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What is amenorrhea secondary. Secondary Amenorrhea: Causes, Symptoms, and Treatment Options

by alexxlab

What are the main causes of secondary amenorrhea. How is secondary amenorrhea diagnosed. What are the treatment options for secondary amenorrhea. When should you see a doctor for absent periods.

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Understanding Secondary Amenorrhea: Definition and Prevalence

Secondary amenorrhea is a condition characterized by the absence of menstrual periods in women who have previously experienced regular menstruation. According to the American College of Obstetricians and Gynecologists, it is diagnosed when a woman who has passed menarche goes six months or longer without menses. The prevalence of secondary amenorrhea due to causes other than pregnancy, lactation, and menopause is approximately 2% to 5% of women of reproductive age.

How does secondary amenorrhea differ from primary amenorrhea? Primary amenorrhea refers to the absence of menstruation by age 15 in girls with normal secondary sexual characteristics or by age 13 in girls without secondary sexual characteristics. Secondary amenorrhea, on the other hand, occurs after a woman has already established regular menstrual cycles.

Common Causes of Secondary Amenorrhea

There are three general categories of causes for secondary amenorrhea:

  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 them in more detail:

Hormonal Causes

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

Structural Causes

  • Damage to the endometrium (Asherman syndrome)
  • Obstruction of the outflow tract (cervical stenosis)

Is stress a factor in secondary amenorrhea? Yes, excessive stress or exercise can lead to hypogonadotropic hypogonadism, which may result in secondary amenorrhea.

Diagnosing Secondary Amenorrhea: The Evaluation Process

The diagnosis of secondary amenorrhea involves a comprehensive approach, including a detailed medical history, physical examination, and laboratory tests. Here’s a step-by-step guide to the evaluation process:

Medical History

A thorough medical history should include:

  • Full menstrual history
  • Current birth control method
  • Pattern of menses (regular or irregular)
  • Any inciting events before the onset of amenorrhea (e.g., childbirth, surgery, trauma, pelvic infection, D and C)
  • Symptoms related to hyperprolactinemia (headaches, vision changes, galactorrhea)
  • Thyroid symptoms (fatigue, weight changes, skin/hair/nail changes, palpitations, tachycardia)
  • Signs of PCOS (hirsutism, acne)
  • Stress levels and exercise routines

Physical Examination

The physical exam should include:

  • Calculation of body mass index (BMI)
  • Assessment of acanthosis nigricans
  • Evaluation of hirsutism, acne, and virilization

Laboratory Tests and Imaging

The evaluation typically follows this sequence:

  1. Urine pregnancy test
  2. If negative, consider clinical picture for PCOS
  3. If not consistent with PCOS, check TSH
  4. If TSH is normal, check serum prolactin
  5. If prolactin is normal, perform a progestin challenge

How is the progestin challenge performed? The patient is given oral progesterone (typically medroxyprogesterone, 10mg PO daily for 5-10 days). If withdrawal bleeding occurs within 2-7 days after completing the progesterone, this indicates that the hypothalamic-pituitary-ovarian axis is intact and that there is sufficient estrogen to stimulate endometrial growth.

Polycystic Ovarian Syndrome (PCOS): A Common Cause of Secondary Amenorrhea

Polycystic ovarian syndrome (PCOS) is one of the most common causes of secondary amenorrhea. How is PCOS diagnosed? According to the Rotterdam criteria, a patient may be diagnosed with PCOS if she has two of the following:

  • Clinical or chemical hyperandrogenism
  • Oligo- or amenorrhea
  • Polycystic ovaries on ultrasound

If a patient has evidence of hirsutism and oligo- or amenorrhea, she can be diagnosed with PCOS without further laboratory testing or imaging. This highlights the importance of a thorough clinical evaluation in diagnosing the cause of secondary amenorrhea.

Treatment Options for Secondary Amenorrhea

The treatment of secondary amenorrhea depends on its underlying cause. Here are some common treatment approaches:

PCOS Treatment

  • Lifestyle modifications (diet and exercise)
  • Oral contraceptives to regulate menstrual cycles and reduce androgen levels
  • Metformin to improve insulin sensitivity
  • Anti-androgen medications for hirsutism and acne

Thyroid Dysfunction Treatment

  • Levothyroxine for hypothyroidism
  • Anti-thyroid medications or radioactive iodine for hyperthyroidism

Hyperprolactinemia Treatment

  • Dopamine agonists (e.g., bromocriptine, cabergoline) to lower prolactin levels
  • Surgery for large prolactinomas

Hypogonadotropic Hypogonadism Treatment

  • Address underlying causes (e.g., stress reduction, weight gain if underweight)
  • Hormone replacement therapy
  • Gonadotropin therapy for those desiring pregnancy

Structural Causes Treatment

  • Hysteroscopic surgery for Asherman syndrome
  • Cervical dilation for cervical stenosis

How effective are these treatments? The success of treatment depends on the underlying cause and individual patient factors. Many women with secondary amenorrhea can resume regular menstrual cycles with appropriate treatment.

When to Seek Medical Attention for Absent Periods

When should you consult a healthcare provider about secondary amenorrhea? It’s advisable to seek medical attention if:

  • You’ve missed three or more consecutive periods
  • Your periods suddenly stop
  • You experience irregular or infrequent periods
  • You have symptoms of PCOS, thyroid dysfunction, or other hormonal imbalances
  • You’re experiencing infertility

Early diagnosis and treatment of secondary amenorrhea can help prevent potential complications and improve overall reproductive health.

The Role of the Interprofessional Team in Managing Secondary Amenorrhea

Managing secondary amenorrhea often requires an interprofessional approach. Who are the key members of this team?

  • Primary care physicians
  • Gynecologists
  • Endocrinologists
  • Reproductive endocrinologists
  • Radiologists
  • Nutritionists
  • Mental health professionals

How does this team collaborate to provide optimal care? Each member brings their expertise to diagnose and treat the underlying cause of secondary amenorrhea. For example, a gynecologist might diagnose PCOS, an endocrinologist could manage thyroid dysfunction, and a nutritionist might help with lifestyle modifications. This collaborative approach ensures comprehensive care and improved outcomes for patients with secondary amenorrhea.

In conclusion, secondary amenorrhea is a complex condition with various potential causes. A systematic approach to diagnosis, involving a detailed history, physical examination, and appropriate laboratory tests, is crucial. Treatment is tailored to the underlying cause and may involve lifestyle modifications, medication, or surgery. With proper management, many women with secondary amenorrhea can resume regular menstrual cycles and maintain good reproductive health.

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.

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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.

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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.

Absent menstrual periods – secondary: MedlinePlus Medical Encyclopedia


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Absence of a woman’s monthly menstrual period is called amenorrhea. Secondary amenorrhea is when a woman who has been having normal menstrual cycles stops getting her periods for 6 months or longer.

Secondary amenorrhea can occur due to natural changes in the body. For example, the most common cause of secondary amenorrhea is pregnancy. Breastfeeding and menopause are also common, but natural causes.

Women who take birth control pills or who receive hormone shots such as Depo-Provera may not have any monthly bleeding. When they stop taking these hormones, their periods may not return for more than 6 months.

You are more likely to have absent periods if you:

  • Are obese
  • Exercise too much and for long periods of time
  • Have very low body fat (less than 15% to 17%)
  • Have severe anxiety or emotional distress
  • Lose a lot of weight suddenly (for example, from strict or extreme diets or after gastric bypass surgery)

Other causes include:

  • Brain (pituitary) tumors
  • Drugs for cancer treatment
  • Medicines to treat schizophrenia or psychosis
  • Overactive thyroid gland
  • Polycystic ovarian syndrome
  • Reduced function of the ovaries

Also, procedures such as a dilation and curettage (D and C) can cause scar tissue to form. This tissue may cause a woman to stop menstruating. This is called Asherman syndrome. Scarring may also be caused by some severe pelvic infections.

In addition to having no menstrual periods, other symptoms can include:

  • Breast size changes
  • Weight gain or weight loss
  • Discharge from the breast or change in breast size
  • Acne and increased hair growth in a male pattern
  • Vaginal dryness
  • Voice changes

If amenorrhea is caused by a pituitary tumor, there may be other symptoms related to the tumor, such as vision loss and headache.

A physical exam and pelvic exam must be done to check for pregnancy. A pregnancy test will be done.

Blood tests may be done to check hormone levels, including:

  • Estradiol levels
  • Follicle stimulating hormone (FSH level)
  • Luteinizing hormone (LH level)
  • Prolactin level
  • Serum hormone levels, such as testosterone levels
  • Thyroid stimulating hormone (TSH)

Other tests that may be performed include:

  • CT scan or MRI scan of the head to look for tumors
  • Biopsy of the lining of the uterus
  • Genetic testing
  • Ultrasound of the pelvis or hysterosonogram (pelvic ultrasound that involves putting saline solution inside the uterus)

Treatment depends on the cause of amenorrhea. Normal monthly periods most often return after the condition is treated.

A lack of menstrual period due to obesity, vigorous exercise, or weight loss may respond to a change in exercise routine or weight control (gain or loss, as needed).

The outlook depends on the cause of amenorrhea. Many of the conditions that cause secondary amenorrhea will respond to treatment.

See your primary health care provider or women’s health care provider if you have missed more than one period so you can get diagnosed and treated, if needed.

Amenorrhea – secondary; No periods – secondary; Absent periods – secondary; Absent menses – secondary; Absence of periods – secondary

  • Secondary amenorrhea

  • Normal uterine anatomy (cut section)

  • Absence of menstruation (amenorrhea)

Bulun SE. Physiology and pathology of the female reproductive axis. In Melmed S, Auchus RJ, Goldfine AB, Koenig RJ, et al. Williams Textbook of Endocrinology. 14th ed. Philadelphia, PA: Elsevier; 2020:chap 17.

Lobo RA. Primary and secondary amenorrhea and precocious puberty. In: Gershenson DM, Lentz GM, Valea FA, Lobo RA, eds. Comprehensive Gynecology. 8th ed. Philadelphia, PA: Elsevier; 2022:chap 36.

Magowan BA, Owen P, Thomson A. The normal menstrual cycle and amenorrhoea. In: Magowan BA, Owen P, Thomson A, eds. Clinical Obstetrics and Gynaecology. 4th ed. Elsevier; 2019:chap 4.

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Secondary amenorrhea. What is Secondary Amenorrhea?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Secondary amenorrhea is the cessation of menstruation for six months or more in women of reproductive age with an established menstrual cycle. The defining feature is the absence of menstruation for at least six months. Secondary amenorrhea may be accompanied by pain in the lower abdomen (in the uterine form), mental disorders (in the psychogenic form), obesity (in the endocrine form), autonomic disorders (in the ovarian form), etc. To establish the causes of amenorrhea, a general and gynecological examination is performed, hormonal studies, ultrasound of the pelvic organs, radiography of the Turkish saddle, hystero- and laparoscopy. Treatment is aimed at correcting the factors that led to secondary amenorrhea.

    ICD-10

    N91.1 Secondary amenorrhea

    • Classification of secondary amenorrhea
    • Causes of secondary amenorrhea
    • Forms of secondary amenorrhea
    • Diagnosis of secondary amenorrhea
    • Treatment of secondary amenorrhea
    • Prices for treatment

    General

    Secondary amenorrhea is a violation of the menstrual cycle, characterized by the absence of menstruation for 6 months or longer. Unlike primary amenorrhea, the secondary form develops in previously menstruating women. At the age of 16-45 years, the incidence of secondary amenorrhea, not associated with physiological causes (pregnancy, lactation, menopause), is 3-10% of cases. Secondary amenorrhea is one of the most difficult problems of reproductive health, since women with this disorder always suffer from infertility. Spontaneous cessation of menstruation indicates a serious dysfunction of the body, which may be in the plane of consideration of gynecology, endocrinology, psychiatry.

    Secondary amenorrhea

    Classification of secondary amenorrhea

    Among secondary amenorrhea, its true and false forms are distinguished. At the heart of true amenorrhea is a violation of the neuroendocrine regulation of the menstrual cycle. False amenorrhea is diagnosed with the preservation of the hormonal function of the ovaries and cyclic changes in the uterus; in this case, the absence of menstruation is associated with anatomical obstacles to the outflow of blood from the uterus and genital tract. With false amenorrhea, blood can accumulate in the fallopian tubes (hematosalpinx), uterus (hematometra), or in the vagina (hematocolpos).

    Depending on the level of gonadotropic hormones that regulate menstrual function, amenorrhea is divided into:

    • hypogonadotropic, caused by organic lesions of the pituitary gland or hypothalamus;
    • hypergonadotropic, caused by impaired ovarian function of genetic, enzymatic, autoimmune or other etiology;
    • normogonadotropic, due to uterine pathology, PCOS, psychogenic factors, malnutrition, debilitating physical exertion, hyperprolactinemia.

    Causes of secondary amenorrhea

    The development of pathological secondary amenorrhea may be associated with various anatomical, genetic, biochemical, hormonal, neuropsychic factors. Taking into account the etiology and level of damage, secondary amenorrhea of ​​hypothalamic, hypothalamic-pituitary, adrenal, ovarian, uterine, psychogenic genesis is distinguished.

    Secondary hypothalamic amenorrhea is observed in women with functional disorders in the “hypothalamus-pituitary-adrenal-ovarian” system – the so-called hypothalamic syndrome. Such a pathology develops under the influence of frequent viral diseases or chronic infections, excessive physical and mental stress, and surgical interventions. It usually occurs in girls 1-3 years after menarche. 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. In the future, as the sympathoadrenal system is depleted, the activity of the hypothalamic-pituitary-adrenal system also decreases, which is accompanied by secondary amenorrhea.

    Hypothalamic dysfunction can also occur in the presence of significant weight loss due to a low-calorie diet or anorexia nervosa. It is known that even a loss of 10-15% of the weight from the physiological and age norm can cause symptoms of secondary amenorrhea, and a weight loss of less than 46 kg leads to the insensitivity of the pituitary gland to stimulation with GnRH. Another cause of hypothalamic amenorrhea can be a false pregnancy. With this syndrome, there is an increased secretion of LH and prolactin with simultaneous inhibition of FSH synthesis.

    Secondary amenorrhea of ​​the hypothalamic-pituitary origin is most often associated with functional and organic hyperprolactinemia. An increase in the production of prolactin is accompanied by a decrease in the synthesis of gonadotropins, which causes the cessation of menstruation. Functional hyperprolactinemia can develop against the background of hypothyroidism, prolonged lactation, stress, abortion, long-term use of psychotropic, hormonal drugs, COCs. The causes of organic hyperprolactinemia may be pituitary tumors (prolactinoma). Disorders of the hypothalamic-pituitary regulation of the menstrual cycle are observed in Sheehan’s syndrome, pituitary adenoma, TBI, and neuroinfections.

    The adrenal variant of secondary amenorrhea occurs in adrenogenital syndrome (congenital adrenal hyperplasia), virilizing tumors of the adrenal glands, hyperplasia of the adrenal cortex, Itsenko-Cushing’s syndrome. Ovarian forms are observed in ovarian failure syndrome, resistant ovary syndrome, PCOS, ovarian tumors, oophoritis, artificial menopause induced by surgery or radiation therapy.

    Uterine forms of secondary amenorrhea are most often associated with inflammatory or traumatic damage to the endometrium. The destruction of the endometrium can occur due to endometritis of tuberculous or gonorrheal etiology, repeated abortions and medical and diagnostic curettage, endometrial ablation. 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. Less common among the uterine factors of amenorrhea are Asherman’s syndrome, atresia of the cervical canal due to electroconization of the cervix.

    Psychogenic or stress amenorrhea accounts for approximately 10% of cases among other forms of the disorder. It can be provoked by acute or chronic emotional and mental trauma. Stress amenorrhea often occurs in women during periods of armed conflict and social disasters, therefore it is often defined as “wartime amenorrhea”. Stressful effects on the body cause the release of a large amount of ACTH, neurotransmitters that block the secretion of gonadotropin-releasing factor, 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.

    Forms of secondary amenorrhea

    Regardless of the cause of secondary amenorrhea, common to all forms is the cessation of menstrual bleeding, which previously occurred more or less regularly, and infertility. The criterion is considered to be the absence of menstruation for 6 or more months in a row. Other symptoms are variable and depend on the form of secondary amenorrhea.

    Psychogenic amenorrhea is additionally accompanied by asthenoneurotic, depressive or hypochondriacal syndromes. Patients note increased fatigue, anxiety, sleep disturbances, a tendency to depression, decreased libido. May be disturbed by tachycardia, dry skin, constipation. Menstruation stops suddenly, there is no period of oligomenorrhea.

    Amenorrhea against the background of weight loss is accompanied by a noticeable weight deficit; a medical examination revealed hypoplasia of the mammary glands and genitals. Other signs of malnutrition include hypotension, bradycardia, hypothermia, hypoglycemia, and constipation. Appetite is reduced, persistent aversion to food and cachexia may develop, indicating the onset of anorexia.

    Secondary amenorrhea in hypothalamic syndrome is combined with early puberty, obesity, hirsutism, the presence of acne and stretch marks on the skin, and vegetative-vascular dystonia. Amenorrhea associated with hyperprolactinemia is characterized by spontaneous galactorrhea. Frequent complaints of cephalalgia, dizziness, arterial hypertension. There are psycho-emotional disorders: mood variability, irritability, depressive reactions.

    In ovarian forms of secondary amenorrhea, the disappearance of menstruation is often preceded by a period of oligomenorrhea. Patients have a history of timely onset of menarche and often normal menstrual function. With resistant ovary syndrome, menstruation stops before the age of 35, but there are no vegetative-vascular disorders characteristic of premature menopause. Amenorrhea associated with ovarian wasting syndrome, on the contrary, is accompanied by hot flashes, facial flushing, sweating, and headaches.

    The defining symptom of false amenorrhea is spastic pain in the lower abdomen, caused by a violation of the outflow of menstrual blood. In chronic endometritis, menstrual irregularity develops gradually: over time, the intensity and duration of menstruation decreases until it stops completely.

    Diagnosis of secondary amenorrhea

    Secondary amenorrhea is diagnosed based on the history and clinical presentation. However, a more difficult task for gynecologists-endocrinologists, neurologists, psychotherapists and other specialists is the differential diagnosis of the form of amenorrhea and the determination of its causes. When determining the gynecological status of the patient, the age of menarche, the nature of menstruation in the past, obstetric history, past gynecological and extragenital diseases, operations and injuries, heredity, nutrition, exposure to stress and other factors affecting menstrual function are taken into account.

    Mandatory for secondary amenorrhea are examination on the chair, functional tests (pupillary symptom, measurement of basal temperature, colpocytology), colposcopy, ultrasound of the pelvic organs. As part of the differential diagnosis, pharmacological tests are widely used: with progesterone, estrogens and gestagens, clomiphene, gonadotropins. To detect intrauterine pathology, hysterosalpingography and hysteroscopy are performed. In ovarian forms of secondary amenorrhea, diagnostic laparoscopy is informative.

    In order to identify hormonal disorders, a study of TSH, T4, insulin, LH and FSH, estradiol, progesterone, testosterone, prolactin, ACTH, cortisol and other hormones is indicated, taking into account the alleged variant of secondary amenorrhea. If a pathology of the pituitary gland is suspected, an x-ray of the Turkish saddle is performed; according to indications, CT or MRI of the pituitary gland is performed. The examination plan includes a consultation with an ophthalmologist with an examination of the fundus (ophthalmoscopy) and examination of the visual fields.

    Treatment of secondary amenorrhea

    Treatment options for secondary amenorrhea are closely related to its form. Therapy is aimed at eliminating the causes of amenorrhea, if possible – restoring menstrual and reproductive functions.

    Secondary amenorrhea caused by underweight or anorexia is treated in conjunction with psychotherapists and nutritionists. Patients are prescribed a high-calorie diet with frequent fractional meals, sedatives, multivitamins, and psychotherapy. If against this background there is no spontaneous recovery of the menstrual cycle, hormone therapy is prescribed for 4-6 months. Patients with a psychogenic form of amenorrhea are recommended to exclude provoking factors, to normalize working and rest conditions. Physiotherapy courses are shown: endonasal electrophoresis, SHVZ massage, balneotherapy.

    If the cause of amenorrhea is hypothyroidism, thyroid hormones are used in long courses. Patients with hyperprolactinemia are shown to take bromocriptine, cabergoline and their analogues. The detection of pituitary macroadenoma based on the results of the examination is the basis for surgical or radiation treatment.

    Therapy of ovarian forms of secondary amenorrhea consists in the appointment of cyclic hormone therapy, low-dose COCs. If an ovarian tumor is detected, an oophorectomy or adnexectomy (removal of the appendages) is required. With atresia of the cervical canal, its bougienage is performed. Treatment of synechia of the uterine cavity is surgical, with the help of hysteroresectoscopy. In infectious processes, the appointment of etiotropic antibiotic therapy is indicated. In the future, to improve metabolic processes in the uterus, it is advisable to carry out physiotherapeutic procedures – ultrasound, electrophoresis, diathermy on the pelvic area.

    In most cases, with the help of properly organized treatment, it is possible to achieve the resumption of menstruation. The prognosis in terms of restoring reproductive function depends on the form of secondary amenorrhea. With persistent infertility, a woman is recommended to consult a reproductologist. Modern reproductive technologies make it possible to perform in vitro fertilization (according to the IMSI or ICSI method), if necessary, using donor sperm, a donor egg or a donor embryo. To increase the chances of pregnancy after artificial insemination and a successful embryological stage, cryopreservation of embryos is performed with their subsequent thawing and implantation into the patient’s uterus. Chronic miscarriage is an indication for the use of surrogate motherhood.

    You can share your medical history, what helped you in the treatment of secondary amenorrhea.

    Sources

    1. self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

      causes, symptoms, signs, classification, diagnosis, treatment, recommendations

      Causes

      Symptoms

      Classification

      Diagnosis

      Treatment

      Prognosis and prevention

      Amenorrhea is a condition in which a female has no menstrual bleeding for 6 months. What is amenorrhea in women, and why can it appear even in girls under 16?

      It is important to remember that this deviation is not considered an independent diagnosis, but is a symptom of other pathologies. In addition, there is a physiological type of amenorrhea, when there is no menstruation due to pregnancy, breastfeeding, menopause. In this case, no treatment is required.

      Causes and triggers

      Primary amenorrhea is a condition in which a girl who has reached the age of 16 has never had a period before. Most often, the symptom is caused by a particular disease, heredity, abnormal development of the uterus or ovaries, impaired patency in the uterus, cervical canal, vagina.

      Secondary amenorrhea occurs in women who have had periods in the past that have suddenly stopped. The causes can be divided into two more groups – physiological and pathological. In the first case, no treatment, examinations and other interventions by the doctor are required.

      But amenorrhea for pathological reasons may occur due to:

      • constant stressful situations;
      • sharp weight loss;
      • diabetes mellitus;
      • hyperthyroidism;
      • hypothyroidism;
      • adrenal tumors;
      • exhausted ovary syndrome;
      • ovarian tumors;
      • intrauterine synechia;
      • endometritis;
      • early menopause.

      Risk factors include hard work, constant physical or emotional overwork, starvation. There are also a number of genetic diseases, one of the manifestations of which is just secondary amenorrhea.

      It is impossible to independently determine the cause of the pathological absence of menstruation, especially in the case when they have already been there before. This can only be done by a gynecologist and other specialists – endocrinologist, oncologist, surgeon.

      Symptoms

      Symptoms of amenorrhea can be very different and depend on what caused the disease. The main complaint for all women with suspected this condition will be the absence of menstruation.

      In the primary form, they do not occur before the age of 16 years. With a secondary period, there is no period for six months, and some medical sources indicate a period of 3 months. The woman is not pregnant, is not breastfeeding, and has no symptoms of menopause.

      Other signs of amenorrhea will appear depending on the causes that caused this pathological condition.

      With a pathology of the hypothalamic-pituitary system, a woman is overweight, her face is round, red stripes appear on her stomach and thighs. Sometimes with this syndrome, on the contrary, there is thinness with mild or absent secondary sexual characteristics. In the presence of a pituitary tumor, headaches, signs of acromegaly, bulging eyes, constant irritability are noted.

      If it turns out that a woman suffers from a congenital disorder of the ovaries, then she has almost no secondary sexual characteristics, she has a male physique, short stature, a barrel-shaped chest, heart and vascular defects, and curvature of the joints. In such patients, Shereshevsky-Turner syndrome, which is a congenital disease, can be suspected.

      Wasted ovary syndrome (OSI) gives a different clinical picture: mental and emotional disorders, decreased sexual desire, VSD. All this happens to women during menopause, but most often young girls suffer from this syndrome. With PCOS, and this is another ovarian lesion, excessive growth of facial hair begins, obesity appears, there is a high risk of developing diabetes and disorders of the heart and blood vessels.

      Uterine amenorrhea can be either primary or secondary. Both conditions are associated with the pathological structure of this organ, which until now has not been identified.

      The absence of menstruation in endocrine disorders, primarily associated with thyroid pathology, is manifested by dry skin, hair loss, and fatigue. Extra hair appears on the face and body, which grows very quickly. Patients from this group with Itsenko-Cushing’s disease are overweight, facial edema.

      Another option is lactational amenorrhea. This is a physiological type of lack of menstruation, which occurs as a result of breastfeeding a child. At the same time, a natural mechanism for suppressing ovulation is triggered.

      Classification

      Amenorrhea is divided into true and false. The first occurs due to the complete absence of periodic changes in the ovaries, endometrium and throughout the body. Such a woman has never had a period, and the sex hormones for the implementation of the cycle are not enough at all.

      False form – a condition in which cyclic changes occur in the ovaries and uterus, but the blood from the vagina is not released, but accumulates in it, or remains in the fallopian tubes or in the uterus.

      The postpartum form can last for 2-3 years, but only while breastfeeding.

      In the classification of pathological amenorrhea, there are three other options: primary, secondary and etiotropic. The latter is normogonadotropic, hypergonadotropic, hypogonadotropic.

      Diagnostics

      The gynecologist is engaged in the diagnosis and treatment of this disorder, if necessary, connecting specialists from other fields of medicine to consult the patient. First, a survey and examination are conducted, the anamnesis of life, the method of contraception used, the duration of the period without menstruation, and the medications used are ascertained. The height and weight of the woman are measured, pregnancy is excluded.

      Diagnosis of amenorrhea is carried out with a choice of the following methods: ultrasound of the pelvic area and internal genital organs, CT of the same area, MRI of the brain, which allows to identify disorders in the hypothalamic-pituitary system.

      Hysteroscopy, hormonal testing, and genetic testing can also be used if you suspect hereditary diseases characterized, among other things, by primary amenorrhea.

      Treatment

      Physiological amenorrhea does not require any treatment and resolves on its own at the end of pregnancy, after childbirth, or after breastfeeding. The period of menopause in older women also does not require any special therapy.

      All pathological forms require mandatory therapy and elimination of the causes that provoked them.

      General clinical recommendations for all types of amenorrhea from gynecologists will sound like this:

    2. start eating right, adjust your diet, give up fatty, high-calorie and other harmful foods;
    3. stop smoking and drinking alcoholic beverages;
    4. avoid too much physical activity.

In the secondary form, weight and metabolism are normalized. If necessary, the doctor prescribes a correction of hormones with natural preparations or hormones of artificial origin.

Often the treatment of amenorrhea, which is false, requires surgical intervention. This helps to get rid of malformations of internal organs, remove tumors in the uterus, and make plastic reconstruction. If violations of the hypothalamic-pituitary system are detected, consultation with a neurosurgeon is mandatory. In case of pathology of the glands, the involvement of an endocrinologist is required, and then the treatment of a patient with amenorrhea is carried out by the joint efforts of different doctors.

Prognosis and prevention

Some of the reasons that caused the sudden cessation of menstruation can be eliminated quite easily, and the prognosis will be favorable. But sometimes no treatment helps, and then a woman can get a chance to become a mother only after the IVF procedure, since the absence of menstruation for a long time is always a high risk of infertility.

At a young age, it is important not to follow trendy diets, but to eat right so as not to disturb the menstrual cycle. It is also necessary to dress strictly according to the weather, take vitamin and mineral complexes, give up power sports and maintain an even emotional state.

The author of the article:

Shklyar Aleksey Alekseevich

obstetrician-gynecologist, surgeon, KMN, head of the direction “Obstetrics and Gynecology”

work experience 11 years

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m. Sukharevskaya

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Inna

30.12.2021 21:55:20

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m. Sukharevskaya

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Shklyar Aleksey Alekseevich

I turned to Shklyar Aleksey Alekseevich I want to express my deepest gratitude to the entire team of the operating unit Aleksey Alekseevich Shklyar. You are all doctors with a capital letter. I never tire of thanking God for bringing me to you. I came to you on the recommendation of Sorvacheva M.V. We got in touch with the doctor by phone and appointed the day of the operation. For the first time, I was pleasantly surprised how Alexey Alekseevich told me everything in detail and reassured me. A couple of weeks later, I arrived at the clinic at 10.00 with a complete list of tests, and already at 11 I was lying on the operating table, to be honest, I didn’t even have time to get scared) Then the anesthetist magician came and I fell asleep sweetly. I woke up already in bed, nothing hurt, there were no side effects, just a normal morning awakening. I would never have believed that this was even possible, I am very grateful for a wonderful dream. Before that, I had more than one general anesthesia in state hospitals, and now I understand for sure that they apparently wanted to kill me there, but it didn’t work out. For the next two hours, until it was impossible to get up, wonderful nurses came to me asking how I felt and if I needed something, they put droppers, and I lay and did not believe that everything terrible was over)) 2 hours after the operation, I was already getting up and drank delicious broth and tea. The rest of the time before sleep, I walked around the ward, I didn’t feel any pain at all, a little weakness and nothing more. The next morning I was fed deliciously and discharged home. After being discharged, Aleksey Alekseevich is constantly in touch, he worries about my well-being more than even my relatives. I needed further treatment, he even helps me with this by calling the best doctors and clinics, supporting me. And now I know for sure that I am in the most reliable hands. Thank you very much again. Prosperity to your clinic and low bow to all your doctors. You are the best!!!

Lilia

15.05.2021 15:21:57

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m. On May 7, 2021, I did a minor gynecological operation in SOD, and I would like to express my gratitude to the attending physician, to the head of the gynecological department Shklyar Aleksey Alekseevich, – for high professionalism, and exceptionally friendly attitude, understandable recommendations. The doctor communicates very correctly, clearly and with explanations.
Special thanks to the anesthetist Alexey Valeryevich Fomin, for the high-quality anesthesia (I was more afraid of anesthesia than the operation itself), but everything went well, I was “not present” at the operation, and the condition after anesthesia was normal, as after waking up in the morning, no “side effects” ‘ did not feel.
After the operation, nothing hurt after half an hour, and after an hour and a half, I went home.
The attitude in the hospital was the most friendly, including from the nurses and the administrator at the reception (unfortunately, I did not ask for names).
It’s been a week since the operation, and only the discharge summary # 140035314 reminds of it.
I’m very glad that I trusted the experience of the Polyclinic ru doctors.

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