Secondary Amenorrhoea

Question 1

Define secondary amenorrhoea.

Answer 1

No menstruation for more than 3 months after previous regular menstrual periods.

Question 2

When is investigation into secondary amenorrhoea usually considered in women with previous regular periods?

Answer 2

3-6 months

Question 3

When is investigation into secondary amenorrhoea usually considered in women with previous infrequent irregular periods?

Answer 3

6-12 months

Question 4

List 12 causes of secondary amenorrhoea.

Answer 4

1. Pregnancy
2. Menopause
3. Hormonal contraception (e.g. IUS or POP)
4. Hypothalamic or pituitary pathology
5. Ovarian causes e.g. polycystic ovarian syndrom
6. Uterine pathology e.g. Asherman’s syndrome
7. Thyroid pathology
8. Hyperprolactinaemia
9. Excessive exercise (e.g. athletes)
10. Low body weight and eating disorders
11. Chronic disease
12. Psychological stress

Question 5

How does physiological or psychological stress lead to amenorrhoea?

Answer 5

The stress reduces the production of GnRH by the hypothalamus. The hypothalamus responds this way to prevent pregnancy in situations where the body may not be fit for it.

Question 6

Name two pituitary causes of secondary amenorrhoea.

Answer 6

1. Pituitary tumours e.g. prolactin-secreting prolactinoma

2. Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome

Question 7

What effect does high prolactin have on the hypothalamus?

Answer 7

Prevents release of GnRH (and therefore there is no release of LH or FSH)

Question 8

What percentage of women with a high prolactin level have galactorrhoea?

Answer 8

30%

Question 9

What is the most common cause of hyperprolactinaemia?

Answer 9

Pituitary adenoma secreting prolactin.

Question 10

How can you assess for a pituitary adenoma?

Answer 10

CT or MRI brain.

Often there is a microadenoma that will not appear on the initial scan, and follow up scans are required to identify tumours that may develop later.

Question 11

Is treatment of hyperprolactinaemia always required?

Answer 11

Not always needed

Question 12

What medications can be used to manage hyperprolactinaemia?

Name two conditions this group of medications is also used to treat.

Answer 12

Dopamine agonists such as bromocriptine or cabergoline can be used to reduce prolactin production.

These medications also treat Parkinson’s disease and acromegaly.

Question 13

How is polycystic ovarian syndrome diagnosed?

Answer 13

Ultrasound of pelvis

Question 14

What does a high FSH suggest in the context of secondary amenorrhoea?

Answer 14

Primary ovarian failure

Question 15

What does a high LH or high LH:FSH ration suggest in the context of secondary amenorrhoea?

Answer 15

Polycystic ovarian syndrome

Question 16

Name 4 conditions a raised testosterone may indicate in the context of secondary amenorrhoea.

Answer 16

1. PCOS
2. Androgen insensitivity syndrome
3. Congenital adrenal hyperplasia

Question 17

What do women with polycystic ovarian syndrome require every 3-4 months and why?

Answer 17

Withdrawal bleed

To reduce risk of endometrial hyperplasia and endometrial cancer

Question 18

How can a withdrawal bleed be stimulate in women with PCOS?

Answer 18

Medroxyprogesterone for 14 days, or regular use of combined oral contraceptive pill.

Question 19

What are patients with amenorrhoea associated with low oestrogen levels at risk of?

Answer 19

Osteoporosis.

Question 20

What is indicated for women with amenorrhoea lasting >12 months to reduce their risk of osteoporosis (2)?

Answer 20

1. Ensure adequate vitamin D and calcium intake

2. Hormone replacement therapy or combined oral contraceptive pill