QuestionSBA
QuestionChoice
Premature ovarian failure refers to loss of normal ovarian function before the age of 40. It is confirmed by oligo/amenorrhoea for at least 4 months and an elevated FSH on two occasions at least 4 weeks apart. In premature ovarian insufficiency, there is hypergonadotrophic hypogonadism since loss of negative feedback of ovarian hormones results in raised gonadotrophic hormones (whereas these would be low in functional hypothalamic amenorrhea).
52947
a
Premature ovarian insufficiency
QuestionChoice
Prolactinoma can result in secondary amenorrhoea as the elevated prolactin levels inhibit the release of FSH and LH. These patients would have a low oestradiol, low FSH/LH and high prolactin levels.
52951
e
Prolactinoma
QuestionChoice
Functional hypothalamic amenorrhoea is a common cause of secondary amenorrhoea. Stress, anorexia or intense exercise result in reduced hypothalamic secretion of gonadotropin-releasing hormone, leading to reduced follicle-stimulating hormone (FSH) and luteinising hormone (LH) and subsequently oestrogen. This is also termed hypogonadotrophic hypogonadism. In this patient, the high FSH and LH levels go against this diagnosis.
52948
b
Functional hypothalamic amenorrhoea
QuestionChoice
In patients under 40 who undergo ovarian failure, this is deemed as premature ovarian insufficiency. However, in women over 40 with menopause symptoms and a low FSH, this is deemed menopause.
52949
c
Menopause
QuestionChoice
Polycystic ovarian syndrome (PCOS) can result in amenorrhoea and often presents with evidence of hyperandrogenism, such as hirsutism, acne or elevated testosterone. These patients tend to have a normal FSH but an elevated LH:FSH ratio and can have a normal, low or high oestradiol. The patient in this case has a high FSH and LH and no signs of hyperandrogenism on examination, which goes against the diagnosis of PCOS.
52950
d
Polycystic ovarian syndrome
Concept
Chapter
# 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)
925
3508
Secondary amenorrhoea
Topic
60
General Practice
10650
A 34-year-old woman presents to her GP with amenorrhoea. She had normal periods up until the last year but has had no periods for the last 4 months. Apart from feeling tired, which she attributes to travelling a lot for work, she reports no other symptoms. Her examination is normal. Her pregnancy test is negative. She has an elevated FSH and LH, a low oestradiol level and a normal prolactin and testosterone level. 

What is the most likely cause of her amenorrhoea?
a