GYN
CMECNE

Secondary Amenorrhea: Workup and Diagnosis  

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Learning Objectives and CME/Disclosure Information

CLINICAL ACTIONS:

An evaluation for secondary amenorrhea should be considered if menses have been absent for over 3 months, or more than 3 typical cycles.

  • Take a thorough history with particular attention to galactorrhea, virilization, signs of estrogen deficiency, acanthosis nigrans
    • An elevated BMI will point towards different diagnoses, primarily polycystic ovarian syndrome (PCOS)
  • Initial tests should include: pregnancy, TSH, prolactin, FSH
    • Brain MRI to check pituitary if elevated prolactin
    • High FSH, consider premature ovarian failure (POF) and genetic follow up
  • If virilization present, check serum testosterone and dehydroepiandrosterone sulfate (DHEAS)
    • Pelvic ultrasound and adrenal CT if elevated to check for androgen secreting tumor
    • Consider polycystic ovary syndrome (PCOS) diagnosis if testosterone and DHEAS normal
  • If all testing normal, consider estrogen-progestin trial to stimulate withdrawal bleeding
    • Positive withdrawal bleed points to hypothalamic/pituitary dysfunction/ovarian insufficiency
    • Negative bleed suggests outflow blockage such as Asherman’s syndrome

SYNOPSIS:

Menstruation requires functionality of the hypothalamus, pituitary, ovary, uterus and outflow tract. When ovulatory dysfunction occurs the cycle of endometrial changes is disrupted, menstrual flow may not occur, and anovulatory amenorrhea is the result. Most secondary amenorrhea is anovulatory. Ovulatory amenorrhea occurs when anatomic abnormalities (outflow obstruction, intrauterine adhesions) prevent normal menstrual flow despite normal hormonal cycles.

KEY POINTS:

When evaluating patients with secondary amenorrhea consider the following:

  • Pregnancy is the most common cause of secondary amenorrhea in women of reproductive age
  • Functional hypothalamic anovulation (e.g., due to excessive exercise, eating disorders, or stress) is common and FSH levels will be normal or low
  • Use or abuse of drugs (e.g. oral contraceptives, depoprogesterone, antidepressants, antipsychotics, antihypertensives, cocaine, chemotherapy, OTC products)
  • Breastfeeding
  • PCOS diagnosis
  • Diagnosis code: ICD-10-CM N91.1

Learn More – Primary Sources:

Amenorrhea: an approach to diagnosis and management

Functional hypothalamic amenorrhea and its influence on women’s health

Evaluation of Amenorrhea, Anovulation, and Abnormal Bleeding

Locate a genetic counselor or genetics services:

Genetic Services Locator-ACMG

Genetic Services Locator-NSGC

Genetic Services Locator-CAGC

Take a post-test and get CME credits

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Related ObG Topics:

Managing Abnormal Uterine Bleeding with Ovulatory Dysfunction
Polycystic Ovary Syndrome: Making the Diagnosis
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