Secondary Amenorrhea (Adolescent Medicine)

by Brian Alverson, MD

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    00:01 We had another lecture on primary amenorrhea. This lecture will be on secondary amenorrhea.

    00:08 So, secondary amenorrhea is the absence of menses for more than six months in a patient who is previously menstruating. Generally, these patients have a normal pubertal development.

    00:20 There’s not a primary problem with how they’re developing in their puberty.

    00:24 Remember, adolescents may have anovulatory cycles. So, they can be fairly irregular especially early on.

    00:32 But a period of six months is too long. This is generally a disruption in the HPO axis. It can be a result of inadequate GnRH release, inadequate LH and FSH release, or insufficient estrogen to stimulate the LH surge and ovulation. So, what is important to ask in a patient who has secondary amenorrhea? It’s important to ask about sexual activity. This patient may be pregnant. It’s important to ask them about eating behaviors. New onset of an eating disorder could certainly result in a secondary amenorrhea.

    01:10 Ask also about competitive athletic events and excessive exercise. Ask about a history of chemotherapy or pelvic radiation. Certainly, you want to ask about a family history of menstrual or gynecologic problems that are going on. Sometimes drugs can cause this, so ask in particular about psychotropic medications or illegal drugs. Ask about underlying hormonal problems that might be going on.

    01:38 So, what do we look for in a physical exam in a girl with secondary amenorrhea? It’s important to assess their Tanner stage and know where they are in their pubertal development. Assess the height, weight, and BMI especially in a very thin-appearing girl. You need to do a genital exam. It’s important to check for clitoromegaly which may result from excessive androgens like testosterone. It’s also important to do a bimanual exam to assess the shape and tenderness of the uterus and ovaries. Check a skin exam for specifically hirsutism, acne, striae, or acanthosis nigricans. Think about an endocrinopathy.

    02:27 Check the thyroid. Look for other physical exam findings of endocrinopathies. So, what are the organic causes of secondary amenorrhea? One is a mass like a prolactinoma in the pituitary gland.

    02:43 Patients may have hyperthyroidism or they may have hypothyroidism. One syndrome that can definitely present with secondary amenorrhea is the polycystic ovarian syndrome. We’ll talk about that more completely in a bit. Additionally, patients may have late-onset congenital adrenal hyperplasia.

    03:03 That would be very rare but you might suspect it in a patient with a large clitoris.

    03:09 Additionally, rarely, patients may have virilizing tumors. So, what testing do we get in these patients? Well, if there is no obvious physical exam findings and we’re worried, we should certainly check a pregnancy test. For patients with concern for thyroid disease, you would get a TSH and a free T4.

    03:31 Likewise, if a patient had concerns for a prolactinoma, we can check her prolactin level.

    03:37 In patients where they are highly virilized, rather the large clitoris, a free and total testosterone is probably indicated. If we’re worried about that HPO axis, we can get an LH and FSH.

    03:49 Remember, insulin levels may be elevated in patients with polycystic ovarian syndrome.

    03:55 If we’re going to image, pelvic ultrasound is the most useful way to start. It’s a very useful way to evaluate patient’s reproductive anatomy. However, if we suspect a central process, we would obtain an MRI of the head with the cut down images of the pituitary especially in patients with elevated prolactin. While we don’t think of this as a typical imaging modality to assess the genitourinary tract, oftentimes patients will get a DEXA scan to see if they have any compromising of their bone mineral density as some of these conditions may result in those problems.

    04:36 One way to assess secondary amenorrhea is to do a progesterone challenge test. In this test, we administer oral progesterone for five to ten days. Then, we look for signs of withdrawal bleeding after that medicine is stopped. So, a positive test is any bleeding that happens more than light spotting that occurs within two weeks after they stop the progesterone. It will usually occur between two and seven days after that progesterone is finished. So, how do we interpret this test? If there is bleeding, that means that the endometrium has been primed by estrogen.

    05:18 This patient likely has anovulation. We should consider the possibility of polycystic ovarian syndrome.

    05:28 If the patient has no bleeding, we now have to think about evaluating for an HPO axis insufficiency.

    05:37 We should also consider outflow tract obstruction through some structural problem.

    05:44 When we treat patients, we want to treat the underlying etiology of the secondary amenorrhea.

    05:53 We should think about nutrition counseling in patients who are having eating disorders.

    05:58 We should think about endocrinology referral or gynecologic referral depending on whether we suspect there is a primary endocrinologic problem like a problem in the HPO axis versus a gynecologic problem like an obstruction of outflow tract. Consider psychologic interview for eating disorders and psychosocial stressors. This is a common cause of secondary amenorrhea in children especially children who are more affluent, living in the suburbs where we see a lot of eating disorders.

    06:30 Consider OCP therapy as a way of regulating the cycle and getting things back on track again in certain applicable individuals. How can we treat PCOS? Well, with polycystic ovarian syndrome, which is associated with patients who are a little bit overweight and have multiple cysts going through their ovaries and they sometimes have hirsutism as well, we generally will treat these patients with oral contraceptive pills. This restores a regular menstrual cycle and it also decreases the testosterone that they have in their system. We will use OCPs because they can protect against endometrial hyperplasia. When we’re choosing our oral contraceptive pill, practitioners may choose a drug that has drospirenone as the progestin component because of its antiandrogenergic properties. In addition to oral contraceptive pills, we will often provide insulin sensitizing-agents such as metformin. Metformin is also used in type II diabetes or the metabolic syndrome. This drug will decrease circulating androgens. It may improve reproductive function and it can improve metabolic complications, thus maybe help with a bit with weight loss.

    07:53 So, that’s my review of secondary amenorrhea in adolescent girls. Thanks for your time.

    About the Lecture

    The lecture Secondary Amenorrhea (Adolescent Medicine) by Brian Alverson, MD is from the course Adolescent Medicine. It contains the following chapters:

    • Secondary Amenorrhea
    • Treating Underlying Etiology

    Included Quiz Questions

    1. Polycystic ovarian syndrome
    2. Pituitary adenoma
    3. Imperforate hymen
    4. Hypothalamic dysplasia
    5. Ovarian tumor
    1. Absence of menses for 7 months with previously irregular menses
    2. Absence of menses for 5 months with previously irregular menses
    3. Absence of menses for 3 months with previously irregular menses
    4. Absence of menses for 2 months with previously regular menses
    1. Primary amenorrhea
    2. Anovulation
    3. Oligoovulation
    4. Hyperandrogenism
    5. Polycystic ovaries on ultrasound
    1. Classic congenital adrenal hyperplasia
    2. Polycystic ovarian syndrome
    3. Prolactinoma
    4. Hyperthyroidism
    5. Hypothyroidism

    Author of lecture Secondary Amenorrhea (Adolescent Medicine)

     Brian Alverson, MD

    Brian Alverson, MD

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    Excellent lecture as usual
    By Jalil Z. on 12. October 2020 for Secondary Amenorrhea (Adolescent Medicine)

    Excellent overview. It helps to visualise the different systems involved. Thank you!