When should I refer a patient with amenorrhoea for specialist evaluation?

Refer a patient with amenorrhoea for specialist evaluation in the following situations:

• Girls with primary amenorrhoea who have no secondary sexual characteristics and have not started menstruating by 13 years of age.
• Girls with normal secondary sexual characteristics who have not started menstruating by 15 years of age.
• Girls who have not started menstruating 3 years after thelarche (breast development), or 5 years after thelarche if it occurred before age 10.
• Refer earlier if there is concern from the patient or parents, or if abnormalities are suspected, such as abdominal or pelvic pain, growth retardation, signs of androgen excess (e.g., hirsutism), thyroid disease, galactorrhoea, suspected genital tract malformation, intracranial tumour, chromosomal anomalies, or suspected eating disorder.
• Immediate referral to a specialist eating disorder service is required if an eating disorder is suspected.
• Referral to a gynaecologist (preferably with adolescent gynaecology expertise) is appropriate for most girls with primary amenorrhoea.
• Referral to an endocrinologist is recommended for girls without secondary sexual characteristics by age 13, or those with hyperprolactinaemia, thyroid disease, or features of androgen excess.
• For amenorrhoea caused by weight loss, excessive exercise, stress, or chronic illness, refer after excluding other hypothalamic or pituitary causes.
• If amenorrhoea persists for more than 6 months, consider osteoporosis risk and possible specialist input.

These referral criteria ensure prompt and comprehensive specialist assessment and management of underlying causes of amenorrhoea.

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