QuestionSBA
QuestionChoice
This is a reasonable next step test if you are concerned that this is secondary amenorrhoea due to a hypothalamic or pituitary cause. In this case it's more likely to be due to intensive exercise
32504
b
Serum FSH and LH measurement
QuestionChoice
TVUS is an invasive examination and would therefore not be the initial investigation of choice. A TVUS may be indicated where the pregnancy test is negative and polycystic ovary syndrome is a possible cause of her amenorrhoea
32506
d
Transvaginal ultrasound scan (TVUS)
QuestionChoice
A high testosterone might indicate an androgen secreting tumour or polycystic ovary syndrome which is less likely in this example
32505
c
Serum testosterone level
QuestionChoice
Whilst the most likely cause is exercise induced amenorrhoea, a urinary pregnancy test is indicated in this patient in the first instance
32503
a
Urinary pregnancy test
QuestionChoice
A random cortisol level is part of the investigation for adrenal insufficiency and therefore will not aid diagnosis here
32507
e
Serum cortisol level
QuestionComment
why all the thumbs down? good question as reminds you to always remember pregnancy
26326
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Sir Pep Guardiola
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# Summary
  
 
Secondary amenorrhoea is characterised by the absence of menstruation for six months or more in a woman who previously had regular menstrual cycles. The most common cause is pregnancy, but other factors such as breastfeeding, menopause, intrauterine adhesions, PCOS, drug-induced amenorrhoea, physical stress, pituitary gland pathology, and thyroid issues can also be responsible. Key signs and symptoms include absence of menstruation, and depending on the underlying cause, symptoms of pregnancy, menopause, or other related conditions. Investigations typically involve pregnancy tests, hormone level checks, and imaging studies. Management strategies depend on the underlying cause and can range from lifestyle changes and medication to surgery in severe cases.
  
 
# Definition
  
 
Secondary amenorrhoea is defined as the absence of menstruation for six months or longer in a woman who has previously had regular menstrual cycles.
  
 
# Epidemiology
  
 
Secondary amenorrhoea is a common condition affecting approximately 4-5% of women of reproductive age. It is most frequently observed in women aged 20-39 years.
  
 
# Aetiology
  
 
The potential causes of secondary amenorrhoea include:
  
 
  - Pregnancy (most common cause)
  - Breastfeeding
  - Menopause
  - Intrauterine adhesions leading to outflow tract obstruction (Asherman's syndrome)
  - Polycystic ovary syndrome (PCOS)
  - Drug-induced amenorrhoea (e.g. contraceptive use)
  - Physical stress, excess exercise, and weight loss
  - Pituitary gland pathology, such as Sheehan syndrome or hyperprolactinaemia
  - Hypothyroidism or hyperthyroidism
  
 
# Signs and Symptoms
  
 
The primary symptom of secondary amenorrhoea is the absence of menstrual periods for six months or longer. Additional symptoms, depending on the underlying cause, may include:
  
 
  - Pregnancy signs: nausea, breast tenderness, increased urination, food cravings or aversions
  - Menopause symptoms: hot flashes, night sweats, sleep problems, mood changes
  - Symptoms of PCOS: acne, weight gain, hirsutism (excessive body hair), thinning hair
  - Symptoms of pituitary gland pathology: headaches, vision problems, unexplained weight gain or loss
  
 
# Differential Diagnosis
  
 
The differential diagnosis for secondary amenorrhoea includes:
  
 
  - **Pregnancy:** confirmed by a positive pregnancy test, ultrasound, and physical examination
  - **Menopause:** diagnosed based on age, symptoms such as hot flashes and night sweats, and elevated FSH levels
  - **PCOS:** diagnosed based on irregular periods, signs of high testosterone levels (acne, hirsutism), and presence of numerous small cysts on the ovaries
  - **Asherman's Syndrome:** diagnosed based on history of uterine surgery and confirmed by hysteroscopy
  
 
# Investigations
    
 **Bedside:**
 
  - Pregnancy test

 **Bloods:**
 
  - Hormone level checks, including FSH, LH, TSH, prolactin, and testosterone

**Imaging:**

  - Ultrasound to identify potential structural abnormalities. Other imaging (e.g. MRI) may also be appropriate, but TVUSS is usually the first line option. 

**Invasive:**

  - Hysteroscopy, in cases where intrauterine adhesions are suspected
  
 
# Management
  
 
The management of secondary amenorrhoea is largely determined by the underlying cause:
  
 
  - For pregnancy: regular prenatal care
  - For menopause: hormone replacement therapy (HRT) if symptoms are troublesome
  - For PCOS: lifestyle changes, hormonal contraceptives, and potentially metformin
  - For Asherman's syndrome: surgical removal of adhesions and hormone therapy
  - For drug-induced amenorrhoea: discontinuing the offending drug if possible and safe to do so
  - For conditions related to physical stress, weight loss, or excessive exercise: lifestyle modifications and nutritional counselling.
  

# NICE Guidelines
[Click here to read NICE guidelines](https://cks.nice.org.uk/topics/amenorrhoea/)

# References 

[Patient info](https://patient.info/doctor/amenorrhoea)
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Secondary amenorrhoea
Topic
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Gynaecology
6501
In young female athletes, exercise-induced amenorrhoea is common, but a urinary pregnancy test should be performed to rule out pregnancy first.
A 17 year old competitive triathlete presents to her GP concerned that her periods have stopped. She tells you she has been stressed recently as she is training intensively for an upcoming national competition.

Which is the most appropriate initial investigation?
a