Amenorrhea icd 10: Alarming symptoms, causes, treatment and more

Amenorrhea  icd 10 – the absence of  menstruation for 6 months in a woman who previously had a normal menstrual cycle; absence of menstruation in girls under 16 years of age (primary amenorrhea).

Amenorrhea icd 10 is not an independent  diagnosis, but a symptom indicating  anatomical, biochemical , genetic, physiological or mental disorders. The frequency of secondary amenorrhea is at least 3%. Amenorrhea can be physiological under certain conditions: menarche, pregnancy, lactation,  menopause.

Amenorrhea ICD-10: N91.2 – Amenorrhea unspecified

ICD-10

International classification of diseases

International Statistical Classification of Diseases and Related Health Problems (ICD-10)

•  Classes ICD-10
•  N00-N99 Diseases of the genitourinary system
•  N80-N98 Non-inflammatory diseases of the female genital organs
•  N91 Lack of menstruation, scanty and infrequent menstruation
•  N91.2 Amenorrhea unspecified

N91.2 AMENORRHEA, UNSPECIFIED
N91 LACK OF MENSES, SCANTY AND INFREQUENT MENSES

N91.0 Primary amenorrhea

N91.1 Secondary amenorrhea

N91.2 Amenorrhea, unspecified

N91.3 Primary oligomenorrhea

N91.4 Secondary oligomenorrhea

N91.5 Oligomenorrhea, unspecified

Classification of amenorrhea icd 10

True amenorrhea : there are no cyclical changes in the  ovaries, endometrium and throughout the body, no menstruation. The hormonal  function of the ovaries is sharply reduced, sex hormones for the implementation of cyclical changes in the endometrium are not enough.

False amenorrhea: the absence of periodic discharge of menstrual fluid from the  vagina in the presence of cyclical changes in the ovaries, uterus and throughout the body (for example, solid  hymen,  vaginal and cervical atresia ; blood secreted during menstruation accumulates in the vagina hematocolpos, hematometer uterus, tubes hematosalpinx)

In many adolescent girls, the duration of amenorrhea is 2 to 12 months during the first 2 years after menarche.

Spontaneous menopause can occur in women after 30 years.

Postpartum amenorrhea : Can last up to 2–3 years in cases of breastfeeding.

Pathological amenorrhea :

1. Primary: no menses or other signs of puberty before age 14 or no menses before age 16 with other signs of puberty
2. Secondary: a woman who has menstruated earlier does not have menstruation within 6 months or within 3 months with a history of oligomenorrhea .
3. Etiotropic classification: amenorrhea is normogonadotropic (eugonadotropic), hypergonadotropic, hypogonadotropic.

I. Amenorrhea  – absence of menstruation for 3 months or more.

II. Cyclic changes in menstruation

• hypermenorrhea (menorrhagia) – an increase in the amount of blood during the onset of menstruation with its normal duration;
• hypomenorrhea  – scanty menstruation on time;
• polymenorrhea  – menstruation lasting more than 7 days with a moderate amount of blood;
• oligomenorrhea  – short (1-2 days), regularly occurring menstruation with a moderate amount of blood;
• opsomenorrhea  – rare menstruation at intervals from 36 days to 3 months lasting 3-5 days with a moderate amount of blood;
• proyomenorrhea  – shortening of the duration of the menstrual cycle (less than 21 days).

III. Uterine bleeding (metrorrhagia)

• anovulatory, arising in the middle of the menstrual cycle against the background of the absence of ovulation – the release of the egg ;
• acyclic (dysfunctional), arising regardless of ovulation.

IV. Algomenorrhea  – painful menstruation.

Dysmenorrhea  – painful menstruation, accompanied by general vegetative-neurotic disorders (instability of mood, emotions, palpitations, sweating, nausea and / or vomiting, lack of appetite, etc.).

Causes of amenorrhea icd 10

Primary amenorrhea icd 10

1. The defeat of the gonads: Turner syndrome,  testicular feminization syndrome, resistant ovary syndrome,  Mayer-Rokitansky-Kuster-Hauser syndrome,  malformations of the uterus and ovaries
2. Extragonadal pathology: hypopituitarism, hypogonadotropic hypogonadism, delayed menarche, congenital  adrenal hyperplasia
3. Violation of the patency of the entrance to the vagina, vagina, cervical canal and uterine cavity.

Secondary amenorrhea icd 10

1. Psychogenic amenorrhea ( stress )
2. Hypothalamic form – amenorrhea against weight loss
3. Hypothalamic – pituitary  form
4. Hyperprolactinemia  – functional and organic forms
5. Hypogonadotropic
6. Postpartum hypopituitarism (Skien’s syndrome)
7. Stop taking oral contraceptives
8. Drugs oral glucocorticoids, danazol, analogs of gonadotropin-releasing hormone, chemotherapy drugs
9. Decompensated endocrinopathies:  diabetes mellitus,  hypo- and  hyperthyroidism
10. Adrenal form
11. Postpubertal adrenogenital syndrome
12. Virilizing tumor of the adrenal gland
13. Ovarian form
14. Ovarian wasting syndrome
15. Refractory ovary syndrome
16. Virilizing tumors of the ovaries
17. Asherman’s syndrome  (intrauterine synechiae)
18. Specific endometritis.

Genetic aspects. There are many inherited disorders associated with amenorrhea (eg aromatase deficiency).

Risk factors of amenorrhea icd 10

1. Physical overload
2. Eating disorders (including overeating and starvation)
3. Psychoemotional stress.

Alarming symptoms of amenorrhea icd 10

The following symptoms are alarming:

• Delayed puberty
• Virilization
• Visual field defects
• Smell impairment
• Spontaneous milk discharge
• Significant weight gain or loss

Clinical picture

1. Lack of menstruation. With delayed menarche, it is important to assess the degree of development of secondary sexual characteristics, the state of the hymen
2. Loss of fertility
3. Vegetative dysfunction
4. Obesity  – 40% of patients
5. Signs of defeminization , masculinization, thyroid or adrenal  dysfunction, and somatic disorders
6. Signs of androgen excess  (increased skin oiliness,  acne, hirsutism).

Diagnosis of amenorrhea icd 10

1. Testing on Pregnancy  (determination of the level of hCG in the blood serum)
2. Prolactin in blood plasma
   1. Normal prolactin concentration (below 20 ng / ml) in the presence of bleeding after discontinuation of  progesterone and in the absence of galactorrhea excludes pituitary tumor
   2. In case of hyperprolactinemia, an examination of the pituitary gland is necessary.
3. FSH and LH
   1. If the cause of the amenorrhea is gonadal dysgenesis, the FSH level will be high (more than 40 mIU / ml). It is necessary to examine the karyotype to exclude the Y  chromosome
   2. Low FSH concentration (below 5 mIU / ml) indicates pituitary hypofunction, possibly due to hypothalamic dysfunction
   3. An increased LH / FSH ratio (not less than 2) is an important diagnostic sign of polycystic ovary disease. The LH content is usually increased, and the FSH concentration is at the lower limit of the norm.
4. T4, TTG
5. Glucose blood test for glucose tolerance
6. Progesterone test (10 mg / day medroxyprogesterone for 7-10 days)
   1. Negative: Menstrual bleeding does not occur in the absence of  estrogenic effects on the endometrium or with pathological changes in the endometrium.
   2. Positive: with anovulation with preserved estrogen secretion , bleeding occurs .

Special studies

1. Laparoscopy  – indicated for the determination of dysgenesis of the Müllerian ducts and ovaries, with suspicion of polycystic ovary
2. Ultrasound can detect cysts
3. X-ray examination of the  Turkish saddle with suspected prolactinoma
4. Assessment of the state of the  endometrium
5. Sequential use of  estrogens and  progesterone (2.5 mg / day of estrogen for 21 days, and in the last 5 days – 20 mg / day of medroxyprogesterone )
6. Subsequent bleeding is a sign of hypo- or hypergonadotropic amenorrhea
7. The absence of bleeding indicates either an abnormality of the genital tract, or the presence of a dysfunctional endometrium
8. The presence of a dysfunctional endometrium can be confirmed by  hysterosalpingography or hysteroscopy
9. Intravenous pyelography is required for all patients with dysgenesis shared duct, often associated with renal abnormalities
10. Computed tomography,  MRI.

Differential diagnosis

1. The first stage is to clarify the primary or secondary nature of amenorrhea icd 10
2. The second stage is the differentiation of the causes that caused amenorrhea icd 10 in each specific case.

Complications of amenorrhea icd 10

• Signs of estrogen deficiency, such as hot flashes, vaginal dryness
• Osteoporosis with prolonged amenorrhea with low levels of estrogen in the blood.

The course and prognosis depend on the cause of the amenorrhea. With the hypothalamic-pituitary etiology of amenorrhea, the onset of menstruation within 6 months was noted in 99% of patients, especially after correction of body weight.

Eugonadotropic amenorrhea

The effectiveness of treatment depends on the identification of etiological factors.  Hormone replacement therapy begins after 6 months of amenorrhea to prevent the development of osteoporosis  and hypercholesterolemia  due to estrogen ^deficiency.

1. Congenital anomalies
   1. Dissection of an overgrown  hymen or transverse vaginal septum
   2. Creation of an artificial vagina in its absence.
2. Acquired anomalies
   1. Curettage of the cervical canal and uterine cavity with or without  hysteroscopy
   2. Insertion of a baby Foley balloon catheter or intrauterine devices  into the uterus
   3. The use of antibiotics  broad spectrum of action for 10 days to prevent infection
   4. Cyclic hormone therapy with high doses of estrogens (10 mg / day of estrogen for 21 days, 10 mg / day of  medroxyprogesterone daily for the last 7 days of the cycle for 6 months) for endometrial  regeneration .
3. Polycystic ovary syndrome. The two main goals of treatment are to reduce  androgen excess symptoms and restore ovulation and fertility. The achievement of the first goal (for example, by  contraception) may precede the achievement of the second.
   1. For relieving symptoms of excess androgens
   2. Oral contraceptives  (combining estrogen with a  progestin)
   3. Glucocorticoid medications, such as  dexamethasone 0.5 mg at bedtime (as ACTH  peaks in the early morning)
   4. Spironolactone 100mg 1-2r / day (reduces the synthesis of androgens in the ovaries and  adrenal glands  and  inhibits the binding of androgens to the receptors of hair follicles and other targets)
   5. The effects of hormone therapy on unwanted hair growth on the face and body rarely occur quickly (improvement is observed no earlier than after 3-6 months).  Artificial hair removal is often necessary: shaving, electrolysis , chemical hair removal .

With infertility

1. Clomiphene citrate , by blocking the binding of estrogen to receptors in target cells (hypothalamus and pituitary gland), stimulates the formation of LH and FSH. When administered from day 5 to day 9 of a progesterone-induced cycle, clomiphene citrate often stimulates follicular maturation and ovulation
2. GonadotropinMenopausal (has the bioactivity of FSH and LH) is administered parenterally daily until the level of estrogen in the blood increases and the maturation of  follicles in the ovaries is detected  using ultrasound. Further, to stimulate ovulation, HCT is administered. Due to the risk of ovarian hyperstimulation and the occurrence of multiple pregnancies, such therapy is carried out only if other methods are ineffective.

1. Gonadorelin 0.1 mg IV or SC can induce ovulation without ovarian hyperstimulation.
2. For chronic  anovulation  and abnormal menstrual bleeding, a progestin (eg, 10 mg of medroxyprogesterone acetate for 10 days every 1 to 3 months) or cyclic estrogen-progestin therapy.(interrupt persistent  endometrial proliferation ).
3. With hypertecosis and androgen-secreting ovarian tumors,  oophorectomy is  indicated
4. Congenital adrenal hyperplasia (adrenogenital syndrome)
5. Hydrocortisone replacement therapy to suppress  ACTH secretion and excessive androgen synthesis
6. Mineralocorticoid replacement therapy (eg,  deoxycorticosterone acetate) for the salt-wasting form of adrenogenital syndrome
7. Surgical correction of external genital anomalies.

Hyperprolactinemia. There is no effective therapy for amenorrhea of this type.

1. Estrogen replacement therapy is indicated for genetic disorders in order to form secondary sexual characteristics (2.5 mg of estrogen for 21 days and medroxyprogesterone 10 mg / day daily for the last 7 days of the cycle). When estrogens with progesterone are prescribed, regular menstrual bleeding occurs, but fertility is not achieved.
2. Bromocriptine recommended for patients with hyperprolactinemia with a normal pituitary gland or microadenoma in a continuous mode from 2.5 to 7.5 mg / day. After 30-60 days, the menstrual cycle is restored, in 70-80% of patients, if desired, pregnancy occurs after 2-3 months.
3. Surgical excision of the  gonads containing the Y chromosome.

Hypogonadotropic amenorrhea

Therapy depends on the patient’s interest in pregnancy.

1. Periodic progestin therapy (medroxyprogesterone 10 mg / day for 5 days every 8 weeks) is prescribed for women who are not interested in pregnancy.
2. Recently, the stimulation of ovulation and even the onset of pregnancy have become possible with the use of synthetic analogs of gonadoliberins (with a potentially active pituitary gland).
3. For women wishing to become pregnant, ovulation is stimulated with clomiphene citrate or gonadotropins.
4. Surgical treatment is indicated for tumors of the central nervous system.
5. Treatment of diseases of the thyroid or adrenal glands.

Contraindications for the use of estrogens

1. Pregnancy
2. Hypercoagulability and increased tendency to thrombus formation
3. MI, history of stroke
4. Estrogen-dependent tumors
5. Severe liver dysfunction.

Precautionary measures

1. Caution should be exercised when prescribing drugs for concomitant diabetes mellitus, epilepsy, or migraine
2. Smoking (especially in women over 35 years old) increases the risk of developing severe side effects from the CVS and central nervous system, for example, cerebral ischemia, angina attacks, thrombophlebitis, PE

When using estrogens, side effects are possible: fluid retention in the body and nausea, thrombophlebitis and arterial hypertension.

Drug interactions

1. Barbiturates, phenytoin (diphenin), rifampicin accelerate the biotransformation of progestins
2. Estrogens slow down the metabolism of glucocorticoids, enhancing their therapeutic and toxic effects
3. Estrogens weaken the effect of oral anticoagulants.

Monitoring depends on the cause of amenorrhea, treatment tactics.  Replacement therapy is recommended to be discontinued after 6 months for self-renewal of menstruation.

Treatment for amenorrhea icd 10

Treatment is directed at the underlying disease; this treatment sometimes results in menstruation recovery. For example, most conditions that obstruct the flow of menstrual blood are surgically corrected.

In the presence of a Y chromosome due to the risk of developing germ cell cancer, removal of the ovaries (gonads) on both sides is recommended.

Problems associated with amenorrhea may, in turn, require treatment, including:

• Ovulation induction with an interest in pregnancy
• Treating manifestations of long-term estrogen deficiency (eg, osteoporosis , cardiovascular disorders, vaginal atrophy)
• Treating manifestations of long-term elevated  estrogen levels (eg, prolonged bleeding, persistent and significant breast tenderness, endometrial hyperplasia and cancer)
• Maximum possible reduction in hirsutism and long-term exposure to elevated androgen levels (such as cardiovascular disorders, hypertension)

Key points

• Primary amenorrhea icd 10 in patients with normal secondary sex characteristics is usually anovulatory (eg, due to genetic disorders).
• In all cases, pregnancy should be ruled out by test, not history.
• Evaluation of patients with primary amenorrhea icd 10 differs from that of patients with secondary amenorrhea icd 10.
• In case of primary amenorrhea icd 10 in a patient with normally developed secondary sexual characteristics, the examination should be started with an ultrasound examination of the pelvic organs in order to exclude congenital anotomic obstructions of the genital tract.
• If the patient has symptoms of virilization, first of all, conditions that cause an increased level of androgens (for example, polycystic ovary syndrome, androgen-producing tumor, Cushing’s syndrome, taking a number of medications) should be excluded.
• If the patient has symptoms and signs of estrogen deficiency (for example, hot flashes, night sweats, dryness and atrophy of the vaginal mucosa), first of all, primary ovarian failure and conditions that cause functional hypothalamic anovulation should be excluded.
• If the patient has galactorrhea, conditions leading to hyperprolactinemia (for example, pituitary dysfunction, taking a number of medications) should be excluded.