What is secondary amenorrhea. How is it diagnosed. What are the common causes of secondary amenorrhea. What treatment options are available for secondary amenorrhea. How does secondary amenorrhea differ from primary amenorrhea.

Understanding Secondary Amenorrhea: Definition and Clinical Significance

Secondary amenorrhea is a condition characterized by the absence of menstrual periods in women who have previously experienced regular menstruation. It occurs when a patient who has passed menarche goes six months or longer without menses. This definition, endorsed by the American College of Obstetricians and Gynecologists, is crucial for healthcare providers to accurately diagnose and manage this condition.

Why is understanding secondary amenorrhea important? It can be an indicator of underlying health issues that require attention. From hormonal imbalances to structural abnormalities, the causes of secondary amenorrhea are diverse and often necessitate a comprehensive evaluation.

Etiology of Secondary Amenorrhea: Unraveling the Underlying Causes

The etiology of secondary amenorrhea can be broadly categorized into three main groups:

1. Hormonal disturbances leading to a lack of a normal menstrual cycle
2. Physical damage to the endometrium, preventing its growth
3. Obstruction of the outflow path of menstrual blood

What are some specific causes within these categories? Let’s explore:

Hormonal Causes:

• Pregnancy
• Lactation
• Thyroid dysfunction
• Hyperprolactinemia
• Hyperandrogenism (including polycystic ovarian syndrome)
• Hypogonadotropic hypogonadism (hypothalamic-pituitary dysfunction)
• Suppression of the endometrium by hormonal birth control

Structural Causes:

• Asherman syndrome (damage to the endometrium)
• Cervical stenosis (obstruction of the outflow tract)

Understanding these diverse etiologies is crucial for healthcare providers to develop an effective diagnostic and treatment strategy.

Epidemiology and Risk Factors: Who is Affected by Secondary Amenorrhea?

Secondary amenorrhea is not uncommon, with a prevalence of approximately 2% to 5% due to causes other than pregnancy, lactation, and menopause. These physiological causes are the most common reasons for secondary amenorrhea.

What factors increase the risk of developing secondary amenorrhea? Several factors can contribute to its occurrence:

• Extreme weight loss or gain
• Excessive exercise
• Stress
• Hormonal imbalances
• Certain medications
• Pelvic surgeries or procedures

Understanding these risk factors can help healthcare providers identify individuals who may be more susceptible to developing secondary amenorrhea and implement preventive measures when possible.

Diagnostic Approach: Unraveling the Mystery of Absent Menses

Diagnosing secondary amenorrhea requires a systematic approach. How should healthcare providers proceed with the evaluation? The process typically involves the following steps:

1. Comprehensive medical history
2. Physical examination
3. Laboratory tests
4. Imaging studies (when indicated)

Medical History:

A thorough medical history should include:

• Full menstrual history
• Current birth control methods
• Pattern of menses (regular vs. irregular)
• Inciting events before onset of amenorrhea
• Symptoms of hyperprolactinemia, thyroid dysfunction, or PCOS
• Stressors and exercise routines

Physical Examination:

The physical exam should assess:

• Body mass index (BMI)
• Signs of acanthosis nigricans
• Presence of hirsutism or acne
• Signs of virilization

Laboratory Tests:

What laboratory tests are crucial in the evaluation of secondary amenorrhea? The diagnostic workup typically includes:

1. Urine pregnancy test (first step for all patients)
2. Thyroid-stimulating hormone (TSH) levels
3. Serum prolactin levels
4. Follicle-stimulating hormone (FSH) and estradiol levels
5. Androgen levels (if PCOS is suspected)

In some cases, additional tests or imaging studies may be necessary to confirm the diagnosis or identify underlying causes.

Treatment Strategies: Tailoring Interventions to Underlying Causes

The treatment of secondary amenorrhea depends on its underlying cause. What are some common treatment approaches for various etiologies?

Hormonal Imbalances:

• Thyroid dysfunction: Thyroid hormone replacement or antithyroid medications
• Hyperprolactinemia: Dopamine agonists (e.g., bromocriptine, cabergoline)
• PCOS: Combined oral contraceptives, metformin, or anti-androgen therapy
• Hypogonadotropic hypogonadism: Gonadotropin therapy or pulsatile GnRH

Structural Causes:

• Asherman syndrome: Hysteroscopic adhesiolysis
• Cervical stenosis: Cervical dilation

In cases where amenorrhea is due to excessive exercise or low body weight, lifestyle modifications may be recommended. For stress-induced amenorrhea, stress management techniques and psychological support can be beneficial.

Differential Diagnosis: Distinguishing Secondary Amenorrhea from Other Conditions

When evaluating a patient with secondary amenorrhea, it’s crucial to consider other conditions that may present similarly. What are some important differential diagnoses to keep in mind?

• Pregnancy (most common cause)
• Primary ovarian insufficiency
• Hypothalamic amenorrhea
• Pituitary disorders (e.g., Sheehan syndrome)
• Eating disorders (e.g., anorexia nervosa)
• Congenital adrenal hyperplasia (late-onset)
• Androgen-secreting tumors

Careful consideration of these potential diagnoses can help healthcare providers avoid misdiagnosis and ensure appropriate management.

The Role of the Interprofessional Team: Collaborative Care for Optimal Outcomes

Managing secondary amenorrhea often requires a multidisciplinary approach. How can an interprofessional team improve patient outcomes? By coordinating care and leveraging diverse expertise, healthcare providers can offer comprehensive management strategies.

Key members of the interprofessional team may include:

• Obstetrician-gynecologists
• Endocrinologists
• Primary care physicians
• Reproductive endocrinologists
• Radiologists
• Nutritionists
• Mental health professionals

Effective communication among team members is crucial for coordinating diagnostic efforts, developing treatment plans, and monitoring patient progress. Regular case discussions and shared decision-making can lead to improved patient care and outcomes.

Future Directions: Emerging Research and Potential Advancements

As our understanding of secondary amenorrhea continues to evolve, what future developments might we anticipate in its diagnosis and management? Several areas of research hold promise:

• Advanced genetic testing to identify hereditary causes of amenorrhea
• Novel biomarkers for early detection of ovarian dysfunction
• Improved imaging techniques for assessing structural abnormalities
• Personalized treatment approaches based on genetic and molecular profiles
• Development of new pharmacological interventions for hormonal imbalances

These advancements may lead to more precise diagnoses, targeted treatments, and improved outcomes for patients with secondary amenorrhea.

In conclusion, secondary amenorrhea is a complex condition with diverse etiologies, requiring a comprehensive approach to diagnosis and management. By understanding its causes, implementing appropriate diagnostic strategies, and utilizing a multidisciplinary team approach, healthcare providers can effectively address this condition and improve patient outcomes. As research in this field continues to advance, we can look forward to even more refined and personalized approaches to managing secondary amenorrhea in the future.

Secondary Amenorrhea – StatPearls – NCBI Bookshelf

Continuing Education Activity

Secondary amenorrhea occurs when a patient who has passed menarche goes six months or longer without menses. While some sources only require three months without menses to diagnose amenorrhea, the American College of Obstetricians and Gynecologists uses the former definition. There are many causes of secondary amenorrhea, and thus it is important to have an interprofessional team involved in the investigation and management of this disorder. This activity reviews the evaluation and treatment of secondary amenorrhea and explains the role of the interprofessional team in the management and care of patients with this condition.

Objectives:

• Identify the etiology of secondary amenorrhea, and how it differs from primary amenorrhea.

• Summarize treatment options for secondary amenorrhea by underlying etiology.

• Review the potential differential diagnoses for secondary amenorrhea.

• Explain interprofessional team strategies for improving care coordination and communication to advance diagnosis and care of secondary amenorrhea to improve outcomes.

Access free multiple choice questions on this topic.

Introduction

Secondary amenorrhea occurs when a patient who has passed menarche goes six months or longer without menses. While some sources only require three months without menses to diagnose amenorrhea, the American College of Obstetricians and Gynecologists uses the former definition.[1][2]

Etiology

There are three general causes of secondary amenorrhea: hormonal disturbance leading to a lack of a normal menstrual cycle, physical damage to the endometrium, which prevents its growth, or obstruction of the outflow path of the menstrual blood.

Epidemiology

Pregnancy, lactation, and menopause are common, physiologic causes of secondary amenorrhea. The prevalence of secondary amenorrhea due to all other causes is approximately 2% to 5%. [3][4]

Pathophysiology

There are many potential causes of secondary amenorrhea. Hormonal causes include pregnancy, lactation, thyroid dysfunction, hyperprolactinemia, hyperandrogenism (including polycystic ovarian syndrome), hypogonadotropic hypogonadism (hypothalamic-pituitary dysfunction), and suppression of the endometrium by hormonal birth control. Structural causes include damage to the endometrium (Asherman syndrome) and obstruction of the outflow tract (cervical stenosis).

History and Physical

History in a patient with secondary amenorrhea should include a full menstrual history. It is important to ascertain what birth control method the patient is using, as the progestin-containing birth control methods (including combined oral contraceptive pills) suppress the growth of the endometrium and may lead to secondary amenorrhea. The pattern of menses is also important – does the patient have a long history of infrequent and irregular periods (suggesting anovulation), or was the amenorrhea abrupt? Were there any inciting events before the onset of secondary amenorrhea, such as childbirth, surgery, trauma, pelvic infection, or D and C? Patients should be asked about headaches, vision changes, and galactorrhea to assess for hyperprolactinemia from pituitary prolactinoma. Thyroid symptoms should also be evaluated (fatigue, weight changes, skin/hair/nail changes, palpitations, tachycardia). Hirsutism and acne suggest PCOS, so patients should be asked about unwanted hair growth and acne. Patients should be asked about stressors and exercise routines, as excessive stress or exercise may lead to hypogonadotropic hypogonadism.

Physical examination should include calculation of body mass index (BMI), as well as assessment of acanthosis nigricans, hirsutism, acne, and virilization.

Evaluation

The first step in the evaluation of any patient with secondary amenorrhea is a urine pregnancy test. Every contraceptive method has a failure rate, and anyone who is menstruating is potentially fertile, regardless of age.[5][6]

If the pregnancy test is negative, consider the clinical picture: hirsutism, acne, and a long history of infrequent and irregular menses suggest polycystic ovarian syndrome. By the Rotterdam criteria, a patient may be diagnosed with PCOS if she has two of the following: clinical or chemical hyperandrogenism, oligo- or amenorrhea, or polycystic ovaries on ultrasound. So if a patient has evidence of hirsutism and oligo- or amenorrhea, she can be diagnosed with PCOS without further laboratory testing or imaging.

If history and physical exam are not consistent with PCOS, a TSH should be ordered. Both hyper- and hypothyroidism can lead to menstrual dysfunction.

If TSH is normal, check serum prolactin. Elevated serum prolactin suggests prolactinoma.

If prolactin is normal, the next step is to perform a progestin challenge. First, the patient is given oral progesterone (typically medroxyprogesterone, 10mg PO qDay x10 days). After stopping the progesterone, the patient would be expected to have a withdrawal bleed. If there is no withdrawal bleed, this means that a) there is insufficient endogenous estrogen to stimulate the growth of the endometrium, b) the endometrium has been damaged and is unable to grow, or c) the outflow of menstrual blood has been obstructed.

If a patient who has a withdrawal bleed also has hirsutism, suspect PCOS, ovarian or adrenal tumors, or Cushing syndrome.

If the patient does not experience a withdrawal bleed after the progestin challenge, the next step is an estrogen-progestin challenge, in which the patient is given combined estrogen and progesterone (such as combined oral contraceptives). If the endometrium is intact and the outflow is not obstructed, the estrogen from the oral contraceptives would be expected to trigger the growth of the endometrium, and stopping the oral contraceptives should lead to a withdrawal bleed. If a patient has a negative progestin challenge (no withdrawal bleed after progesterone treatment) but a positive estrogen-progestin challenge (bleeding after one month of combined oral contraceptives), suspect hypogonadism and check FSH and estradiol.

If FSH is elevated and estradiol is low, suspect ovarian failure. (The pituitary is yelling at the ovaries to make estrogen, but they are not responding.)

If FSH is low and estradiol is low, suspect hypothalamic-pituitary dysfunction, such as due to stress, exercise, or pituitary infarct (Sheehan’s syndrome).

If the estrogen-progesterone challenge is negative (no bleeding after a month of combined oral contraceptives), suspect damage to the endometrium (Asherman’s syndrome) or outflow obstruction, such as from cervical stenosis. Transvaginal ultrasound may be performed to evaluate for hematometra (trapped menstrual blood in the uterus). Hysteroscopy would be an appropriate next step to evaluate for Asherman syndrome. If trapped blood is evacuated during cervical dilation, this suggests cervical stenosis as the cause and is also potentially curative.

Treatment / Management

Treatment depends on the underlying cause of amenorrhea.[7][8]

• Polycystic ovarian syndrome is treated with weight loss, metformin for insulin resistance, and cycle control with combined oral contraceptives or endometrial protection with progestin-containing birth control methods (medroxyprogesterone acetate depot injection, etonogestrel subcutaneous implant, or levonorgestrel intrauterine system).

• Hypothyroidism is treated with thyroxine replacement.

• Hyperthyroidism is treated with thioamides, ablation, or surgery.

• Hyperprolactinemia is treated with bromocriptine, cabergoline, or excision of prolactinoma.

• Ovarian failure may be treated with hormone replacement, depending on the patient’s age, symptoms, and other risk factors.

• Hypothalamic-pituitary dysfunction may be treated with lifestyle changes or with hormone replacement.

• Asherman syndrome is treated with hysteroscopic lysis of adhesions.

• Cervical stenosis is treated with cervical dilation.

Differential Diagnosis

• Anorexia

• Anxiety disorders

• Congenital adrenal hyperplasia

• Depression

• Follicle-stimulating hormone abnormalities

• Iatrogenic Cushing syndrome

• Luteinizing hormone deficiency

• Ovarian insufficiency

• Pregnancy diagnosis

• Prolactinoma

Deterrence and Patient Education

As pregnancy is the most common cause of amenorrhea, young girls should be taught to monitor their cycles and use contraception to avoid unwanted pregnancy. Moreover, it is important to take gynecological history on regular visits as amenorrhea may be a result of an endocrinological disorder. A woman should contact her provider if irregularities in menstruation arise.

Pearls and Other Issues

Always remember to order a urine pregnancy test!

Bear in mind that hormonal contraceptives inhibit the hypothalamic-pituitary axis, so patients must be off hormonal contraceptives for at least three months before testing FSH and estradiol. In addition, standard estradiol assays do not detect ethinyl estradiol, the estrogen in birth control.

Remember that it is common and not pathologic for patients on hormonal contraception to be amenorrheic. Amenorrhea on birth control does not require further evaluation unless there are other concerning symptoms.[9]

Enhancing Healthcare Team Outcomes

There are many causes of secondary amenorrhea, and thus it is important to have an interprofessional team involved in the investigation and management of this disorder. Apart from infertility, the biggest concern is the ongoing bone loss that occurs due to a lack of sex hormones. Healthcare workers, including nurse practitioners, should educate the patient on the importance of bone health while they are being worked up for the cause of secondary amenorrhea. Besides increasing calcium in the diet, the patient should participate in regular exercise. The loss of fertility in many women is also associated with significant emotional distress, and hence a referral to a mental health counselor is recommended. The outcomes of women with secondary amenorrhea depend on the cause.[5][10]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

References

1.

Sehemby M, Bansal P, Sarathi V, Kolhe A, Kothari K, Jadhav-Ramteke S, Lila AR, Bandgar T, Shah NS. Virilising ovarian tumors: a single-center experience. Endocr Connect. 2018 Dec;7(12):1362-1369. [PMC free article: PMC6280592] [PubMed: 30400027]

2.

Maciejewska-Jeske M, Szeliga A, Męczekalski B. Consequences of premature ovarian insufficiency on women’s sexual health. Prz Menopauzalny. 2018 Sep;17(3):127-130. [PMC free article: PMC6196782] [PubMed: 30357022]

3.

Martini MG, Solmi F, Krug I, Karwautz A, Wagner G, Fernandez-Aranda F, Treasure J, Micali N. Associations between eating disorder diagnoses, behaviors, and menstrual dysfunction in a clinical sample. Arch Womens Ment Health. 2016 Jun;19(3):553-7. [PubMed: 26399871]

4.

Chandeying P, Pantasri T. Prevalence of conditions causing chronic anovulation and the proposed algorithm for anovulation evaluation. J Obstet Gynaecol Res. 2015 Jul;41(7):1074-9. [PubMed: 25772812]

5.

Pereira K, Brown AJ. Secondary amenorrhea: Diagnostic approach and treatment considerations. Nurse Pract. 2017 Sep 21;42(9):34-41. [PubMed: 28832422]

6.

Chaloutsou K, Aggelidis P, Pampanos A, Theochari E, Michala L. Premature Ovarian Insufficiency: An Adolescent Series. J Pediatr Adolesc Gynecol. 2017 Dec;30(6):615-619. [PubMed: 28502828]

7.

Practice Committee of the American Society for Reproductive Medicine. Current evaluation of amenorrhea. Fertil Steril. 2006 Nov;86(5 Suppl 1):S148-55. [PubMed: 17055812]

8.

Rosenfield RL. Puberty and its disorders in girls. Endocrinol Metab Clin North Am. 1991 Mar;20(1):15-42. [PubMed: 2029884]

9.

Gabby LC, McDaniel KE, Gordon BJ, Al-Marayati LA. Hematometrocolpos following Low Transverse Cesarean Delivery Complicated by Uterine Dehiscence. Case Rep Obstet Gynecol. 2021;2021:5591893. [PMC free article: PMC8261190] [PubMed: 34258089]

10.

Du X, Zhang W, Wang X, Yu X, Li Z, Guan Y. Follicle-Stimulating Hormone-Secreting Pituitary Adenoma Inducing Spontaneous Ovarian Hyperstimulation Syndrome, Treatment Using In Vitro Fertilization and Embryo Transfer: A Case Report. Front Endocrinol (Lausanne). 2021;12:621456. [PMC free article: PMC8264655] [PubMed: 34248835]

Disclosure: Megan Lord declares no relevant financial relationships with ineligible companies.

Disclosure: Manjusha Sahni declares no relevant financial relationships with ineligible companies.

Secondary Amenorrhea – StatPearls – NCBI Bookshelf

Continuing Education Activity

Secondary amenorrhea occurs when a patient who has passed menarche goes six months or longer without menses. While some sources only require three months without menses to diagnose amenorrhea, the American College of Obstetricians and Gynecologists uses the former definition. There are many causes of secondary amenorrhea, and thus it is important to have an interprofessional team involved in the investigation and management of this disorder. This activity reviews the evaluation and treatment of secondary amenorrhea and explains the role of the interprofessional team in the management and care of patients with this condition.

Objectives:

• Identify the etiology of secondary amenorrhea, and how it differs from primary amenorrhea.

• Summarize treatment options for secondary amenorrhea by underlying etiology.

• Review the potential differential diagnoses for secondary amenorrhea.

• Explain interprofessional team strategies for improving care coordination and communication to advance diagnosis and care of secondary amenorrhea to improve outcomes.

Access free multiple choice questions on this topic.

Introduction

Secondary amenorrhea occurs when a patient who has passed menarche goes six months or longer without menses. While some sources only require three months without menses to diagnose amenorrhea, the American College of Obstetricians and Gynecologists uses the former definition.[1][2]

Etiology

There are three general causes of secondary amenorrhea: hormonal disturbance leading to a lack of a normal menstrual cycle, physical damage to the endometrium, which prevents its growth, or obstruction of the outflow path of the menstrual blood.

Epidemiology

Pregnancy, lactation, and menopause are common, physiologic causes of secondary amenorrhea. The prevalence of secondary amenorrhea due to all other causes is approximately 2% to 5%.[3][4]

Pathophysiology

There are many potential causes of secondary amenorrhea. Hormonal causes include pregnancy, lactation, thyroid dysfunction, hyperprolactinemia, hyperandrogenism (including polycystic ovarian syndrome), hypogonadotropic hypogonadism (hypothalamic-pituitary dysfunction), and suppression of the endometrium by hormonal birth control. Structural causes include damage to the endometrium (Asherman syndrome) and obstruction of the outflow tract (cervical stenosis).

History and Physical

History in a patient with secondary amenorrhea should include a full menstrual history. It is important to ascertain what birth control method the patient is using, as the progestin-containing birth control methods (including combined oral contraceptive pills) suppress the growth of the endometrium and may lead to secondary amenorrhea. The pattern of menses is also important – does the patient have a long history of infrequent and irregular periods (suggesting anovulation), or was the amenorrhea abrupt? Were there any inciting events before the onset of secondary amenorrhea, such as childbirth, surgery, trauma, pelvic infection, or D and C? Patients should be asked about headaches, vision changes, and galactorrhea to assess for hyperprolactinemia from pituitary prolactinoma. Thyroid symptoms should also be evaluated (fatigue, weight changes, skin/hair/nail changes, palpitations, tachycardia). Hirsutism and acne suggest PCOS, so patients should be asked about unwanted hair growth and acne. Patients should be asked about stressors and exercise routines, as excessive stress or exercise may lead to hypogonadotropic hypogonadism.

Physical examination should include calculation of body mass index (BMI), as well as assessment of acanthosis nigricans, hirsutism, acne, and virilization.

Evaluation

The first step in the evaluation of any patient with secondary amenorrhea is a urine pregnancy test. Every contraceptive method has a failure rate, and anyone who is menstruating is potentially fertile, regardless of age.[5][6]

If the pregnancy test is negative, consider the clinical picture: hirsutism, acne, and a long history of infrequent and irregular menses suggest polycystic ovarian syndrome. By the Rotterdam criteria, a patient may be diagnosed with PCOS if she has two of the following: clinical or chemical hyperandrogenism, oligo- or amenorrhea, or polycystic ovaries on ultrasound. So if a patient has evidence of hirsutism and oligo- or amenorrhea, she can be diagnosed with PCOS without further laboratory testing or imaging.

If history and physical exam are not consistent with PCOS, a TSH should be ordered. Both hyper- and hypothyroidism can lead to menstrual dysfunction.

If TSH is normal, check serum prolactin. Elevated serum prolactin suggests prolactinoma.

If prolactin is normal, the next step is to perform a progestin challenge. First, the patient is given oral progesterone (typically medroxyprogesterone, 10mg PO qDay x10 days). After stopping the progesterone, the patient would be expected to have a withdrawal bleed. If there is no withdrawal bleed, this means that a) there is insufficient endogenous estrogen to stimulate the growth of the endometrium, b) the endometrium has been damaged and is unable to grow, or c) the outflow of menstrual blood has been obstructed.

If a patient who has a withdrawal bleed also has hirsutism, suspect PCOS, ovarian or adrenal tumors, or Cushing syndrome.

If the patient does not experience a withdrawal bleed after the progestin challenge, the next step is an estrogen-progestin challenge, in which the patient is given combined estrogen and progesterone (such as combined oral contraceptives). If the endometrium is intact and the outflow is not obstructed, the estrogen from the oral contraceptives would be expected to trigger the growth of the endometrium, and stopping the oral contraceptives should lead to a withdrawal bleed. If a patient has a negative progestin challenge (no withdrawal bleed after progesterone treatment) but a positive estrogen-progestin challenge (bleeding after one month of combined oral contraceptives), suspect hypogonadism and check FSH and estradiol.

If FSH is elevated and estradiol is low, suspect ovarian failure. (The pituitary is yelling at the ovaries to make estrogen, but they are not responding.)

If FSH is low and estradiol is low, suspect hypothalamic-pituitary dysfunction, such as due to stress, exercise, or pituitary infarct (Sheehan’s syndrome).

If the estrogen-progesterone challenge is negative (no bleeding after a month of combined oral contraceptives), suspect damage to the endometrium (Asherman’s syndrome) or outflow obstruction, such as from cervical stenosis. Transvaginal ultrasound may be performed to evaluate for hematometra (trapped menstrual blood in the uterus). Hysteroscopy would be an appropriate next step to evaluate for Asherman syndrome. If trapped blood is evacuated during cervical dilation, this suggests cervical stenosis as the cause and is also potentially curative.

Treatment / Management

Treatment depends on the underlying cause of amenorrhea.[7][8]

• Polycystic ovarian syndrome is treated with weight loss, metformin for insulin resistance, and cycle control with combined oral contraceptives or endometrial protection with progestin-containing birth control methods (medroxyprogesterone acetate depot injection, etonogestrel subcutaneous implant, or levonorgestrel intrauterine system).

• Hypothyroidism is treated with thyroxine replacement.

• Hyperthyroidism is treated with thioamides, ablation, or surgery.

• Hyperprolactinemia is treated with bromocriptine, cabergoline, or excision of prolactinoma.

• Ovarian failure may be treated with hormone replacement, depending on the patient’s age, symptoms, and other risk factors.

• Hypothalamic-pituitary dysfunction may be treated with lifestyle changes or with hormone replacement.

• Asherman syndrome is treated with hysteroscopic lysis of adhesions.

• Cervical stenosis is treated with cervical dilation.

Differential Diagnosis

• Anorexia

• Anxiety disorders

• Congenital adrenal hyperplasia

• Depression

• Follicle-stimulating hormone abnormalities

• Iatrogenic Cushing syndrome

• Luteinizing hormone deficiency

• Ovarian insufficiency

• Pregnancy diagnosis

• Prolactinoma

Deterrence and Patient Education

As pregnancy is the most common cause of amenorrhea, young girls should be taught to monitor their cycles and use contraception to avoid unwanted pregnancy. Moreover, it is important to take gynecological history on regular visits as amenorrhea may be a result of an endocrinological disorder. A woman should contact her provider if irregularities in menstruation arise.

Pearls and Other Issues

Always remember to order a urine pregnancy test!

Bear in mind that hormonal contraceptives inhibit the hypothalamic-pituitary axis, so patients must be off hormonal contraceptives for at least three months before testing FSH and estradiol. In addition, standard estradiol assays do not detect ethinyl estradiol, the estrogen in birth control.

Remember that it is common and not pathologic for patients on hormonal contraception to be amenorrheic. Amenorrhea on birth control does not require further evaluation unless there are other concerning symptoms.[9]

Enhancing Healthcare Team Outcomes

There are many causes of secondary amenorrhea, and thus it is important to have an interprofessional team involved in the investigation and management of this disorder. Apart from infertility, the biggest concern is the ongoing bone loss that occurs due to a lack of sex hormones. Healthcare workers, including nurse practitioners, should educate the patient on the importance of bone health while they are being worked up for the cause of secondary amenorrhea. Besides increasing calcium in the diet, the patient should participate in regular exercise. The loss of fertility in many women is also associated with significant emotional distress, and hence a referral to a mental health counselor is recommended. The outcomes of women with secondary amenorrhea depend on the cause.[5][10]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

References

1.

Sehemby M, Bansal P, Sarathi V, Kolhe A, Kothari K, Jadhav-Ramteke S, Lila AR, Bandgar T, Shah NS. Virilising ovarian tumors: a single-center experience. Endocr Connect. 2018 Dec;7(12):1362-1369. [PMC free article: PMC6280592] [PubMed: 30400027]

2.

Maciejewska-Jeske M, Szeliga A, Męczekalski B. Consequences of premature ovarian insufficiency on women’s sexual health. Prz Menopauzalny. 2018 Sep;17(3):127-130. [PMC free article: PMC6196782] [PubMed: 30357022]

3.

Martini MG, Solmi F, Krug I, Karwautz A, Wagner G, Fernandez-Aranda F, Treasure J, Micali N. Associations between eating disorder diagnoses, behaviors, and menstrual dysfunction in a clinical sample. Arch Womens Ment Health. 2016 Jun;19(3):553-7. [PubMed: 26399871]

4.

Chandeying P, Pantasri T. Prevalence of conditions causing chronic anovulation and the proposed algorithm for anovulation evaluation. J Obstet Gynaecol Res. 2015 Jul;41(7):1074-9. [PubMed: 25772812]

5.

Pereira K, Brown AJ. Secondary amenorrhea: Diagnostic approach and treatment considerations. Nurse Pract. 2017 Sep 21;42(9):34-41. [PubMed: 28832422]

6.

Chaloutsou K, Aggelidis P, Pampanos A, Theochari E, Michala L. Premature Ovarian Insufficiency: An Adolescent Series. J Pediatr Adolesc Gynecol. 2017 Dec;30(6):615-619. [PubMed: 28502828]

7.

Practice Committee of the American Society for Reproductive Medicine. Current evaluation of amenorrhea. Fertil Steril. 2006 Nov;86(5 Suppl 1):S148-55. [PubMed: 17055812]

8.

Rosenfield RL. Puberty and its disorders in girls. Endocrinol Metab Clin North Am. 1991 Mar;20(1):15-42. [PubMed: 2029884]

9.

Gabby LC, McDaniel KE, Gordon BJ, Al-Marayati LA. Hematometrocolpos following Low Transverse Cesarean Delivery Complicated by Uterine Dehiscence. Case Rep Obstet Gynecol. 2021;2021:5591893. [PMC free article: PMC8261190] [PubMed: 34258089]

10.

Du X, Zhang W, Wang X, Yu X, Li Z, Guan Y. Follicle-Stimulating Hormone-Secreting Pituitary Adenoma Inducing Spontaneous Ovarian Hyperstimulation Syndrome, Treatment Using In Vitro Fertilization and Embryo Transfer: A Case Report. Front Endocrinol (Lausanne). 2021;12:621456. [PMC free article: PMC8264655] [PubMed: 34248835]

Disclosure: Megan Lord declares no relevant financial relationships with ineligible companies.

Disclosure: Manjusha Sahni declares no relevant financial relationships with ineligible companies.

Secondary amenorrhea – causes, symptoms, diagnosis, treatment and prevention

Amenorrhea is the medical term for the absence of menstruation. Primary amenorrhea is defined as when menstruation has never started by age 15. Whereas secondary amenorrhea is the absence of menstruation for three consecutive cycles in a woman who previously had a regular cycle, or a pronounced violation of the cycle for six months in a row.

Secondary amenorrhea is one of the most difficult reproductive health problems, as women with this disorder always suffer from infertility. Spontaneous cessation of menstruation is an alarming symptom that indicates a serious dysfunction of the body.

It is important to consult a gynecologist in a timely manner if you have not had your period for more than three months in a row. At our clinic, you will receive all the medical care and support you need to maintain your health and well-being.

Mechanism of development of secondary amenorrhea

The menstrual cycle is a complex process that involves the production of hormones from various glands in the body. It can be divided into four main phases: menstrual phase, follicular phase, ovulatory phase, and luteal phase.

1. The menstrual phase lasts about seven days and is known as menstruation (bleeding).

At this time, the level of estrogen and progesterone decreases, which causes separation of the uterine lining – this is how bleeding begins. In response to a decrease in hormone levels, receptors in the hypothalamus and pituitary gland begin to produce gonadotropin-releasing hormone (GnRH).

2. The follicular phase lasts 10 to 16 days.

During this period, the pituitary gland secretes follicle-stimulating hormone (FSH). This causes the ovaries to create follicles containing immature eggs.

3. Ovulation phase – lasts approximately 2-3 days.

At this time, the dominant follicle is formed and turns into a mature egg, which is released during ovulation. The egg travels from the ovary to the fallopian tube, where it can potentially be fertilized by a sperm. Estrogen levels reach a critical level, causing a sudden release of luteinizing hormone (LH) from the pituitary gland.

4. Luteal phase – lasts approximately 14 days.

The rest of the dominant follicle turns into a corpus luteum, which is essentially a mass of cells that produce the hormone progesterone. This thickens the lining of the uterus, preparing the body for pregnancy if the egg is fertilized.

If pregnancy does not occur, the corpus luteum disintegrates, causing estrogen and progesterone levels to drop, which causes a new menstrual period to begin.

As we can see, the brain, ovaries, and uterus work together and interact through hormones (chemical signals sent through the blood from one part of the body to another) to keep the cycle going. Pregnancy, menopause, hormonal imbalances, thyroid disorders, polycystic ovary syndrome (PCOS), excessive weight loss or gain, strenuous exercise, certain medications can all cause a cycle to be disrupted or stopped. The task of the gynecologist is to accurately determine the cause of secondary amenorrhea and eliminate it, if possible. Without treatment, secondary amenorrhea can lead to severe consequences, including infertility.

Symptoms of secondary amenorrhea

The main symptom of secondary amenorrhea is the absence of menstruation for more than three months in a row or an irregular cycle, when the duration between periods is much longer than usual.

Depending on the cause that caused secondary amenorrhea, concomitant changes in appearance or well-being may appear:

• discharge from the mammary glands;

• increased hair loss;

• blurred vision;

• pain in the lower abdomen;

• loss of appetite;

• sudden weight loss;

• headache;

• temperature increase;

• male-pattern unwanted hair growth;

• acne and pimples, etc.

Be sure to contact an ON CLINIC gynecologist if you have a long period delay, or you have never had a period, and you are 15 years old or older.

Causes of secondary amenorrhea

There are so many causes of secondary amenorrhea that in medicine it is customary to combine them into large groups.

1. Physiological factors:

• pregnancy – is considered the most typical and common cause of amenorrhea, especially in women of reproductive age;

• breastfeeding – since prolactin, necessary for the production of milk, suppresses the activity of hormones that ensure the menstrual cycle;

• Menopause is a natural process that occurs when a woman’s menstrual periods stop permanently.

2. Medicines:

• contraceptives – sometimes taking birth control can cause a missed period. Even after stopping birth control pills, it may take some time before regular ovulation and menstruation return. This also includes some types of intrauterine devices;

• neuroleptics;

• chemotherapy used to treat cancer;

• antidepressants;

• blood pressure medications;

• allergy medications.

3. Lifestyle:

• too low or high BMI – often in women suffering from eating disorders, such as anorexia or bulimia, menstruation stops completely. Low or overweight disrupts many hormonal functions in the body, including stopping ovulation;

• excessive physical activity – this especially applies to athletes, professional dancers, workers of heavy physical labor. In them, the loss of menstruation is facilitated by high energy costs, low levels of body fat, and stress. In medicine, they even distinguish a syndrome called the “Triad of female athletes”;

• stress – it can temporarily change the functioning of the endocrine system, and as a result, ovulation and menstruation can stop. The cycle usually recovers after the stress is relieved.

4. Hormonal imbalance:

• polycystic ovary syndrome (PCOS) – causes relatively high fluctuations in hormone levels, leading to irregular or no periods

• thyroid dysfunction – an overactive thyroid gland (hyperthyroidism) or an underactive thyroid gland (hypothyroidism) can cause menstrual irregularities, including amenorrhea;

• pituitary tumor – usually such tumors are benign, but can disrupt the hormonal regulation of menstruation;

• Premature menopause – it is said if menstruation stops by the age of 40.

5. Structural problems

• scarring of the uterus – Asherman’s syndrome, in which scar tissue forms inside the uterus. It may occur after diagnostic curettage, caesarean section, surgical termination of pregnancy, or operations on the uterine cavity. Scarring of the uterus prevents the normal excretion of menstrual flow;
• congenital malformations of the genital organs – sometimes a child is already born without a uterus, cervix or vagina. Because the reproductive system has not fully developed, menstrual cycles do not appear during puberty and later;
• obstruction of the reproductive tract – due to structural abnormalities, such as adhesions, tumors, cervical stenosis, etc., menstruation may not occur.

Classification of secondary amenorrhea

Secondary amenorrhea is divided into false and true forms. With true amenorrhea, the neuroendocrine regulation of the menstrual cycle is disturbed. They say about false when the hormonal function of the ovaries and cyclic changes in the uterus are preserved, and anatomical changes prevent the outflow of blood. Then the blood accumulates in the uterus, vagina or fallopian tubes.

In order for the practitioner to assess the clinical situation, WHO proposes to classify cases of secondary amenorrhea into three large groups:

• I – cases of amenorrhea with a lack of endogenous estrogen synthesis in combination with normal or low levels of FSH in the absence of pathology of the hypothalamic-pituitary system or a high concentration of prolactin.

• II – amenorrhea with normal estrogen synthesis and normal concentrations of prolactin and FSH.

• III – amenorrhea with high levels of FSH in the blood serum, indicating premature ovarian failure (POF).

An accurate diagnosis can only be made by a doctor after a thorough and comprehensive examination. Consult a gynecologist if you observe a lack of menstruation for more than three cycles in a row.

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Diagnosis of secondary amenorrhea

Diagnosis of secondary amenorrhea always begins with anamnesis. Your gynecologist will ask about your menstrual history, including age of onset, regularity of your periods, any recent changes in your menstrual cycle, as well as surgical procedures, medications, changes in weight or diet, exercise, work habits, and medical conditions. He will then perform a thorough physical examination and a gynecological examination. All this information will help determine the suspected causes of amenorrhea and, if necessary, refer them for further diagnosis.

Pregnancy is usually ruled out first as the most likely cause. If pregnancy tests show a negative result, then a complete blood and urine test is prescribed, as well as biochemical tests to determine the level of hormones, including levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol and thyroid-stimulating hormone (TSH).

To assess the state of the reproductive system, an ultrasound examination of the uterus and ovaries, hysteroscopy and laparoscopy can be performed.

To make an accurate diagnosis, the doctor must answer three basic questions:

• Do the ovaries produce normal amounts of estrogen?
• Is the patient ovulating?
• Do the ovaries secrete normal amounts of androgens?

For this, special tests are carried out:

1. Gestagen test

To assess the estrogen saturation of the body and the response of the endometrium to the effects of progesterone.

Within 10-14 days, special steroid hormones are introduced – gestagens, which are analogues of progesterone. With a positive result, after the end of the medication for 3-5 days, a menstrual-like reaction should appear. With negative bleeding does not occur.

2. Estrogen-gestagen test

In order to exclude the uterine form of amenorrhea and to identify the degree of estrogen deficiency in the case of a negative test with progesterone.

In the first phase, lasting 8-10 days, it is necessary to take estrogens, then progestins for 5-7 days. If 2-4 days after the test, there is no menstrual-like reaction, then this is assessed as a negative reaction, and indicates the uterine form of amenorrhea. A positive test indicates ovarian hypofunction.

3. Gonadoliberin test

To assess the function of the hypothalamus and pituitary gland.

Introduction of the hormone gonadoliberin (GnRH) and measurement of the level of gonadotropic hormones (FSH and LH). Follicle-stimulating hormone (FSH) is produced by the pituitary gland and affects the formation (maturation and growth) of female follicles and male spermatozoa. Luteinizing hormone (LH) is a hormone that is involved in the process of ovulation. It stimulates the development of the genital organs. .

If the level of these hormones increases after the administration of GnRH, then this indicates the normal function of the hypothalamus and pituitary gland.

Complications of secondary amenorrhea

Secondary amenorrhea can lead to other pathologies and cause various complications:

• reproductive dysfunction – in the absence of menstruation, the chances of becoming pregnant are reduced;

• destruction of bone tissue – a lack of estrogen can lead to bone loss and the development of osteoporosis;

• the development of cardiovascular diseases – a lack of estrogen increases the risk of developing cardiovascular diseases in women;

• development of depression;

• metabolic disorders and obesity.

Therefore, it is recommended to consult a gynecologist with a prolonged absence of menstruation to determine the cause and prescribe the necessary treatment.

Treatment of secondary amenorrhea

The choice of therapy always depends on the underlying cause of secondary amenorrhea. First of all, treatment is aimed at eliminating this cause, and then, if possible, they try to restore the cycle and reproductive function.

For example, hypothalamic amenorrhea associated with weight loss, excessive exercise, another medical condition, or emotional stress is usually treated without problems by addressing the underlying cause. For example, weight gain and less exercise can usually restore menstrual cycles in women without additional measures if their amenorrhea is due to weight loss or excessive exercise only and no additional cause of amenorrhea has been identified.

In premature ovarian failure, hormone therapy may be recommended both to prevent the unpleasant symptoms of estrogen depletion and to prevent complications of low estrogen levels such as osteoporosis. These may be oral contraceptive pills for those women who do not want pregnancy, or alternative estrogen and progesterone preparations. While postmenopausal hormone therapy is associated with certain health risks in older women, younger women with premature ovarian failure may benefit from this therapy to prevent bone loss.

Women with PCOS (polycystic ovary syndrome) are given treatment that lowers the levels or activity of male hormones or androgens.

Assisted reproductive technologies and drugs that stimulate the maturation of ovarian follicles are given to women with certain types of amenorrhea who want to become pregnant.

If amenorrhea is caused by hypothyroidism, then thyroid hormones are used in long courses.

When amenorrhea is caused by anorexia, complex treatment is recommended: a high-calorie diet, sedatives, psychotherapy, etc. Other specialists are involved in the treatment, for example, a psychiatrist or nutritionist.

In some cases, surgery may be required to remove the tumor or cyst that is causing the amenorrhea.

It is important to consult with your doctor to determine the underlying cause of secondary amenorrhea and develop an appropriate treatment plan. Treatment options may vary depending on the individual case and comorbidities.

Prevention of secondary amenorrhea

In some cases, secondary amenorrhea can be prevented and complications can be prevented. To do this, you should regularly undergo preventive medical examinations, visit a gynecologist, as well as lead a healthy lifestyle, eat right, exercise and avoid stress.

Advantages of amenorrhea treatment at ON CLINIC

• We employ experienced gynecologists-endocrinologists who are highly qualified and professionally experienced in the treatment of gynecological diseases of any complexity.

• Our clinic is equipped with modern medical equipment, which allows us to conduct accurate diagnostic tests and effectively treat patients.

• We offer an individual approach to each patient, taking into account his health characteristics and medical history.

• In our clinic, we use various methods of treatment, including medication, surgery, physiotherapy and others.

• After the end of the course of treatment, we conduct follow-up to monitor the effectiveness of the treatment and prevent the recurrence of the disease.

Q&A

Is secondary amenorrhea treated in all cases?

Secondary amenorrhea is most often reversible. However, if the cause of amenorrhea is associated with serious diseases or developmental disorders of the reproductive system, then the treatment may be more complex and lengthy, and sometimes does not lead to the desired result. Contact your doctor for more information.

Is it possible to get pregnant with secondary amenorrhea?

Most often, the main complication of secondary amenorrhea is infertility, so getting pregnant naturally with this diagnosis can be difficult. Consultation of the gynecologist is necessary.

Is it possible to play sports with secondary amenorrhea?

If the cause of amenorrhea is not excessive physical activity, then you can exercise moderately.

References

• Kulakov V. I., Savelyeva G. M., Manukhina I. B. Gynecology. National leadership. – M., 2009. – S. 309-318.
• Dzeranova LK, Ilovayskaya IA Diagnosis and treatment of hyperprolactinemia: clinical recommendations of the International Society of Endocrinology and the view of Russian experts // Effective pharmacotherapy. – 2012. – no. 18. – S. 28-33.
• Legro R. S. et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline //The Journal of Clinical Endocrinology & Metabolism. – 2013. – T. 98. – no. 12. – S. 4565-4592.
• Lindsay T. Fourman, Pouneh K. Fazeli. Neuroendocrine Causes of Amenorrhea // J Clin Endocrinol Metab, 2015; 100(3): 812–824.

Secondary amenorrhea: types, causes, treatment.

Save article:

What is it? Secondary amenorrhea is manifested as the cessation of menstruation in a woman of reproductive age for up to 6 months or even more. It is not classified as a disease and is classified as a type of cycle disorder.

How does it affect? Other symptoms accompanying secondary amenorrhea are pain in the lower abdomen, mental distortions, obesity, vegetative manifestations. Each of them indicates a specific form of VA, so treatment is aimed at eliminating the disease in a specific area.

In this article:

1. What is secondary amenorrhea in women
2. Main causes of secondary amenorrhea
3. What are the symptoms of secondary amenorrhea
4. Possible complications of secondary amenorrhea
5. Diagnosis and treatment of secondary amenorrhea

What is secondary amenorrhea in women

Secondary amenorrhea is the absence of menstruation for six months or more. This phenomenon can be observed in women who have previously menstruated.

Up to 10% of women aged 16 to 45 suffer from secondary amenorrhea, not associated with physiological causes, such as pregnancy or menopause. It is important to understand that the consequences of secondary amenorrhea are extremely serious.

All women who have such a violation suffer from infertility. Therefore, secondary amenorrhea is one of the most serious reproductive health problems. The occurrence of such a phenomenon may indicate problems not only in the field of gynecology, but also in psychiatry and endocrinology.

Experts distinguish two forms of amenorrhea: true and false.

• True amenorrhea is due to a violation of the neuroendocrine system.
• With false secondary amenorrhea hormones can be produced by the ovaries in accordance with the norm. In this case, cyclic changes in the uterus do not occur. Usually such a violation is associated with the occurrence of obstructions to the outflow of blood from the genitals. In this case, blood can accumulate in the fallopian tubes (hematosalpinx), uterus (hematometra), or in the vagina (hematocolpos).

Main causes of secondary amenorrhea

When secondary amenorrhea occurs in girls, gynecologists pay attention to many factors. It can affect both genetic predisposition or hormonal changes, as well as psychological reasons. The genesis of the disease is divided into several types: uterine, psychogenic, hypothalamic, hypothalamic-pituitary, adrenal. The division into these types occurs in accordance with the level of damage to the body systems and the etiology of the disease.

Hypothalamic amenorrhea

It occurs in women with disorders in the hypothalamus-pituitary-adrenal-ovarian chain and is characterized by the so-called hypothalamic syndrome. Often this pathology occurs under the influence of external causes. They can serve as infections or viral diseases, increased physical and psychological stress, as well as operations or injuries.

Hypothalamic amenorrhea often develops in girls within 3 years after the first menstruation. The pathogenesis of the hypothalamic syndrome is associated with hyperactivation of the sympathoadrenal system and stimulation of the hypothalamic structures. Against this background, there is an increased secretion of LH, FSH, prolactin, ACTH, TSH, cortisol, aldosterone; decrease in the level of estradiol and progesterone, growth hormone.

Over time, the sympathoadrenol system is depleted, due to which the activity of the hypothalamic-pituitary-adrenal system decreases, which leads to irregularities in the menstrual cycle.

Often, disorders in the hypothalamus occur due to sudden weight loss. Women who are on a diet or suffer from anorexia should be very careful. Don’t lose weight too fast. This should happen gradually. Doctors have developed norms that state what body weight is optimal for your height and age.

Losing more than 10% of the weight recommended by the health care system can already lead to amenorrhea. In addition to changes in body weight, a false pregnancy can be the cause of the disorder. With this phenomenon, a change in the hormonal background is observed, as a result of which FSH synthesis is inhibited.

Secondary amenorrhea of ​​hypothalamic-pituitary origin

The cause of secondary amenorrhea of ​​the hypothalamic-pituitary genesis is considered to be organic and functional hyperprolactinemia. The production of the hormone prolactin increases, which reduces the synthesis of gonadotropins. As a result, menstruation stops. There can be many reasons for the development of functional hyperprolactinemia: stress, abortion, taking hormonal or psychotropic substances, lactation, etc.

Organic hyperprolactinemia is most often caused by pituitary tumors. Secondary amenorrhea of ​​the hypothalamic-pituitary origin also develops against the background of pituitary adenoma, neuroinfections, and Sheehan’s syndrome.

Adrenal form of secondary amenorrhea

Adrenal form of secondary amenorrhea is observed with virilizing tumors of the adrenal glands, Itsenko-Cushing’s syndrome, adrenogenital syndrome and hyperplasia of the adrenal cortex. Ovarian forms develop with ovarian failure syndrome, resistant ovary syndrome, PCOS, ovarian tumors, oophoritis, artificial menopause induced by surgery or radiation therapy.

Secondary uterine amenorrhea

Secondary uterine amenorrhea often results from damage to the uterine endometrium. This can happen due to injury or inflammation. Endometritis of tuberculous or gonorrheal etiology, multiple abortions or curettage of the uterus, as well as endometrial ablations often lead to endometrial damage. At the same time, as a result of damage to the basal layer of the uterus, the cyclic transformation of the endometrium in response to hormonal stimulation and its desquamation does not occur.

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The above reasons are the most common for the occurrence of secondary uterine amenorrhea, but not only they can serve as an impetus for the development of the disease. Violation of menstruation of this type can begin against the background of Asherman’s syndrome, atresia of the cervical canal due to electroconization of the cervix.

Psychogenic or stress amenorrhea

Psychogenic or stress amenorrhea is quite rare. The manifestation of this genesis of the disease is about 10% of all cases. Psychogenic amenorrhea develops against the background of chronic or acute psychological trauma. Often such a violation of the menstrual cycle is observed during armed conflicts, wars or social disasters, therefore it is also called “wartime amenorrhea”.

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The release of a large amount of ACTH, neurotransmitters that block the secretion of gonadotropin-releasing factor, has a stressful effect on the body, which leads to a disruption in the production of gonadotropic hormones (FSH and LH) by the pituitary gland and a decrease in the synthesis of sex hormones by the ovaries.

What are the symptoms of secondary amenorrhea

When contacting a doctor, women mainly complain about the absence of menstruation for six months or more. At the same time, most patients have a female body type and have normal development of secondary sexual characteristics and pelvic organs.

When applying, the doctor examines the presence of factors that could lead to the onset of amenorrhea. The most common of them are:

• Surgical interventions . These include any operations that were performed on the pelvic organs: abortion or diagnostic curettage, removal of the fallopian tubes or ovarian cysts, resection of the ovaries, conization of the cervix (a surgical intervention that is performed for cervical dysplasia and is the removal of a cone-shaped area), removal uterine fibroids.
• Stressful or emotionally unstable condition , sudden weight loss, constant high physical or psychological stress.
• Presence of symptoms of endocrinological diseases . They can manifest as discharge from the mammary glands, baldness or hirsutism (growth of hair on the face of women), acne. Also, symptoms such as persistent headaches, increased dryness of the skin, the presence of stretch marks of the skin, apathy, drowsiness, sudden weight gain or oligomenorrhea preceding amenorrhea (a menstrual cycle disorder in which its duration is more than 35 days) should be alerted.
• Presence of symptoms of ovarian failure . These include a feeling of dryness in the vagina, insomnia, frequent muscle pain and hot flashes (unexplained flashes of heat accompanied by such phenomena as rapid heartbeat, reddening of the skin, sudden sweating and trembling).
• Taking psychotropic or hormonal drugs .

If amenorrhea is associated with atresia of the cervical canal, which arose after surgery, then it is accompanied by sharp pains in the lower abdomen. In such a situation, it is possible to quickly identify the cause of the pathology. This type of secondary amenorrhea is treated quite easily: specialists expand the cervical canal with a metal rod (bougie), and the blood can again flow freely from the uterus.

Possible complications of secondary amenorrhea

Many patients have a question whether it is possible to become pregnant with secondary amenorrhea. The answer to this question is clear. Women suffering from such a violation of the reproductive system are most often infertile. It is important to understand that fertility disorders can become irreversible if the disease is started.

In addition, complications after the disease can manifest themselves in the form of osteoporosis (a violation of the structure of bone tissue due to a decrease in its density), cardiovascular diseases or oncology. Organs that are hormone-dependent are especially prone to the occurrence of tumor formations. The bone mineral density of women also depends on the production of hormones.

For example, a decrease in estrogen levels leads to an increase in bone fragility. This area has not yet been fully explored, despite the obviousness of the observed patterns.

During or after amenorrhea, bone fractures are especially common in girls and women who are professionally involved in sports. Those who are passionate about running, skiing or swimming are at risk.

It has been established that not all types of amenorrhea cause complications in the form of osteoporosis. Menstrual disorders that are associated with the use of hormonal drugs or with anatomical defects, that is, physiological amenorrhea, do not have such an effect on the body.

Diagnosis and treatment of secondary amenorrhea

When diagnosing a disease, the doctor uses different methods. To begin with, the gynecologist must conduct a survey of the patient and establish how long she has not had menstruation, whether there are comorbidities and other issues. It is important to identify which drugs and psychotropic drugs a woman takes, as well as what hereditary factors could affect the development of the disease.

The interview is followed by a physical examination. During this process, height and weight are measured, and body type is assessed. The patient is examined for an increase in hairiness of the skin or, conversely, baldness, as well as the presence of acne, stretch marks, discharge from the mammary glands and hyperpigmentation.

Then it is necessary to conduct an ultrasound examination of the small pelvis, during which it will be possible to determine the volume of the ovaries, the number of follicles.

It is necessary to measure the level of hormones such as FSH, LH, estradiol, testosterone, prolactin, TSH, progesterone. To identify the clinical picture, tests for ACTH, DHEAS, 17-OH-progesterone, cortisol can be performed. It also makes sense to take the following samples from the patient:

• Gestagen test . For the study, the patient is prescribed hormonal steroid drugs similar to progesterone. A woman should take them for two weeks. After this period, it is necessary to determine whether there was a menstrual-like reaction to the drugs.
• Estrogen-gestogen test . Such a study consists of two phases. At the first stage, the woman takes drugs containing estrogen, and at the second – progestogen. After the course, the gynecologist evaluates whether there was a menstrual-like reaction to taking hormones.
• Gonadoliberin test . The patient is injected with GnRH (an analogue of the gonadotropin-releasing hormone of the hypothalamus), after which the change in the level of FSH and LH is assessed.

A benign tumor of the pituitary gland can lead to secondary amenorrhea. To identify it, the patient needs an MRI of the brain. Also during and after treatment, a densitometry procedure is performed, which helps to assess bone density using x-rays.

Treatment methods for secondary amenorrhea are selected according to its type. The goal of therapy is to neutralize the causes of menstrual irregularities and restore menstruation and reproductive function.

Amenorrhea, which was caused by a sharp weight loss or anorexia, is treated with the involvement of nutritionists and psychotherapists. In this case, the patient is prescribed multivitamins and sedatives. In addition, an individual diet with an increased calorie content is being developed for a woman. Meals should be frequent throughout the day.

If this approach does not help restore the menstrual cycle, then the patient is additionally prescribed hormonal drugs. The duration of their reception can be up to six months. If it is established that amenorrhea is of a psychogenic type, then it is necessary to exclude factors that provoke diseases from the lifestyle. It is necessary to normalize the psychological and physical stress. As an additional measure, it is recommended to use various types of massage, as well as electrophoresis.

With hypothyroid amenorrhea, courses of thyroid hormones are prescribed.

With secondary amenorrhea of ​​the ovarian type, hormone therapy is prescribed. It is important to pay attention to the presence of concomitant factors. For example, if an ovarian tumor is detected, it will be necessary to remove the appendages. If it is established that one of the causes of amenorrhea is the presence of an infection, then it is necessary to carry out antibiotic therapy.

It is important not to delay the visit to the doctor and consult a gynecologist at the first sign of the disease. In this case, most likely, it will be possible to quickly achieve the restoration of the menstrual cycle. Reproductive function can also be restored with the right treatment. It largely depends on the form of amenorrhea. If, after the resumption of menstruation, infertility persists, then the patient will need to contact a reproductologist.

In the Kirov sanatorium you can take all the tests, get a doctor’s consultation.

For the treatment of hormonal disorders, the sanatorium offers radon baths and drinking radon water in combination with drug treatment.