Amenorrhea and bone health in adolescents and young women

We present an update on amenorrhea in adolescent girls and young women. Amenorrhea may herald the onset of estrogen deficiency, which can adversely affect peak bone mass and ultimate risk of osteoporosis.

Adolescence is a critical period for bone accretion. Important modifiable factors that optimize bone accretion during this time are calcium intake, vitamin D, nutrition, and exercise. Another modifiable factor in the hands of the clinician is the prompt recognition and therapy of amenorrhea associated with estrogen deficient states, caused by conditions such as hyperprolactinemia and ovarian failure. An important recent observation is that adolescents with amenorrhea who diet, but who do not meet diagnostic criteria for anorexia nervosa, are nonetheless at significant risk for low bone density. Also, multiple factors contribute to the bone loss experienced by patients with anorexia nervosa, and the associated estrogen deficiency may not be the major contributor. Recent evidence also suggests that the contraceptive depot medroxyprogesterone acetate may contribute to impaired bone accretion. While estrogen/progestin replacement therapy has a clear role in the management of girls and young women with primary ovarian insufficiency, the exact role of this therapy in the amenorrhea associated with anorexia nervosa or exercise remains controversial.

Increasingly, osteoporosis prevention is recognized as an important role for health care providers of adolescent girls and young women. Viewed from this perspective, there is a need for more aggressive evaluation and management of amenorrhea, and research is needed to define sound and cost effective strategies.