Gynecology Book

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Secondary Amenorrhea

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  1. Definition
    1. Previously regular cycles: 3 months of no Menses
    2. Previously irregular cycles: 6 months of no Menses
  2. Causes: General
    1. Luteal Phase dysfunction
      1. Insufficient Progesterone
    2. Anovulation
      1. Unopposed Estrogen leads to long cycles
    3. HypoEstrogenemia (Most common)
      1. Able to conceive
  3. Causes: Axis Associated
    1. See Hypogonadism
    2. Axis 1: Hypothalamic or Central
      1. Anovulation (50%)
      2. Post-Hormonal Contraception (Post-Pill)
    3. Axis 2: Pituitary
      1. Hyperprolactinemia (25%)
      2. Sheehan's Syndrome (rare)
      3. Hypothyroidism (1%): Prolactin-like effect
    4. Axis 3: Ovary
      1. Polycystic Ovary Syndrome (8%)
      2. Turners Syndrome (1%)
        1. Findings: Short stature, Web neck, Shield chest
      3. Premature Ovarian Failure (10%)
      4. Oophoritis (rare)
        1. Chemotherapy or Radiation
        2. Infection (e.g. Mumps, Tuberculosis)
    5. Axis 4: Uterus
      1. Asherman's Syndrome (5%)
      2. Endometritis
  4. History
    1. Menstrual history
      1. Age at Menarche
      2. Menstrual Cycle characteristics
      3. Premenstrual symptoms
    2. Obstetric history and other past medical history
    3. Medications
    4. Female Athlete Triad
      1. Diet, Weight change, or Eating disorder
      2. Overtraining or Exercise addiction
      3. History of Stress Fractures
    5. Prolactinoma symptoms
      1. Galactorrhea
      2. Headache
      3. Bitemporal field cut
    6. Polycystic ovary symptoms and signs
      1. Hirsutism
      2. Acne Vulgaris
    7. Family History of genetic anomaly
    8. Other history
      1. Vasomotor Symptoms of Menopause (e.g. Hot Flushes)
      2. Hypothyroidism symptoms
      3. Anosmia (Kallmann Syndrome)
  5. Examination
    1. Rule out uterine or ovarian anomaly
    2. Focus areas
      1. Body Mass Index
      2. Hyperandrogenism (e.g. Hirsutism)
      3. Cushing's Disease Signs
      4. Thyromegaly
  6. Initial tests:
    1. Urine Pregnancy Test (Beta hCG)
    2. Serum Prolactin
    3. Thyroid Stimulating Hormone (TSH)
  7. Algorithm
    1. Step 0: Evaluate Tests above
      1. Pregnancy
      2. Hypothyroidism or Hyperthyroidism
      3. Hyperprolactinemia (especially if >100 ng/ml)
    2. Step 1: Progesterone Challenge Test
    3. Step 2a: Any bleeding with Progesterone (within 7 days)
      1. Suggests Progesterone insufficiency (Anovulation)
        1. Unopposed Estrogen with risk of Endometrial Cancer
      2. Option 1: Treat Anovulation empirically
        1. Provera 10 mg qd for 10 days per month or
        2. Oral Contraceptives
      3. Option 2: Check serum Luteinizing hormone (LH)
        1. Luteinizing hormone (LH) High
          1. Polycystic Ovary Syndrome
            1. Androgen Excess
            2. Unopposed Estrogen
          2. Needs Progesterone cycling (see above)
        2. Luteinizing hormone (LH) Low or Normal
          1. Hypothalamic origin
          2. Check Pituitary MRI or CT (Cone down Sella)
    4. Step 2b: No Bleeding occurs with Progesterone Challenge
      1. Ascertain Estrogen Level
        1. Perform Estrogen-Progesterone Challenge Test or
        2. Check Serum Estrogen level or
      2. Estrogen Normal (no bleeding occurs with OCP)
        1. Suggests uterine bleeding outflow obstruction
        2. Example: abnormal uterus (e.g. Asherman's Syndrome)
      3. Estrogen Low (bleeding occurs with OCP)
        1. Obtain Serum FSH and Serum LH
        2. Serum FSH and Serum LH <5
          1. See Hypogonadotropic Hypogonadism
          2. Hypothalamic origin
          3. Check Pituitary MRI or CT (Cone down Sella)
        3. Serum FSH >20 and Serum LH >40
          1. See Hypergonadotropic Hypogonadism
          2. Suggests ovarian failure
          3. Female Athlete Triad
          4. Premature Ovarian Failure
  8. References
    1. Master-Hunter (2006) Am Fam Physician 73:1374
    2. Mclver (1997) Mayo Clin Proc 72:1161

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