Etiology, diagnosis, and treatment of secondary amenorrhea
- Corrine K Welt, MD
Corrine K Welt, MD
- Professor of Medicine
- University of Utah School of Medicine
- Robert L Barbieri, MD
Robert L Barbieri, MD
- Editor-in-Chief — Obstetrics, Gynecology and Women's Health
- Section Editor — General Gynecology and Female Reproductive Endocrinology
- Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
- Section Editors
- Peter J Snyder, MD
Peter J Snyder, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Pituitary Disease; Male Reproductive Endocrinology
- Professor of Medicine
- University of Pennsylvania School of Medicine
- William F Crowley, Jr, MD
William F Crowley, Jr, MD
- Section Editor — Female Reproductive Endocrinology
- Daniel K. Podolsky Professor of Medicine
- Harvard Medical School
- Mitchell Geffner, MD
Mitchell Geffner, MD
- Section Editor — Pediatric Endocrinology
- Professor of Pediatrics
- Keck School of Medicine, University of Southern California
Amenorrhea (absence of menses) can be a transient, intermittent, or permanent condition resulting from dysfunction of the hypothalamus, pituitary, ovaries, uterus, or vagina (table 1 and table 2). It is often classified as either primary (absence of menarche by age 15 years) or secondary (absence of menses for more than three months in girls or women who previously had regular menstrual cycles or six months in girls or women who had irregular menses). The menstrual cycle is susceptible to outside influences; thus, missing a single menstrual period is rarely important. In contrast, prolonged amenorrhea may be the earliest sign of a decline in general health or signal an underlying condition such as hypothyroidism.
The causes and diagnosis of secondary amenorrhea and a brief summary of treatment options are reviewed here. The etiologic and diagnostic considerations for oligomenorrhea are the same as for amenorrhea. Primary amenorrhea is discussed separately. (See "Evaluation and management of primary amenorrhea".)
Pregnancy — Pregnancy is the most common cause of secondary amenorrhea. It may occur even in women who claim that they have not been sexually active or are positive that intercourse occurred at a "safe" time. It is also important to note that apparent menstrual bleeding does not exclude pregnancy, since a substantial number of pregnancies are associated with some early first trimester bleeding. Thus, a pregnancy test (measurements of serum or urinary human chorionic gonadotropin [hCG]) is recommended as a first step in evaluating any woman with amenorrhea. (See 'Diagnosis' below.)
Once pregnancy has been ruled out, a logical approach to women with either primary or secondary amenorrhea is to consider disorders based upon the levels of control of the menstrual cycle: hypothalamus, pituitary, ovary, and uterus. The most common causes of secondary amenorrhea are disorders of the [1,2]:
●Ovary – 40 percent
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- Hypothalamic dysfunction
- - Congenital GnRH deficiency
- - Functional hypothalamic amenorrhea
- Risk factors
- Role of leptin deficiency
- Genetic basis
- - Infiltrative lesions
- - Systemic illness
- Type 1 diabetes mellitus
- Celiac disease
- Pituitary disease
- - Hyperprolactinemia
- - Other sellar masses
- - Other diseases of the pituitary
- Thyroid disease
- Ovarian disorders
- - Polycystic ovary syndrome
- - Primary ovarian insufficiency (premature ovarian failure)
- - Other
- Uterine disorders
- Step 1: Rule out pregnancy
- Step 2: History
- Step 3: Physical examination
- Step 4: Basic laboratory testing
- Step 5: Follow-up testing
- - Assessment of estrogen status
- - High serum prolactin concentration
- - High serum FSH concentration
- - Normal or low serum FSH concentrations
- - Normal lab results and history of uterine instrumentation
- - High serum androgen concentrations
- Hypothalamic amenorrhea
- - Lifestyle changes
- - Cognitive behavioral therapy
- - Leptin administration
- - Management of low bone density
- Primary ovarian insufficiency (premature ovarian failure)
- Polycystic ovary syndrome
- Intrauterine adhesions
- INFORMATION FOR PATIENTS