• Credits
  • Section Writer: Dr. Om J Lakhani
  • Section Editor: Dr. Om J Lakhani

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• Q. Which is the Most common cause of secondary amenorrhea ?

  • Pregnancy

• Q. Enlist the causes of secondary amenorrhea ?

  • Pregnancy
    • Hypothalamic causes – Functional hypothalamic amenorrhea
  • Pituitary
    • Prolactinoma
    • NFPA/ other pituitary adenoma
    • Empty sella
    • Sheehan's syndrome
  • Ovarian
    • PCOS
    • POI
    • Ovarian tumors
  • Adrenal
    • Cushing’s syndrome
    • Adrenal tumor
    • CAH
  • Uterine
    • Uterine adhesions- Asherman syndrome
  • Others
    • hypothyroidism and hyperthyroidism

• Q. What is the definition of secondary amenorrhea ?

  • Absence of menses for 3 months for women who previously had normal menses
  • And 6 months for women who previously had irregular menses

• Q. What is oligomenorrhea ?

  • Cycle length >35 days
  • <9 periods in a year

• #Clinicalpearl

  • Causes of secondary amenorrhea and oligomenorrhea are similar
  • Both are similar condition just extension of each other

• Q. What is the 2nd most common cause of after pregnancy ?

  • Hypothalamic amenorrhea

• Q. Can systemic disorders lead to amenorrhea ?

  • Yes
  • They are again hypothalamic amenorrhea
  • Typically seen in type 1 diabetes and celiac
  • Also need to rule out autoimmune causes in above cases

• Q. What is the relation of Type 1 diabetes and amenorrhea ?

  • 70% of girls with type 1 have oligo/amenorrhea
  • More likely if HbA1c > 7.6
  • Even in well controlled type 1 – prevelance is 20%

• Q. What is the link between hypothyroidism and amneorrhea ?

  • More likely with severe hyperthyroidism compared to mild-moderate
  • 2.5% of women with severe hyperthyroidism had amenorrhea

• Q. Does hypothyrodisim produce amenorrhea ?

  • Generally hypothyroidism is associated with excessive menstrual bleed
  • However , rare cases hypothyroidism may also be linked with amenorrhea
  • This is probably due to pituitary hyperplasia and lactotroph hyperplasia seen in uncontrolled hypthyroidism

• Q. Which is the only uterine cause of secondary amenorrhea ?

  • Asherman syndrome  - intrauterine adhesions
  • This is due to previous D and C etc
  • Evaluation and management of secondary amenorrhea

• **Diagnosis **

• Q. what is the first step in evaluation of Secondary amenorrhea ?

  • Beta HCG in urine to rule out pregnancy
  • Serum betaHCG is more sensitive

• Q. What is the progesterone withdrawal test ?

  • Medroxyprogesterone – 10 mg for 10 days and then stop.
  • Look for menstrual bleeding

• Q. What is the are tests done to see the estrogen status ?

  • Direct measure of E2 level
  • Progesterone challenge test- withdrawal bleeding suggests normal exposure of endometrium to progesterone
  • Endometrial thickening - <4 mm – suggest hypoestrogenic status

• Q. When is MRI performed based on prolactin levels ?

  • If prolactin is >50 ng/ml – repeated twice and other causes of hyperprolactinemia like drugs and thyroid are ruled out  then MRI is performed

• Q. How is diagnosis of Asherman syndrome carried out ?

  • Step 1 – history – amenorrhea with history of uterine instrumentation or DNC- think of asherman
  • Step 2-  progesterone challenge test- if no withdrawal bleeding  Asherman ruled out
  • Step 3- Estrogen + Progesterone challenge test- if bleeding seen – Asherman is ruled out
  • Step 4- if no bleeding → hysterosalpingography or Hysteroscopy

• Q. How is estrogen + progesterone challenge test carried out ?

  • E+ P challenge test
  • Conjugated estrogen – Premarin – 0.625 mg for 35 days
  • Medroxyprogesterone added in dose of 10 mg on days 26-35

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