemic disorders), with the first-line recommendation from Amenorrhea - disease-level clinical article (amenorrhea-full.txt) · Egyptian National Drug Formulary - Endocrine System 2024 (estradiol monograph, Note on adding a progestogen, Dosage Adjustment: Hepatic Impairment, and Contra-indications) · Egyptian National Drug Formulary - Endocrine System 2024 (progesterone monograph, Dosage regimen, Oral: Adjunctive use with Estrogen, as hormone replacement therapy)", "review_status": "reviewed", "verified_against": "No dose - referral pathway, no medicine given in primary care · Amenorrhea - disease-level clinical article (amenorrhea-full.txt) · Egyptian National Drug Formulary - Endocrine System 2024 (cabergoline monograph, Indications and Dosage Regimen, Hyperprolactinemic disorders), with the first-line recommendation from Amenorrhea - disease-level clinical article (amenorrhea-full.txt) · Egyptian National Drug Formulary - Endocrine System 2024 (estradiol monograph, Note on adding a progestogen, Dosage Adjustment: Hepatic Impairment, and Contra-indications) · Egyptian National Drug Formulary - Endocrine System 2024 (progesterone monograph, Dosage regimen, Oral: Adjunctive use with Estrogen, as hormone replacement therapy)", "verified_date": "2026-08", "treatments": [ { "id": 138, "generic": "Recognise and refer (Referral & Advice)", "line": 1, "is_adjunct": false, "form": null, "strength_mg": null, "adult_dose": "Amenorrhoea (complete absence of periods). Exclude pregnancy first in any woman of reproductive age, then work out the cause - outflow tract, hypothalamic, pituitary, ovarian, thyroid or drug - because the treatment is the cause's treatment, not the symptom's. The article sets the same two tasks: put right whatever is producing the amenorrhoea, and keep the patient under review for the complications it brings.", "adult_duration": "Refer, with advice", "dose_source": "No dose - referral pathway, no medicine given in primary care", "rationale": "Amenorrhoea (complete absence of periods). Exclude pregnancy first in any woman of reproductive age, then work out the cause - outflow tract, hypothalamic, pituitary, ovarian, thyroid or drug - because the treatment is the cause's treatment, not the symptom's. The article sets the same two tasks: put right whatever is producing the amenorrhoea, and keep the patient under review for the complications it brings.", "cautions": [ "There is no single drug for amenorrhoea, because it is a presentation and not a disease - what gets treated is whatever is causing it, with the patient watched for complications as that proceeds. (Amenorrhea - StatPearls - NCBI Bookshelf, NBK482168) The drug rows below are the treatments for two of those causes: cabergoline for hyperprolactinaemia, and hormone replacement where the ovaries have failed. Neither is started before the cause is known and pregnancy is excluded.", "RED FLAG - Vision changes, anosmia, headaches, galactorrhea, or other focal neurologic deficits accompanying amenorrhea suggest an intracranial process (e.g. pituitary tumor) and warrant more urgent evaluation.", "Functional hypothalamic amenorrhoea is treated without a prescription. What matters most in FHA is undoing whatever is driving it: putting weight back on, taking stress out of the picture, changing how she lives, and changing what she eats. (Amenorrhea - StatPearls - NCBI Bookshelf, NBK482168)", "RED FLAG - Hirsutism or virilisation suggests an androgen-secreting cause: investigate before treating the amenorrhoea itself." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "Children follow the same pathway: recognise and refer. No primary-care medicine is implied.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [], "condition_id": "amenorrhea" }, { "id": 139, "generic": "Cabergoline", "line": 1, "is_adjunct": false, "form": "oral.solid", "strength_mg": 0.5, "adult_dose": "0.5 mg a week to start, given as one weekly dose or two divided weekly doses. Increase by 0.5 mg a week no sooner than every 4 weeks, guided by the serum prolactin. Usual maintenance 0.5 to 2 mg a week; up to 4.5 mg a week has been used, divided into two or more weekly doses.", "adult_duration": "Until prolactin has been normal for 6 months, then it may be stopped with periodic prolactin monitoring; use beyond 24 months is not established", "dose_source": "Egyptian National Drug Formulary - Endocrine System 2024 (cabergoline monograph, Indications and Dosage Regimen, Hyperprolactinemic disorders), with the first-line recommendation from Amenorrhea - disease-level clinical article (amenorrhea-full.txt)", "rationale": "Cabergoline is the one drug that treats a common and correctable endocrine cause of amenorrhoea. The article puts it first: where a prolactin-secreting pituitary tumour is the cause, a dopamine agonist - cabergoline specifically - is the opening choice. The Egyptian formulary covers the same ground in its own Indications, taking in raised prolactin whether no cause is found or a pituitary adenoma is producing it, and prints the weekly regimen. Eighteen Egyptian products are registered, from CABERGOLACTO 0.5 mg at 36 EGP for two tablets, which is roughly a month at the starting dose. Endocrinology confirms the diagnosis and images the pituitary first - the row is here so the regimen is visible and recognisable, not so that a raised prolactin is treated blind.", "cautions": [ "IMAGE THE PITUITARY AND CHECK THE VISUAL FIELDS FIRST. A prolactinoma is a mass. Where the visual fields are closing in quickly, that is a neurosurgical referral, and the bigger tumours may be dealt with by an operation.", "CONTRAINDICATED, per the formulary: pre-eclampsia and eclampsia; post-partum or uncontrolled hypertension; severe impairment of liver function; any past fibrotic disorder of the lung, the pericardium or the retroperitoneum; history of psychosis or risk of post-partum psychosis; hypersensitivity to any ergot alkaloid; and, where the course is to be a long one, valvular heart disease shown on an echocardiogram done beforehand - so an echocardiogram is needed before a long course.", "Stop the offending drug first where there is one. Where a medicine has raised the prolactin, the treatment is to withdraw that medicine wherever it can be withdrawn; only where it cannot may a dopamine agonist be weighed up, and cautiously. Antipsychotics, metoclopramide and domperidone are the usual culprits.", "Do not stop it abruptly after long-term use - the formulary records neuroleptic malignant syndrome on abrupt withdrawal or a large dose reduction, and advises gradual reduction.", "It restores fertility. A woman who did not want to conceive needs contraception advice as her periods return.", "Titrate on the prolactin level, not on the symptom - the formulary raises the dose on what the serum prolactin shows, and no sooner than every 4 weeks." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "The formulary states no paediatric dose for hyperprolactinaemia. An adolescent with primary amenorrhoea and a raised prolactin goes to paediatric endocrinology.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [ { "trade_name": "CABERGOLACTO 0.5 MG 2 TABS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "IDI > NOVELL PHARMA", "price_egp": 36.0, "pack_count": 2, "unit_price": 18.0, "strength_mg": 0.5, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "CABERGLOBE 0.5 MG 2 TABS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "EGPI > GLOBE INTERNATIONAL PHARMACEUTICALS", "price_egp": 45.0, "pack_count": 2, "unit_price": 22.5, "strength_mg": 0.5, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "MARVIGOLINE 0.5 MG 2 TABS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "RAMEDA", "price_egp": 66.0, "pack_count": 2, "unit_price": 33.0, "strength_mg": 0.5, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "CABROSTINEX 0.5 MG 8 TABS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "MEDIZEN PHARMACEUTICAL INDUSTRIES > ROTABIOGEN", "price_egp": 339.0, "pack_count": 8, "unit_price": 42.38, "strength_mg": 0.5, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "GOLINOTECH 0.5 MG 2 TABS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "EUROPEAN EGYPTIAN PHARM. IND. > PHARMA-TECH", "price_egp": 103.0, "pack_count": 2, "unit_price": 51.5, "strength_mg": 0.5, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "DOSTILACT 0.5 MG 2 TABS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "ATCO PHARMA > OMEGA PHARMA OPCI", "price_egp": 105.0, "pack_count": 2, "unit_price": 52.5, "strength_mg": 0.5, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "DOSTINEX 0.5 MG 2 TABS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "PFIZER", "price_egp": 172.0, "pack_count": 2, "unit_price": 86.0, "strength_mg": 0.5, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "DELCABRIN 0.5 MG 2 SCORED TABS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "EGPI > HEALTH WELL EGYPT", "price_egp": 105.0, "pack_count": null, "unit_price": null, "strength_mg": 0.5, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null } ], "condition_id": "amenorrhea" }, { "id": 140, "generic": "Estradiol", "line": 1, "is_adjunct": false, "form": "topical", "strength_mg": null, "adult_dose": "A transdermal patch delivering 100 micrograms (0.100 mg) of estradiol daily. The article's alternative is conjugated oestrogen 0.625 mg orally daily, which Egypt does not register as a tablet. The Egyptian formulary's oral figure, for comparison, is estradiol valerate 1 mg daily, increased to 2 mg if needed - that is the menopausal replacement dose, not the physiological dose a young woman needs.", "adult_duration": "Long-term, to the usual age of menopause - this is replacement, not symptom relief", "dose_source": "Amenorrhea - disease-level clinical article (amenorrhea-full.txt)", "rationale": "Where the ovaries have stopped making oestrogen - premature ovarian insufficiency, Kallmann syndrome - replacing it is not symptom relief but protection of the skeleton and of the cardiovascular system, and the article makes that the indication in women still of reproductive age. It gives the maintenance regimen in the same paragraph: oestradiol 100 mcg daily by transdermal patch, or conjugated oestrogen 0.625 mg daily by mouth. The patch is the arm that is buyable in Egypt: FEM 7 is registered at 50, 75 and 100 micrograms, and the only conjugated-oestrogen product in the register is an unlicensed-import vaginal cream. The same regimen already sits on the `premature-ovarian-insufficiency` card; it is repeated here because amenorrhoea is what the patient and the treating doctor actually type.", "cautions": [ "GIVEN WITH a progestogen whenever the uterus is intact - oestrogen alone grows the endometrium. The formulary names this very presentation: where the uterus has not been removed, estradiol is accompanied by a progestogen for 12 to 14 days or more of every 28-day cycle, begun on the first day of bleeding, or on any day at all where the periods are very infrequent or absent altogether.", "CONTRAINDICATED, per the formulary: endometrial hyperplasia that has not been treated; breast cancer known or suspected; a deep vein thrombosis or pulmonary embolism now active, or either one in the past; undiagnosed abnormal genital bleeding; oestrogen-dependent neoplasia; recent arterial thromboembolic disease; and liver disease - it is barred outright while hepatic function is disturbed.", "EXCLUDE PREGNANCY FIRST. It is the commonest cause of absent periods and nothing on this card should be started before a pregnancy test.", "This is not the treatment for functional hypothalamic amenorrhoea. Where that is the cause, what the article prefers is eating properly and holding a normal weight; a combined hormonal contraceptive on its own is NOT advised as treatment for the amenorrhoea. (Amenorrhea - StatPearls - NCBI Bookshelf, NBK482168) Restoring weight, reducing stress, and treating an eating disorder is the treatment there.", "Nor is it the treatment for PCOS. Where cycles are chronically anovulatory - PCOS being the example given - the first-line choice is a combined hormonal contraceptive, which holds off endometrial hyperplasia and cancer while also treating the hirsutism and the acne. (Amenorrhea - StatPearls - NCBI Bookshelf, NBK482168)", "Bone protection goes with it. The article also advises calcium 1,200 mg by mouth daily and vitamin D 1,000 IU by mouth daily, alongside regular weight-bearing exercise, so that bone density is kept up. (Amenorrhea - StatPearls - NCBI Bookshelf, NBK482168) No calcium or vitamin D row is written here because the general question of adding them on an article-only indication is still awaiting a clinical decision (DECISIONS-NEEDED item 32).", "Contraception is a separate conversation. A minority of women with POI remain able to conceive, and some of them will want contraception. (Amenorrhea - StatPearls - NCBI Bookshelf, NBK482168)", "The Egyptian product this row means is the FEM 7 transdermal patch, registered at 50, 75 and 100 micrograms. The route is recorded as topical because that is how the register files patches; it is a skin patch, not a cream. Two other products file under the same ingredient name and are deliberately excluded - ETHINYL OESTRADIOL tablets (a different molecule, the contraceptive oestrogen) and FOLONE oily ampoules (an intramuscular depot).", "Started and monitored by gynaecology or endocrinology once the cause is known." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "Not a paediatric prescription. An adolescent with primary amenorrhoea and no endogenous oestrogen needs puberty induced on a paediatric-endocrine schedule, which starts far lower than this and is not stated in any document held here.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [ { "trade_name": "FEM 7 - 50 MCG 4 TRANSDERMAL PATCHES", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "MERCK KGAA F.R.GERMANY > MERCK KGAA F.R-EGYPT", "price_egp": 30.0, "pack_count": null, "unit_price": null, "strength_mg": 0.05, "exact_strength": true, "exact_form": false, "discontinued": false, "also_contains": null }, { "trade_name": "FEM 7 - 75 MCG 4 TRANSDERMAL PATCHES", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "MERCK KGAA F.R.GERMANY > MERCK KGAA F.R-EGYPT", "price_egp": 40.0, "pack_count": null, "unit_price": null, "strength_mg": 0.075, "exact_strength": true, "exact_form": false, "discontinued": false, "also_contains": null }, { "trade_name": "FEM 7 - 100 MCG 4 TRANSDERMAL PATCHES", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "MERCK KGAA F.R.GERMANY > MERCK KGAA F.R-EGYPT", "price_egp": 50.0, "pack_count": null, "unit_price": null, "strength_mg": 0.1, "exact_strength": true, "exact_form": false, "discontinued": false, "also_contains": null } ], "condition_id": "amenorrhea" }, { "id": 141, "generic": "Progesterone", "line": 1, "is_adjunct": true, "form": "oral.solid", "strength_mg": 200.0, "adult_dose": "Oral micronised progesterone 200 mg daily for 12 days of each month. The Egyptian formulary's own HRT schedule is the same amount on named days: 200 mg at bedtime for 12 days, beginning on day 15 of the cycle and ending on day 26.", "adult_duration": "12 days every month, for as long as the oestrogen is taken", "dose_source": "Amenorrhea - disease-level clinical article (amenorrhea-full.txt)", "rationale": "Unopposed oestrogen in a woman with a uterus is the harm this prevents. The article gives indication and dose together: where the endometrium needs protecting, add micronised progesterone by mouth, 200 mg daily, for 12 days out of every month. The Egyptian formulary's HRT regimen agrees on the amount and adds the calendar. The two rows share a regimen marker so the screen says to give them together. Micronised progesterone 200 mg capsules are registered in Egypt.", "cautions": [ "GIVEN WITH the oestrogen, not instead of it, and only where the uterus is intact. After hysterectomy the oestrogen is given alone.", "The formulary's schedule: with the uterus still in place, a progestogen accompanies estradiol for 12 to 14 days or more in each 28-day cycle, started on the first day of bleeding - or on any day whatever, where periods are very infrequent or have stopped.", "It is sedating - the formulary's HRT regimen is written for bedtime, which is also how it is best tolerated.", "EXCLUDE PREGNANCY FIRST, before any hormone is started for absent periods." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "Not a paediatric prescription.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [ { "trade_name": "UTROCARE 200 MG 30 S.G. CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SAFE PHARMA > OCTOBER PHARMA", "price_egp": 204.0, "pack_count": null, "unit_price": null, "strength_mg": 200.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "PROGEST 200MG 30 ORAL/VAGINAL CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "PHARCO", "price_egp": 246.0, "pack_count": null, "unit_price": null, "strength_mg": 200.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "HYSTROGEST 200 MG 30 S.G.CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SAFE PHARMA > GLOBE INTERNATIONAL PHARMACEUTICALS", "price_egp": 264.0, "pack_count": null, "unit_price": null, "strength_mg": 200.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null } ], "condition_id": "amenorrhea" } ] }