Secondary Amenorrhea
Differential Overview
❑ Pregnancy
❑ Menopause
❑ Functional hypothalamic amenorrhea
❑ Drugs
❑ Anorexia nervosa
❑ Post-contraceptive
❑ Endometrial scarring
❑ Endocrinopathy
❑ Hyperprolactinemia
❑ Premature ovarian failure
❑ Polycystic ovary syndrome
❑ Chromophobe adenoma
❑ Ovarian tumors
❑ Panhypopituitarism
❑ Müllerian dysgenesis
Diagnostic Approach
Evaluation should always begin with a history and a urine hCG for pregnancy. On physical examination, attention should be paid to darkening of the areola, and evidence of estrogenization of the vagina.
Estrogen sufficiency can be assessed by observing a fern-like pattern of cervical mucous on a slide or by giving medroxyprogesterone for 5 days and looking for withdrawal bleeding. Bleeding suggests suppression of LH surge as seen in functional amenorrhea or polycystic ovary syndrome.
Clinical Findings
Pregnancy A bluish cervix with an enlarged uterus and darkening of the areola are clues.
Menopause Manifestations include hot flashes, emotional lability, vaginal dryness, and low libido. The average age of onset is 50.
Functional hypothalamic amenorrhea GnRH suppression is triggered by emotional stress, concurrent illness, sudden weight loss, drug use (oral contraceptives or phenothiazines), or physical stress including athletic training. It often occurs in young professional women who work long hours, eat lightly, and engage in vigorous daily aerobic activity. Loss of cyclic LH production may cause mild hirsutism and acne because of stimulation of ovarian androgens.
Drugs Drugs that increase prolactin: phenothiazines, tricyclic antidepressants, MAO inhibitors, calcium channel blockers, methyldopa, and reserpine. Drugs with estrogenic activity: digoxin, marijuana, and oral contraceptives. Drugs with ovarian toxicity: busulfan, chlorambucil, cisplatin, cyclophosphamide, and fluorouracil.
Anorexia nervosa Amenorrhea occurs at about 10% below ideal body weight, a BMI of less than 18.5 kg/m2. An overly thin habitus especially with a decrease in weight, yellow pallor from hypercarotenemia, lanugo (downy) hair, and hypotension are clues. The disorder is frequently hidden from the physician by the patient. Enlarged parotid glands and eroded dental enamel occur with coexisting bulimia.
Post-contraceptive Amenorrhea rarely lasts more than 6 months following discontinuation of contraceptives.
Endometrial scarring In Asherman syndrome, there is a prior history of endometrial infection or postpartum hemorrhage followed by curettage or radiation therapy.
Endocrinopathy An endocrine disorder is usually evident by the time amenorrhea occurs; the exception is mild hypothyroidism. Uncontrolled diabetes can produce amenorrhea, especially in the setting of insulin resistance.
Hyperprolactinemia Galactorrhea combined with amenorrhea distinguishes hyperprolactinemia. A prolactin-secreting pituitary adenoma accounts for 20% of cases of secondary amenorrhea. Microadenomas may enlarge with pregnancy so that prolonged postpartum amenorrhea is suspicious for prolactin-secreting adenoma. Failure to lactate in addition suggests Sheehan syndrome (postpartum pituitary necrosis).
Premature ovarian failure The presence of another autoimmune glandular disease provides a clue, particularly associated with antithyroid or antiadrenal antibodies. It can also be idiopathic or as a result of radiation or chemotherapy.
Polycystic ovary syndrome PLOS is characterized by amenorrhea, and hyperandrogenism (hirsuitism and acne). The onset occurs at puberty and findings worsen with weight gain. A BMI of greater than 30 kg/m2 is seen in 50%. The patient has ovaries that are bilaterally enlarged and cystic.
Chromophobe adenoma These adenomas often enlarge to the point that headache and visual field defects (bitemporal hemianopsia) are present at the time that amenorrhea develops. Hypothyroidism, adrenal insufficiency, and diabetes insipidus may accompany the amenorrhea.
Ovarian tumors Bilateral ovarian tumors rarely cause amenorrhea, but granulosa-cell tumors, which produce excess estrogen, and arrhenoblastomas with virilization do.
Panhypopituitarism Panhypopituitarism is usually due to postpartum hemorrhage, heralded by failure of lactation, failure of menses to restart, loss of body hair, and asthenia.
Müllerian dysgenesis Cyclic abdominal pain and distension, hirsutism, large and lobulated ovaries, obesity, and acanthosis nigricans are findings.
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Light periods
Read excerpts from these other book chapters related to Light periods:
Medical Books Excerpts
- AMENORRHEA
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- Amenorrhea
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Amenorrhea
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Amenorrhea
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
- Amenorrhea
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Amenorrhea
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Amenorrhea
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Light periods
|
|
More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
|
|
» Next page: Amenorrhea (Signs & Symptoms: A 2-in-1 Reference for Nurses)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
