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 a serum prolactin. Elevated serum prolactin suggests prolactinoma.

1. DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S. INDIA
SECONDARY AMENORRHOEA

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause
Society, India, Indian medico-legal & ethics association(IMLEA),
ISOPRB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN
2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. AMENORRHOEA
• Amenorrhea is classified as either primary or secondary.
• Primary amenorrhea is the lack of menstruation by the
age of 16yrs in the presence of normal development of
secondary sexual characters.
• Secondary amenorrhea is the absence of menstruation
for 6 consecutive months after menarche or in a woman
who has had a normal menstrual cycle.
• In a woman of childbearing age, the most common causes
of absent menstrual periods are pregnancy and lactation

4. 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.

5. Pathophysiology
• 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’s syndrome) and obstruction of the outflow tract
(cervical stenosis).

6. • Epidemiology
• Pregnancy, lactation,
and menopause are
common, physiologic
causes of secondary
amenorrhea.
• Prevalence of secondary
amenorrhea due to all
other causes is
approximately 2% - 5%

7. Spontaneous, cyclic menstruation requires an intact and
functional hypothalamic-pituitary ovarian axis
(HPOA),endometrium and genital outflow tract.
Abnormalities in any of these structures may result in
amenorrhea

8. CAUSES :

9. EVALUATION

10. 1.Hypothalamus
• Changes in GnRH signaling from the
hypothalamus to the pituitary can
disrupt this communication and
cause low gonadotropin (LH and FSH)
secretion and secondary amenorrhea
• Isolated deficit of gonadotropins
represent a rare cause of
hypothalamic amenorrhea, including
the Kallman syndrome and the
idiopathic hypogonadotropic
hypogonadism

11. • A common condition that results from disruption in this
process is functional hypothalamic amenorrhea (FHA),
which accounts for approximately 35% of all pathologic
secondary amenorrhea
• FHA is caused by stress from events such as severe
restrictive dieting, poor nutritional status, extreme
psychological stress, or excessive exercise.
• Recently genetic mutations have been associated with
FHA
• Less commonly, infiltrative diseases of hypothalamus
such as lymphoma, sarcoidosis or Langerhans cell
histiocytosis can interfere with hypothalamic function

12. PITUITARY GLAND
• The pituitary gland responds to GnRH signaling to
produce LH and FSH (also in a pulsatile fashion)
• Any change in the secretion of pituitary hormones can
lead to sec amen eg hyperprolactinaemia
• even a small change in prolactin may be sufficient to
change the menstrual pattern.
• Elevated prolactin levels should also prompt a check of
thyroid function because hypothyroidism can cause
hyperprolactinemia

13. PITUITARY GLAND
• An intact stalk is necessary for transmitting inhibitory signals to
the prolactin-secreting cells to prevent secretion. When normal
“tonic” inhibition is lifted by stalk compression, the pituitary
gland produces more prolactin. A common cause of stalk
compression is a pituitary adenoma.
• Any structural lesion in or near the pituitary gland can cause a
modest elevation in prolactin. When prolactin levels are
elevated (2 to 10 times normal), this usually indicates a
prolactin-lactotroph-secreting pituitary adenoma

14. PITUITARY GLAND
• Amenorrhea occurs when the process disrupts pituitary
function and results in decreased gonadotropin secretion
• Pituitary infarction can cause amenorrhea and sheehan
syndrome is a result of pituitary infarction following
postpartum hemorrhage or severe hypotension
• Results in partial or total loss of hormone secretion
• Can cause various endocrine deficiencies, such as
hypogonadotropic hypogonadism (loss of lh and fsh
secretion);secondary hypothyroidism (loss of thyroid-
stimulating hormone [tsh] secretion); and secondary
adrenal insufficiency (loss of adrenocorticotropic
hormone secretion).

15. 3 OVARIES
• PCOS is the most common endocrine disorder in women of
reproductive age, occurring in 7% to 10% of all young
women.
• It is characterised by altered FSH:LH ratio
• Hyperandrogenism
• Increased insulin resistance
• increased risk for prediabetes, type 2 diabetes mellitus
(T2DM), metabolic syndrome, fatty liver disease, and
obstructive sleep apnea

16. OVARIES
• When menopause or spontaneous loss of ovarian function
occurs prior to age 40, it is called spontaneous primary ovarian
insufficiency (POI), formerly referred to as premature ovarian
failure.
• Spontaneous POI is characterized by permanent cessation of
ovulation and menstruation. It can be idiopathic, a result of
prior surgery or chemotherapy, or a result of an autoimmune
process.
• FSHwill be elevated (greater than 30 to 40 IU/L) with low
estradiol levels (usually below 30 pg/mL)
• rare causes-Turner syndrome (lack of a second X chromosome),
fragile X syndrome, radiation to the pelvis, and a history of
mumps or cytomegalovirus.

17. 4. Uterus
• A less common cause of amenorrhea is Asherman
syndrome, which is fibrosis of the endometrium and
resulting lack of regeneration that leads to amenorrhea.
This can occur after instrumentation of the uterine cavity,
such as uterine curettage, myomectomy, cervical biopsy, or
polypectomy or insertion of an intrauterine device (IUD).
• More recently, therapeutic endometrial ablation has been
known to cause sec amen

18. Uterus
Women with
endometrial
tuberculosis can
develop secendory
amenorrhoea

19. 5. OTHER CAUSES
• Adrenal factors:Adrenal tumor or hyperplasia
• Cushing’s syndrome
• Thyroid factors : Hypothyroid state
• General disease :Malnutrition,tuberculosis,chronic
nephritis,diabetes etc.
• Iatrogenic : Contraceptive pills (Postpill
amenorrhoea)..Suppression of Gnrh release
• Psychotrophic drugs : phenothiazine derivatives…Dopamine
receptor blocking agents raise the prolactin level
• Antihypertensive drugs : reserpine or dopamine antagonists
: Dopamine depleting agents raise the prolactin level

20. WORK UP FOR A CASE OF SECONDARY
AMENORRHEA

21. HISTORY
Menstrual Cycle – Age of Menarche & Previous Menstrual History
Previous Pregnancies – Severe PPH( Sheehan’s Syndrome )
Weight Change – Excessive Weight Loss
Hot Flushes, Decreased Libido – Premature Menopause
Certain Medications
Contraception
Associated Symptoms – Cushing’s Disease, Hypothyroidism
Previous Gynaecological Surgery
Chronic illness

22. HISTORY. . .
• Review the menstrual intervals since menarche, and note
when any changes may have occurred along with any
other changes in medical history, social history,
medications, or weight that may have coincided with a
change in the menstrual pattern.
• Some women may consider “spotting” to be a normal
menstrual cycle, so ascertaining typical menstrual flow is
also important.
• Pregnancy and lactation

23. HISTORY
• Social and weight history
• any behaviors consistent with eating disorders or
excessive focus on weight and exercise. This would
include history of severe caloric restriction, laxative or
diuretic use, extreme and prolonged exercise regimens,
or evidence of obsession with weight/exercise
• Psychological stressors may include domestic violence
and/or a history of sexual or psychological trauma.
Health stressors could include severe or life-threatening
illness or injuries, noting the relationship of these events
to any change in the menstrual cycle or amenorrhea.

24. EXAMINATION
 GENERAL EXAMINATION
•Nutritional Status
•Extreme Emaciation Or Marked Obesity
•Presence Of Acne Or Hirsutism
•Discharge Of Milk From Breasts
ABDOMINAL EXAMINATION
• Presence Of Striae Associated With Obesity May be related to
Cushing’s Disease
• A Mass In The Lower Abdomen.
PELVIC EXAMINATION
• Enlargement of Clitoris
• Adnexal Mass Suggestive Of Tubercular tubo-ovarian mass or
ovarian tumor

29. PELVIC ULTRASOUND
• endometrial lining,
• including thickening of the lining
(indicating lack of adequate
endometrial shedding)
• or absence of lining, as seen in
FHA or Asherman syndrome.
• diagnosis of PCOS,

30. DIAGNOSTIC APPROACH
• It is important to correlate hyperandrogenism with the
physical exam. If the patient has significant hirsutism,
persistent adult acne, or male pattern scalp hair loss, there
is strong positive evidence for clinical hyperandrogenism
and supports suspicion for PCOS or other androgen excess
disorders

32. Treatment / Management
Treatment depends on the underlying cause of the
amenorrhea
• 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’s syndrome is treated with hysteroscopic lysis of adhesions.
• Cervical stenosis is treated with cervical dilation.

33. NEGATIVE PREGNANCY TEST
FSH, LH and THYROID Function Test
Progesterone Challenge Test
WITHDRAWAL BLEEDING NO WITHDRAWAL BLEEDING
ANOVULATION
FSH normal + High LH
PCOS High Prolactin
Pituitary Tumor
HYPOESTROGENIC COMPROMISED
OUTFLOW TRACT
Positive E-P
Challenge Test Negative E-P
Challenge Test
Normal or
Low FSH
Very High
FSH Normal FSH
Asherman’s Syndrome
HSG or Hysteroscopy
Ovarian
Failure
Hypothalamic
Pituitay Failure
INVESTIGATING SECONDARY AMENORRHEA