Secondary amenorrhoea

Question 1

Differential diagnosis of causes

Answer 1

Pregnancy
Menopause/premature ovarian insufficiency

Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors

Uterine pathology e.g. Asherman’s syndrome

PCOS
Hormonal contraceptives
Thyroid function abnormalities

Hyperprolactinaemia e.g. from a prolactinoma
Cushings

Question 2

Investigations in secondary amenorrhoea

Answer 2

Pregnancy test (urine or blood beta HCG)

Bloods:

• FSH
• LH
• Prolactin
• TFTs - TSH followed by T3/T4 if this is abnormal
• Testosterone (raised in PCOS, Androgen insensitivity syndrome, congenital adrenal hyperplasia)

Pelvic USS - PCOS, AIS,
MRI - if suspect prolactinoma

Question 3

Management of secondary amenorrhoea

Answer 3

Treat underlying cause
Replacement hormones can induce menstruation and improve symptoms.

Offer hormone replacement therapy or COCP if persists more than 12 months to reduce osteoporosis risk

Advise maintaining a healthy lifestyle to optimize bone health. This involves doing weight-bearing exercises, avoidance of smoking, eating a balanced diet, and maintenance of normal body weight.

Question 4

Questions to ask

Answer 4

Any chance of pregnancy

Vaginal dryness, hot flushes (menopause, premature ovarian insufficiency)

Excessive weight loss or exercise

Chronic illnesses?

Any pelvic surgeries in the past

Any hirsutism or acne (PCOS, Androgen insensitivity syndrome)

Galactorrhoea - milky discharge from the nipple

Headache or vision changes

Weight gain/BMI (PCOS, Cushings)