For a patient presenting with primary amenorrhoea, the initial consideration in primary care is to refer them to secondary care for specialist investigation and management of the underlying cause NICE CKS.
Referral to secondary care should be considered for:
- Girls who have no secondary sexual characteristics and have not started menstruating by 13 years of age NICE CKS.
- Girls with normal secondary sexual characteristics who have not started menstruating by 15 years of age NICE CKS.
- Girls who have not started menstruating 3 years after thelarche (onset of breast development) or 5 years after thelarche if that occurred before the age of 10 NICE CKS.
Earlier referral should be considered if an abnormality is suspected, such as in those with:
- Abdominal or pelvic pain NICE CKS.
- Growth retardation NICE CKS.
- Symptoms and signs of androgen excess (such as hirsutism) or thyroid disease NICE CKS.
- Galactorrhoea NICE CKS.
- Suspected genital tract malformation, intracranial tumour (for example, prolactinoma), or chromosomal anomaly (for example, Turner's syndrome or androgen insensitivity) NICE CKS.
- Suspected eating disorder, which requires immediate referral to a community-based, age-appropriate eating disorder service NICE CKS.
Referral to a gynaecologist, preferably with a special interest in adolescent gynaecology, is appropriate for most girls with primary amenorrhoea NICE CKS. Referral to an endocrinologist is recommended for girls not showing any secondary sexual characteristics by age 13, or those with hyperprolactinaemia, thyroid disease, or features of androgen excess NICE CKS. Explicit UK-based recommendations on primary care management and when to refer are lacking in published literature, with recommendations based on expert opinion due to the specialist nature of required investigations NICE CKS.