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 faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
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 Jan 25 2023, 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.
Menstruation requires functionality of the hypothalamus, pituitary, ovary, uterus and outflow tract. Secondary amenorrhea occurs when menses stop for 3 or more months. The most common causes of secondary amenorrhea include pregnancy, polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, and ovarian failure. Most secondary amenorrhea is anovulatory. When ovulatory dysfunction occurs, menstrual flow may not occur, and anovulatory amenorrhea is the result. Ovulatory amenorrhea occurs when anatomic abnormalities (outflow obstruction, intrauterine adhesions) prevent normal menstrual flow despite normal hormonal cycles.
An evaluation for secondary amenorrhea should be considered if menses have been absent for over 3 months, or there is oligomenorrhea resulting in less than 9 cycles a year
Take a thorough history
Menstrual history | Sexual history | Past medical history |Current medications | Lifestyle factors |
Physical exam: particular attention to galactorrhea, virilization, signs of estrogen deficiency, acanthosis nigricans
Constitutional features: height, weight, BMI
Genital exam: inner and outer genitalia
Always rule out pregnancy!
Initial tests should include: TSH, prolactin, FSH, LH
Brain MRI to check pituitary if elevated prolactin
High FSH, consider premature ovarian failure (POF) and genetic follow up
Should be confirmed with multiple FSH levels in the menopausal range
If history or physical are suggestive of hyperandrogenism, check serum free 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
Rotterdam Criteria: 1. Oligo- or anovulation 2. Clinical or biochemical signs of hyperandrogenism 3. Ultrasound evidence of polycystic ovaries
Estrogen-progestin trial to stimulate withdrawal bleeding is no longer recommended
Unreliability in correlation with estrogen status and high false positive rate
Functional hypothalamic amenorrhea: a low estrogen state independent of structural disease
Occurs when HOP access is suppressed from stress, weight loss, exercise, eating disorder
Low FSH, LH, and estradiol (although this can fluctuate)
Female athelete triage: insufficient caloric intake, low bone density, amenorrhea
Treatment: aim to correct underlying cause via nutritional rehabilitation, reduction in stress and exercise
Combined OCs should not be used for bone density correction
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 another causeis common and FSH levels will be normal or low. Treat with lifestyle modications aimed at underlying cause
Use or abuse of drugsDrug use (e.g. oral contraceptives, depoprogesterone, antidepressants, antipsychotics, antihypertensives, cocaine, chemotherapy, OTC products)
Progestin challenge test has fallen out of favor due to unreliability in correlation with estrogen status
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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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