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 3. Prolactin Prolactin ↑ Surgery or
Bromocriptine
after just 2 cycles, even 1 for UPT. In general, the workup
4. Medications Prolactin ↑ Switch or D/C
begins with 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 Emotional Stress
ovary, then the anterior pituitary with the hypothalamus as the Hypothalamus Anorexia 5. Diagnosis of Exclusion
diagnosis of exclusion. The chart and diagram to the right give Weight Loss / Exercise
an overview of the topics discussed and the order in which they Adenoma
should be investigated. The next page has an algorithm that can Ant Pit Sheehan’s 4. MRI
be used to 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 Endometrium Asherman’s 2. Estrogen and Progesterone
a 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
synthroid (see medicine, endo).
TRH Hypothalamus GnRH
Pituitary Tumor (Prolactinoma)
While a tumor of the anterior pituitary can either cause crush
Ant Pituitary
syndrome (↓FSH and ↓LH), bleed (apoplexy), or die Prolactin Dopamine Dopa
(Sheehan’s), it’s more likely that an otherwhise healthy woman Antag
TSH FSH
would develop amenorrhea from a tumor that produces Ovary LH
prolactin erroneously (the first free would make her much T4
sicker than “just stopped bleeding”). Just as in thyroid disease,
elevated prolactin will inhibit the axis and turn off her cycle. It Endometrium
doesn’t matter how you get prolactin; if you have there’s too
much it messes with the axis. Sucpect prolactinoma if
galactorrhea and amenorrhea. Screen her prolactin level and Means “inhibits”
get an MRI if it’s elevated. The options are bromocriptine if Means “stimulates
small or surgery if large or desires pregnancy. See medicine, Green = ↑FSH/LH = Normal
endo. Red = ↓ FSH/LH = Amenorrhea

Medications
Anything that inhibits dopamine (aka Prolactin-Inhibiting
Factor) will disinhibit prolactin. Unrestrained prolactin acts
just like a prolactinoma (i.e. prolactinemia), presenting with
galactorrhea and amenorrhea. Switch medications (typically
a typical for an atypical antipsychotic) or add bromocriptine. If
it’s the medication that could be the culprit there’s no need for
an MRI if you’ve found prolactinemia!

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 Gynecology [SECONDARY AMENORRHEA]

Menopause
If menopause occurs in a woman <40 years old it’s pathologic. 2o Amenorrhea
Unfortunately, nothing can be done for her. Menopause is
menopause and there are no more cycles for her. The typical
UPT
findings of menopause will be present (↑FSH and ↑LH) and
TSH HP Axis
absent follicles on ultrasound. 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 MRI
procedure to be done. Progestin
Drugs Challenge
Asherman’s Syndrome
Ø Bleed Bleeds
Scarring and fibrosis of the endometrium prevents the Prolactinoma
endometrium from developing properly, and, if nothing grows,
Bromocriptine
nothing can slough off. It’s an unresponsive endometrium.
Surgery
She’s hormonally intact (FSH and LH induce estrogen, ? Anovulation
ovulation, and progesterone), but she is anatomically deficient.
PCOS workup
This is a product of vigorous D+C (and is a complication of
Estrogen and
elective abortions). It can also be done on purpose with
Progesterone
endometrial ablation to help patients with menometrorrhagia
who are no longer interested in pregnancy. Don’t forget to check
Ø Bleed Bleeds
their 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
Normal
or extreme weight loss / exercise, that might induce ↑FSH/LH FSH, LH,
amenorrhea. Emotional stress might have her miss a single cycle FSH, LH Ratio
Ovaries Ø Ovaries
(bringing her in to check for pregnancy), but it shouldn’t cause and Ratio
prolonged cycle 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 Bromocriptine 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

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