Secondary amenorrhoea

Question 1

What is secondary amenorrhoea defined as?

Answer 1

secondary amenorrhoea is defined as no menstruation for more than 3 months after previous regular menstruations

Question 2

When would investigation and assessment be considered for secondary amenorrhoea?

Answer 2

• after 3-6 months in women with previous regular menstruations
• after 6-12 months in women with previous irregular menstruations

Question 3

What is the most common cause of secondary amenorrhoea?

Answer 3

-Pregnancy

Question 4

What are other causes of secondary amenorrhoea?

Answer 4

• Menopause and premature ovarian failure
• Hormonal contraception eg IUS or POP
• Hypothalamic or pituitary pathology
• Ovarian causes such as POS
• Uterine pathology such as Asherman’s syndrome
• Thyroid pathology
• Hyperprolactinaemia
• stress due to exercise/low weight/chronic disease/psychological stress

Question 5

How can excessive exercise/low weight/chronic diseases/psychological stress lead to secondary amenorrhoea?

Answer 5

-causes psychological/physiological stress which the hypothalamus responds by reducing the production of GnRH so less oestrogen produced

Question 6

What are some pituitary causes of secondary amenorrhoea?

Answer 6

• pituitary tumours, like a prolactin secreting prolactinoma
• pituitary failiure due to trauma, radiotherapy, surgery or Sheehan syndrome

Question 7

How does hyperprolactinaemia cause secondary amenorrhoea?

Answer 7

-the high prolactin levels act on the hypothalamus to prevent the release of GnRH so no release of LH and FSH leading to hypogonadotropic gonadism

Question 8

What is the most common cause of hyperprolactinaemia?

Answer 8

-a pituitary adenoma secreting prolactin

Question 9

What investigations should you do for high levels of prolactin?

Answer 9

-CT of MRI scan of brain to assess for pituitary tumour

Question 10

What treatment can be used for hyperprolactinaemia?

Answer 10

• often no treatment is required

- dopamine agonists such as bromocriptine or cabergolin can be used to reduce prolactin production

Question 11

What does assessment of secondary amenorrhoea invlove?

Answer 11

• detailed history and examination for potential causes
• hormonal blood tests
• US of pelvis to diagnose POS

Question 12

What hormonal blood tests are used to investigate secondary amenorrhoea?

Answer 12

• Beta HCG urine/blood tests to rule out pregnancy
• LH and FSH -> high FSH suggests primary ovarian failure, high LH or LH:FSH ratio suggests POS
• Prolactin to assess for hyperprolactinaemia
• TFTs
• testosterone -> when raised indicates POS, androgen insensitivity syndrome or congenital adrenal hyperplasia

Question 13

What does the management of secondary amenorrhoea involve?

Answer 13

• establishing and treating the underlying cause

- where necessary, replacement hormones can be used to induce menstruation and improve symptoms

Question 14

What are patients with amenorrhoea at increased risk of?

Answer 14

• osteoporosis
• as low oestrogen levels
• if amenorrhoea lasts > 12 months treatment is indicated for osteoporosis
• treatment includes: ensuring adequate vit D and calcium intake, and HRT or combined OCP