Evaluation and management 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
- 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 ). Missing a single menstrual period may not be important to assess, but amenorrhea lasting three months or more and oligomenorrhea (fewer than nine menstrual cycles per year or cycle length greater than 35 days) require investigation. The etiologic and diagnostic considerations for oligomenorrhea are the same as for secondary amenorrhea.
The evaluation of secondary amenorrhea and a brief summary of treatment options are reviewed here. The epidemiology and causes of secondary amenorrhea, and overviews of primary amenorrhea and abnormal uterine bleeding in adolescents, are discussed separately. (See "Epidemiology and causes of secondary amenorrhea" and "Evaluation and management of primary amenorrhea" and "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis".)
APPROACH TO EVALUATION
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. Determining the site of the defect is important because it determines the appropriate therapeutic regimen. While the most common causes of secondary amenorrhea are likely to be functional hypothalamic amenorrhea or polycystic ovary syndrome (PCOS), disorders with an anatomic or pathologic cause must be ruled out (algorithm 1) [2,3].
Rule out pregnancy — A pregnancy test is recommended as a first step in evaluating any woman with secondary amenorrhea. Measurement of serum beta subunit of human chorionic gonadotropin (hCG) is the most sensitive test. Commercially available home kits for measurement of hCG in urine are improving, but the clinician who suspects pregnancy should order a serum hCG measurement, even if the woman had a negative home test.
History — The woman should be asked about any past medical history, risk factors, or symptoms that might suggest any of the major causes of secondary amenorrhea or oligomenorrhea (algorithm 1 and table 1). The history should include the following questions:
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- APPROACH TO EVALUATION
- Rule out pregnancy
- Physical exam
- Initial laboratory testing
- Follow-up testing based upon initial results
- - Assessment of estrogen status
- - Normal or low serum FSH concentrations
- - High serum prolactin concentration
- - High serum FSH concentration
- - Normal laboratory results and history of uterine instrumentation
- - High serum androgen concentrations
- - Abnormal TSH
- Hypothalamic amenorrhea
- Primary ovarian insufficiency (premature ovarian failure)
- Intrauterine adhesions
- Polycystic ovary syndrome
- Thyroid disease
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS