Gynecology Book

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Secondary Amenorrhea

Aka: Secondary Amenorrhea
  1. See Also
    1. Amenorrhea
    2. Primary Amenorrhea
    3. Delayed Puberty
    4. Hypogonadism
  2. Definition
    1. Previously regular cycles: 3 months of no Menses
    2. Previously irregular cycles: 6 months of no Menses
  3. Causes: Axis Associated
    1. See Hypogonadism
    2. Axis 1: Hypothalamic or Central
      1. Anovulation (50% of secondary causes)
      2. Post-Hor monal Contraception (Post-Pill Amenorrhea)
      3. CNS injury
        1. Traumatic Brain Injury
        2. Meningitis
        3. CNS Neoplasm
      4. Miscellaneous
        1. Eating Disorder (e.g. Anorexia Nervosa)
        2. Malabsorption, malnutrition or rapid weight loss
    3. Axis 2: Pituitary
      1. Hyperprolactinemia (25% of secondary causes)
        1. See Medication Causes of Hyperprolactinemia
      2. Sheehan Syndrome (rare)
      3. Hypothyroidism (1% of secondary causes): Prolactin-like effect
      4. Pituitary infiltration (e.g. Sarcoidosis)
      5. Cushing Syndrome
    4. Axis 3: Ovary
      1. Polycystic Ovary Syndrome (8% of secondary causes)
      2. Premature Ovarian Failure (10% of secondary causes)
      3. Oophoritis (rare)
        1. Chemotherapy or Radiation
        2. Infection (e.g. Mumps, Tuberculosis)
    5. Axis 4: Uterus
      1. Asherman's Syndrome (5%)
      2. Endometritis
      3. Cervical stenosis
  4. Causes: Miscellaneous
    1. Other endocrine causes
      1. See Hypoandrogenism
      2. Adrenal hyperplasia (adult onset)
      3. Androgen-secreting tumor
      4. Cushing Syndrome
      5. Polycystic Ovary Syndrome
      6. Severe Hyperthyroidism
    2. Physiologic causes
      1. Pregnancy!
      2. Lactation
      3. Contraception
      4. Menopause
      5. Exogenous androgens
  5. Pathophysiology: Mechanisms
    1. Luteal Phase dysfunction
      1. Insufficient Progesterone
    2. Anovulation
      1. Unopposed Estrogen leads to long cycles
    3. Hypoestrogenemia (Most common)
      1. Able to conceive
  6. 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. Growth abnormalities
      1. Short Stature (Turner Syndrome)
    9. Other history
      1. Vasomotor Symptoms of Menopause (e.g. Hot Flushes)
      2. Hypothyroidism symptoms
      3. Anosmia (Kallmann Syndrome)
  7. 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
  8. Labs
    1. Urine Pregnancy Test (UPT)
    2. Serum Luteinizing hormone (LH)
    3. Serum Follicle Stimulating Hormone (FSH)
    4. Thyroid Stimulating Hormone (TSH)
    5. Serum Prolactin
    6. Serum Estrogen
  9. Imaging
    1. Pelvic Ultrasound
  10. Approach: Protocol 1
    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 Challenge Test (within 7 days)
      1. Suggests Progesterone insufficiency (Anovulation)
        1. Unopposed Estrogen with risk of Endometrial Cancer
      2. Option 1: Treat Anovulation empirically (especially if otherwise asymptomatic)
        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. Management
            1. Progesterone cycling (see above regarding Unopposed Estrogen)
        2. Luteinizing hormone (LH) Low or Normal
          1. Hypothalamic Amenorrhea
            1. Eating Disorder
            2. Chronic illness
            3. Pituitary Lesion (may present with Headaches and vision changes)
          2. Evaluation
            1. 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
      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
  11. Approach: Protocol 2
    1. Step 0: Evaluate Tests above
      1. Pregnancy
      2. Hypothyroidism or Hyperthyroidism
      3. Hyperprolactinemia (especially if >100 ng/ml)
    2. Step 1: FSH and LH increased
      1. Evaluation
        1. Confirm with repeat LH and FSH in one month
        2. Obtain karyotype for Turner Syndrome if Short Stature
      2. Diagnosis
        1. Primary Ovarian Insufficiency (Premature Ovarian Failure)
    3. Step 2: Hyperandrogenism findings
      1. Evaluation
        1. Serum Androgens (Serum Testosterone and DHEA-S)
          1. Consider adrenal or ovarian tumor if very high androgen levels or rapid onset of symptoms
        2. 17-Hydroxyprogesterone (at 7am)
          1. Consider late-onset Congenital Adrenal Hyperplasia
      2. Diagnosis
        1. Polycystic Ovary Syndrome (PCOS)
    4. Step 3: Pituitary or other CNS Lesion suspected (e.g. Headache, vision change)
      1. Evaluation
        1. Head MRI or Head CT with cone-down sella turcica views
      2. Diagnosis
        1. Pituitary Lesion
    5. Step 4: Structural abnormality suspected
      1. Evaluation
        1. Consider Oral Contraceptive cycling trial (failed trial suggests structural abnormality)
        2. Consider Hysteroscopy
      2. Diagnosis
        1. Outflow obstruction
        2. Uterine abnormality
    6. Step 5: Functional Amenorrhea suspected
      1. Evaluation
        1. Nutritional History
        2. Eating Disorder history
      2. Diagnosis
        1. Femal athlete triad
        2. Poor nutritional status
  12. References
    1. (2008) Fertil Steril 90(5 suppl): S219-25 [PubMed]
    2. Klein (2013) Am Fam Physician 87(11): 781-88 [PubMed]
    3. Master-Hunter (2006) Am Fam Physician 73:1374-87 [PubMed]
    4. Mclver (1997) Mayo Clin Proc 72:1161-9 [PubMed]

Secondary physiologic amenorrhea (C0232940)

Definition (NCI) The cessation of menstruation for six months or more in a female that is not pregnant, breastfeeding or menopausal.(NICHD)
Concepts Disease or Syndrome (T047)
ICD10 N91.1
SnomedCT 198413004, 156036003, 86030004
Dutch secundaire amenorroe, amenorroe; secundair, secundair; amenorroe, Secundaire amenorroe
French Aménorrhée secondaire
German Amenorrhoe sekundaer, sekundaere Amenorrhoe, Sekundaere Amenorrhoe
Italian Amenorrea secondaria
Portuguese Amenorreia secundária
Spanish Amenorrea secundaria, amenorrea fisiológica secundaria (hallazgo), amenorrea fisiológica secundaria, amenorrea secundaria
Japanese 続発性無月経症, 続発性無月経, ゾクハツセイムゲッケイショウ, ゾクハツセイムゲッケイ
English secondary amenorrhea, secondary amenorrhea (diagnosis), Amenorrhoea secondary, amenorrhoea secondary, amenorrhea secondary, Secondary amenorrhoea (finding), Secondary Amenorrhea, Secondary physiologic amenorrhea, Secondary amenorrhea, Secondary amenorrhoea, Secondary physiologic amenorrhoea, Secondary physiologic amenorrhea (finding), Amenorrhea secondary, amenorrhea; secondary, secondary; amenorrhea, secondary amenorrhoea, Amenorrhea;secondary, Amenorrhoea;secondary
Czech Amenorea sekundární, Sekundární amenorea
Korean 속발성 무월경
Hungarian Másodlagos vérzéshiány, Secunder amenorrhoea, másodlagos amenorrhoea
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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