IVF and Fertility Specialists Clinic
Secondary Amenorrhea - Stepwise diagnostic approach and treatment for absent menstrual periods in a woman that previously had periods
What Is Secondary Amenorrhea?
Secondary amenorrhea is the absence of menstrual periods for 6 months in a woman who had previously been regular, or for 12 months in a woman who had irregular periods.
How Common Is Secondary Amenorrhea?
This problem is seen in about 1% of women of reproductive age.
Secondary Amenorrhea is a Symptom
Secondary amenorrhea is a symptom that can be caused by many pathological states. The diagnostic evaluation should lead to the correct diagnosis if the problem is approached in a logical stepwise manner.
Step 1 - Patient History
A good history can reveal the etiologic diagnosis in up to 85% of cases of amenorrhea.
A detailed menstrual history should be taken.
Step 2 - Physical Examination
Signs of androgen excess such as hirsutism (excess hair growth) and clitoromegaly (enlargement of the clitoris).
The breast exam may reveal galactorrhea (milky discharge from the breasts).
Estrogen deficiency may be suggested on pelvic exam by a smooth vagina that lacks the normal rugae (wrinkles) and a dry endocervix with no mucous.
Step 3 - Suggest Certain Etiologies from History and Exam
If the history and physical exam are suggestive of a certain etiology then the initial workup can be tailored appropriately.
Example Case Study:
For example, a 32 year old woman who has previously had regular periods now comes to the doctor after 8 months of not having any period following a D&C for heavy bleeding after a miscarriage. She most likely has intrauterine adhesions causing her lack of periods.
A reasonable approach to this patient would be:
Step 4 - Perform Diagnostic Evaluations
Some patients will not demonstrate any obvious etiology for their amenorrhea on history and physical exam. These patients can be worked up in a logical manner using a stepwise approach.
Diagnostic approaches may vary, however, differences pertain mainly to the order in which tests are performed.
There are several ways that a workup for secondary amenorrhea can be approached. One reasonable diagnostic approach is described here. If your doctor did things differently, that doesn't mean that he or she was wrong or that this approach is wrong. Every case should be treated individually.
Diagnostic Evaluation A - Thyroid Function
Diagnostic Evaluation B - Progestational Challenge (Progesterone Withdrawal Test)
The progestational challenge test is performed by giving a progestin (medication).
Read more about the specifics of the Progestational Challenge (Progesterone Withdrawal Test) - A Diagnostic Test for Secondary Amenorrhea.
Possible Diagnoses for Women with Withdrawal Bleeding
Chronic anovulation should be managed by periodic progestin withdrawal, or oral contraceptive pills if the patient does not currently desire pregnancy.
If the anovulatory state has been longstanding, endometrial biopsy should be considered to rule out significant hyperplasia or carcinoma of the endometrium.
Possible Diagnoses for Women without Withdrawal Bleeding
If adhesions are found, they should be hysteroscopically lysed if the woman wants pregnancy or regular periods.
Diagnostic Evaluation C - FSH testing
If the patient did bleed after the combined hormonal regimen (or if that step was skipped) the next test to obtain is an FSH level. This should not be drawn for about 2 weeks after the estrogen-progestin regimen is completed so that the hormone levels are not affected by the medications.
FSH Levels Indicating Ovarian Failure
Ovarian Failure (Premature Menopause)
Once ovarian failure is confirmed, consideration should be given to 3 possibilities:
Read more on Premature Ovarian Failure - Causes and Treatments
Patients who do not bleed after the progestin challenge but do bleed after estrogen/progestin and have normal or low FSH and LH levels have hypothalamic amenorrhea.
Hypothalamic dysfunction results in abnormal release of LH and FSH hormones from the pituitary. The end result is a lack of proper follicle development and ovulation.
Possible Causes of Hypothalamic Amenorrhea
Hypothalamic Amenorrhea of Uncertain Etiology
Patients with normal prolactin levels and normal imaging studies have hypothalamic amenorrhea of uncertain cause. If amenorrhea and lack of withdrawal bleeding persists, prolactin levels should be measured annually since a small microadenoma could be "hiding".
Treating Amenorrhea Caused by Anorexia Nervosa
Weight loss as a result of anorexia nervosa is an important diagnosis to make because of the mortality rate of 5-15%. Psychiatric counseling is indicated in most cases.
In this condition, as well as in the other hypothalamic amenorrhea situations, the patients can be significantly hypoestrogenic (a low estrogen situation similar to menopause).
If the state is persistent, hormone replacement therapy should be considered for protection against osteoporosis.
One approach is to get an estradiol level and if it is less than 30 pg/ml, counsel the patient that hormonal replacement therapy is indicated.
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