Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Choose when to start an evaluation for secondary amenorrhea 2. List the most common causes of secondary amenorrhea in women of reproductive age
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
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
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.
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)
OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.
Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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