# Amenorrhea (absent periods) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - 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) - Verified date: 2026-08 ## 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) ## Treatment metadata - Recognise and refer (Referral & Advice) - Cabergoline — 0.5 mg — oral.solid - Estradiol — topical - Progesterone — 200 mg — oral.solid ## Complete treatment card ```text AMENORRHEA (ABSENT PERIODS) 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 against 3 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (9) - Primary amenorrhea is defined as no periods by age 15, or by three years after breast budding starts [absent periods] - Secondary amenorrhea is absence of periods for three months or more if cycles were previously regular, or six months or more if cycles were previously irregular [absent periods] - A history of significant weight loss should be asked about [weight loss] - Loss of smell, milky nipple discharge, headaches, or visual changes point toward a brain or pituitary cause [loss of smell · nipple discharge] - Restrictive eating, heavy exercise, and psychological stress point toward functional hypothalamic amenorrhea [absent periods] - Hot flashes, night sweats, vaginal dryness, painful intercourse, or mood swings suggest low estrogen [hot flushes · night sweats · painful intercourse · vaginal dryness] - Cyclic pelvic pain, or a past uterine or cervical procedure, raises concern for a blocked outflow tract [abdominal pain · pelvic pain] - Male-pattern hair growth or hair loss and excess acne point to elevated androgens [acne · hair loss] - Excess urination and thirst raise concern for uncontrolled diabetes SIGNS - what you find (11) - A low BMI or recent weight loss is typical of functional hypothalamic amenorrhea [absent periods · weight loss] - Short stature without any breast or pubic hair development strongly points to gonadal dysgenesis [short stature] - A low hairline, high-arched palate, and webbed neck are classic Turner syndrome stigmata - A rounded moon-shaped face and a fat pad at the back of the neck suggest Cushing syndrome - Spontaneous or expressible milky nipple discharge points to elevated prolactin [nipple discharge] - Widely spaced nipples can be a feature of Turner syndrome - A palpable lower-abdominal mass may be an enlarged uterus or an ovarian mass [abdominal mass] - Elbow deformity, bowed or knock knees, or a short fourth metacarpal are further Turner stigmata [foot deformity · visible deformity] - Darkened, thickened skin folds (acanthosis nigricans) occur with PCOS or uncontrolled diabetes - A bulge felt on rectal exam from the proximal vagina suggests trapped menstrual blood behind a blocked outflow tract - The pelvic exam is usually normal in secondary amenorrhea but is key for spotting outflow tract abnormalities in primary amenorrhea [absent periods] TESTS (12) - Urine pregnancy testing is done first in every patient - Serum FSH, LH, and estradiol are checked in every patient - Pelvic ultrasound is part of the initial workup for every patient - Low FSH together with low estradiol points to a hypothalamic or pituitary cause - High FSH with low estradiol points to ovarian failure or gonadal dysgenesis - Elevated testosterone with polycystic ovaries on ultrasound is typical of PCOS - A high fasting 17-hydroxyprogesterone points to nonclassic congenital adrenal hyperplasia rather than PCOS - A high DHEAS points to an androgen-producing adrenal tumor - Karyotype testing is used when Turner syndrome or gonadal dysgenesis is suspected - MRI or CT of the head is considered when an intracranial cause is suspected, such as high prolactin or focal deficits - Pelvic ultrasound can detect uterine or vaginal anomalies and a distended uterus filled with trapped blood - An abnormal TSH points to thyroid disease as the underlying cause IF NOT THIS - what else fits (12) - Pregnancy is the first cause to rule out - Breastfeeding-related lactation can suppress periods - Menopause is on the differential - Certain medications, chemotherapy, or radiation can cause it - Functional hypothalamic amenorrhea is a hypothalamic cause - A prolactin-secreting or other hormone-secreting pituitary tumor is considered - Kallmann syndrome belongs on the differential - Primary ovarian insufficiency is an ovarian cause - Gonadal dysgenesis, such as Turner syndrome, is an ovarian cause - PCOS or other causes of excess androgen are considered - Thyroid disease is considered among the endocrine causes - Structural outflow tract problems such as an imperforate hymen or Müllerian agenesis are considered Source StatPearls "Amenorrhea" - disease-level clinical article Status traced to the source above !! MULTI-DRUG REGIMEN - all 2 drugs are given TOGETHER. Not a choice between them. !! the regimen: Estradiol + Progesterone Rx: Main treatment | Hyperprolactinaemia or prolactinoma - first-line | Oestrogen replacement in ovarian failure (POI, Kallmann) | Endometrial protection - GIVEN WITH the oestrogen when the uterus is intact MAIN TREATMENT 1. RECOGNISE AND REFER (REFERRAL & ADVICE) [1st line] Adult 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. - Refer, with advice Peds Children follow the same pathway: recognise and refer. No primary-care medicine is implied. Source No dose - referral pathway, no medicine given in primary care Why 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. Caution 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. HYPERPROLACTINAEMIA OR PROLACTINOMA - FIRST-LINE 2. CABERGOLINE [1st line] Adult 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. - Until prolactin has been normal for 6 months, then it may be stopped with periodic prolactin monitoring; use beyond 24 months is not established Peds The formulary states no paediatric dose for hyperprolactinaemia. An adolescent with primary amenorrhoea and a raised prolactin goes to paediatric endocrinology. 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) Why 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. Caution 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. Egypt CABERGOLACTO 0.5 MG 2 TABS. IDI > NOVELL ... 36.00 EGP (18.00/unit) CABERGLOBE 0.5 MG 2 TABS. EGPI > GLOBE ... 45.00 EGP (22.50/unit) MARVIGOLINE 0.5 MG 2 TABS. RAMEDA 66.00 EGP (33.00/unit) CABROSTINEX 0.5 MG 8 TABS. MEDIZEN PHARM... 339.00 EGP (42.38/unit) GOLINOTECH 0.5 MG 2 TABS. EUROPEAN EGYP... 103.00 EGP (51.50/unit) DOSTILACT 0.5 MG 2 TABS. ATCO PHARMA >... 105.00 EGP (52.50/unit) DOSTINEX 0.5 MG 2 TABS. PFIZER 172.00 EGP (86.00/unit) DELCABRIN 0.5 MG 2 SCORED TABS. EGPI > HEALTH... 105.00 EGP OESTROGEN REPLACEMENT IN OVARIAN FAILURE (POI, KALLMANN) 3. ESTRADIOL [1 of 2 - GIVE ALL TOGETHER] Adult 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. - Long-term, to the usual age of menopause - this is replacement, not symptom relief Peds 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. Source Amenorrhea - disease-level clinical article (amenorrhea-full.txt) Why 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. Caution 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. Egypt FEM 7 - 50 MCG 4 TRANSDERMAL PATCHES MERCK KGAA F.R.GERMANY > MERCK KGA... 30.00 EGP -> ? different route - not topical FEM 7 - 75 MCG 4 TRANSDERMAL PATCHES MERCK KGAA F.R.GERMANY > MERCK KGA... 40.00 EGP -> ? different route - not topical FEM 7 - 100 MCG 4 TRANSDERMAL PATCHES MERCK KGAA F.R.GERMANY > MERCK KG... 50.00 EGP -> ? different route - not topical ENDOMETRIAL PROTECTION - GIVEN WITH THE OESTROGEN WHEN THE UTERUS IS INTACT - give alongside 4. PROGESTERONE [2 of 2 - GIVE ALL TOGETHER] Adult 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. x 12 days every month, for as long as the oestrogen is taken Peds Not a paediatric prescription. Source Amenorrhea - disease-level clinical article (amenorrhea-full.txt) Why 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. Caution 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. Egypt UTROCARE 200 MG 30 S.G. CAPS. SAFE PHARMA >... 204.00 EGP PROGEST 200MG 30 ORAL/VAGINAL CAPS. PHARCO 246.00 EGP HYSTROGEST 200 MG 30 S.G.CAPS. SAFE PHARMA >... 264.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)