Gynecology - Secondary Amenorrhea

Gynecology [SECONDARY AMENORRHEA]
Introduction
If a woman is within her reproductive age and was having Disease State Test Treatment
periods that have since stopped for > 6 months she’s said to 1. Pregnancy UPT Prenatal Care
have secondary amenorrhea. Most OBs won’t wait 6 months to 2. Thyroid TSH ↑ Levothyroxine
decide if she’s pregnant so diagnostic intervention can begin after 3. Prolactin Prolactin ↑ Surgery or
Bromocriptine
just 2 cycles, even 1 for UPT. In general, the workup begins with
4. Medications Prolactin ↑ Switch or D/C
the “three most common causes” (pregnancy, thyroid, and
prolactin) then proceeds in reverse order of how the HP axis is set
up; beginning with the endometrium, then the ovary, then the Emotional Stress
anterior pituitary with the hypothalamus as the diagnosis of Hypothalamus Anorexia 5. Diagnosis of Exclusion
exclusion. The chart and diagram to the right give an overview of Weight Loss / Exercise
the topics discussed and the order in which they should be Adenoma
investigated. The next page has an algorithm that can be used to Ant Pit Sheehan’s 4. MRI
work up a patient with secondary amenorrhea. Apoplexy
Ovary Menopause 3. FSH/LH and U/S

Pregnancy Resistant Ovary
The most common cause of 2o amenorrhea is pregnancy. Get a
UPT to rule out pregnancy in every patient every time. There is a Endometrium Asherman’s 2. Estrogen and Progesterone
section called “OB” for this condition. Ablation
1. Progestin Challenge
Thyroid Disease See the correlation to the algorithm on the next page
While both hyper and hypo thyroidism can cause absence of
bleeding or too much bleeding, it’s usually ↑TRH secondary to
Hypothyroid that causes ↑ prolactin thereby inhibiting GnRH
that leads to the amenorrhea. During the first visit we screen with
a TSH alongside the UPT. If the TSH is elevated she needs
levothyroxine (see medicine, endo).
Hypothalamus GnRH
TRH
Pituitary Tumor (Prolactinoma)
While a tumor of the anterior pituitary can either cause crush
Ant Pituitary Prolactin Dopamine Dopa
syndrome (↓ FSH and ↓ LH), bleed (apoplexy), or die
(Sheehan’s)*, it’s more likely that an otherwhise healthy woman Antag
TSH FSH
would develop amenorrhea from a tumor that produces prolactin Ovary LH
erroneously (the first three would make her much sicker than T4
“just stopped bleeding”). Just as in thyroid disease, elevated
prolactin will inhibit the axis and turn off her cycle. It doesn’t Endometrium
matter how the prolactin is increased; if there’s too much it
messes with the axis. Suspect prolactinoma if there’s
galactorrhea and amenorrhea. Screen with a prolactin and get Means “inhibits”
an MRI if it’s elevated. The options are pramixpaxole or Means “stimulates”
ropinerole. Surgery and Bromocriptine are usually wrong. Green = ↑ FSH/LH = Normal
Red = ↓ FSH/LH = Amenorrhea
Medications
Anything that inhibits dopamine (aka Prolactin-Inhibiting
Factor) will disinhibit prolactin. Unrestrained prolactin acts just *Sheehan’s and Apoplexy can occur in women without a
like a prolactinoma (i.e. prolactinemia), presenting with Tumor.
galactorrhea and amenorrhea. Dopamine antagonists (atypical
antipsychotics) disinhibit prolactin. Usually they’re on these
because of shizophrenia, so it wouldn’t be a good idea to give a
dopamine agonist. But if she has to be on a medication and she
has this side effect, pramipaxole or ropinerole can be used.

© OnlineMedEd. http://www.onlinemeded.org
Gynecology [SECONDARY AMENORRHEA]

Menopause
If menopause occurs in a woman >40 years old it’s physiologic.
2o Amenorrhea
Unfortunately, nothing can be done for her. Menopause is
menopause and there are no more cycles happening. The typical
findings of menopause will be present (↑FSH and ↑LH) and
UPT
absent follicles on ultrasound. Only give consideration to
TSH HP Axis
working up menopause if she is younger than 40. Prolactin
Savage Syndrome = Resistant Ovary Syndrome

This is effectively menopause. It’s caused by an FSH-R
insensitivity. The FSH and LH will be elevated trying to induce
ovulation (just like in menopause) but nothing will happen. An Prolactinemia Thyroid Pregnant
ultrasound will show many follicles (she’s NOT in menopause Levothyroxine Prenatal Care
yet). Try giving HRT to achieve pregnancy but this is generally
considered menopausal; there’s no treatment or procedure to be MRI
done. Progestin
Drugs Challenge
Asherman’s Syndrome
Ø Bleed Bleeds
Scarring and fibrosis of the endometrium prevents the Prolactinoma
endometrium from proliferating properly, and, if nothing grows,
Dopamine
nothing can slough off. It’s an unresponsive endometrium.
Agonists
She’s hormonally intact (FSH and LH induce estrogen, ovulation, ? Anovulation
Ropinirole
and progesterone), but she is anatomically deficient. This is a
PCOS workup
product of vigorous D+C (and is a complication of elective
abortions). It can also be done on purpose with endometrial Estrogen and
Progesterone
ablation to help patients with menometrorrhagia who are no
longer interested in pregnancy. Don’t forget to check their
Ø Bleed Bleeds
surgical history!
Hypothalamus
There isn’t a test for the hypothalamus; it’s diagnosis by Endometrial
Dysfxn ?
exclusion. All endocrine function begins there. While it’s
determined by exclusion something can likely be elicited from Supportive
the history that’d allow for reassurance if TSH, UPT, and
Prolactin are negative. If the woman has experienced anorexia or Normal
extreme weight loss / exercise, that might induce amenorrhea. ↑FSH/LH FSH, LH,
Emotional stress might have her miss a single cycle (bringing her FSH, LH Ratio
Ovaries Ø Ovaries
in to check for pregnancy), but it shouldn’t cause prolonged cycle and Ratio
loss.
Algorithm: Ultrasound MRI Brain

1. Is it the common stuff?
(UPT, TSH, Prolactin, Meds)
2. Is the endometrium ready to bleed? follicles follicles Pituitary Pituitary
(Progestin Challenge)
3. Is the endometrium capable of bleeding?
(Estrogen and Progesterone)
Menopause Resistant Pituitary Hypothalamus
4. Is there a signal coming from the
Ovary
pituitary? (FSH and LH) Symptom Relief Ropinirole Weight Gain
5a. Is there a problem with the anterior Symptom Relief Surgery Emotional Stress
pituitary? (MRI)
5b. Are there follicles? (U/S)
6. All has been negative - Hypothalamus

© OnlineMedEd. http://www.onlinemeded.org

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Gynecology [SECONDARY AMENORRHEA]

Ovary Menopause 3. FSH/LH and U/S

Savage Syndrome = Resistant Ovary Syndrome

Algorithm: Ultrasound MRI Brain

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