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Essay 304 - Secondary amenorrhoea

Posted by MADHURI S.
Causes Pregnancy should be ruled out in women of reproductive age group as commonest reason for secondary amenorrhea. Endocrine disorders like hyperprolictinemia due to macro or micro prolactinoma, hyperandrogenism due to delayed onset adrenal hyperplasia , androgen secreting tumour arising from ovary or adrenal gland, Cushing syndrome can lead to secondary amenorrhea . History of sudden weight loss due to chronic illness, stress can present as sec amenorrhea as opposed to anorexia nervosa lead to primary amenorrhea. Chronic illness such as renal or hepatic failure lead to a anovulation. Shehan syndrome involving postpartum pituitary necrosis leads to panhypopitutarism and abense of menses along with hypothyroidism , cortisol deficiency .asherman syndrome is post dialation and curettage condition which leads to synechie formation inside the uterine cavity and infrequent and cessation of menstruation. Past history of chemotherapy , radiotherapy may lead to ovarian failure and secondary amenorrhea .drugs which leads to high prolactin level such as dopamine antagonist,methyl dopa antipsychotics , metoclopromide lead to drug induced amenorrhea. Contraception like depot medroxy progesterone acetate injection, ius like Mirena can lead to prolonged period of amenorrhea.Premature ovarian failure which is idiopathic in most of the cases leads to secondary amenorrhea. Clinical assessment Appropriate history and examination should be done to guide further management. Detail menstural history , age at menarche, pattern of menstual cycle, regularity is inquired . Her obstetric history , history of excessive bleeding immediate in post partum period, failure of lactation, previous surgical termination of pregnancy should be asked. Feeling of morning sickness, weight gain may indicate pregnancy.History of galactorrhea, frontal headache , vision defects will be feature of prolactinoma. Endocrine pathologies such as adrenal hyperplasia may present as weight gain, signs of virilisation such as deepening of voice, breast atrophy, clitoromegaly, male pattern distribution of hair and increase libido. Androgen secreting tumour present with rapid onset of above symptoms . History drug intake , past history of cancer needing chemotherapy , radiotherapy should be inquired . Her contraceptive history and cervical smear testing noted. Her social history, use of recreational drugs asked. Patient with ovarian failure may present with hot flushes, vaginal dryness, loss of libido, women's family history of autoimmune disorder like hypothyroidism , pernicious anaemia,insulin dependent diabetes should be inquired. Family history of fragile x syndrome done. Past history chronic illnesses, tuberculosis ruled out. Patient weight and height noted and body mass index calculated and any signs karyotype abnormality as shield chest, low hair line, wide carrying angle noted ,If history is suggestive of excess prolactin breast examined for any milky secretion,neck for any swelling, per abdominal examination done to exclude any masses as pregnancy , tumour,signs of virilisation noted and ferryman galleway scoring system used for distribution of hair. Per speculum and pelvic examination done for vaginal atrophy due to menopause and and pelvic masses. Investigations Urine pregnancy test along with if needed quantitative assessment of beta human chorionic gonadotropin is done . Hormonal assay consist of follicular stimulating hormone, luetinising hormone done . Both FSH and LH will be low in Sheehan syndrome while elevated in premature ovarian failure along with low estrogen levels. If history is suggestive of hyperproctinoma serum prolactin and tosh is measured. Further levels more than 1000 u need assessment with x ray skull or ct scan to exclude any pituitary tumour, in case of Sheehan there will be feature of atropic gland. Ultrasound pelvic and trasvaginal will be simple ,inexpensive investigation to rule out pregnancy , any masses arising from ovary or adrenal gland. Serum testosterone , androstenedione helpful for adrenal tumor . 17 hydroxyprogestone level will be elevated in suspected cah. In cases of premature varin failure karyotype to rule out chromosomal abnormality such as turner syndrme( 45x0) ,fragile x permutation to see trineucliotide repeat sequence more than 200 is done even though mostly in 70percetage it is idiopathic . Hysteroslpingography is gold standard for diagnosis of asherman syndrome.chest X-ray in suspected TB, renal and liver function test , electrolyte if history is suggestive of chronic disease.
Posted by MADHURI S.
Causes Pregnancy should be ruled out in women of reproductive age group as commonest reason for secondary amenorrhea. Endocrine disorders like hyperprolictinemia due to macro or micro prolactinoma, hyperandrogenism due to delayed onset adrenal hyperplasia , androgen secreting tumour arising from ovary or adrenal gland, Cushing syndrome can lead to secondary amenorrhea . History of sudden weight loss due to chronic illness, stress can present as sec amenorrhea as opposed to anorexia nervosa lead to primary amenorrhea. Chronic illness such as renal or hepatic failure lead to a anovulation. Shehan syndrome involving postpartum pituitary necrosis leads to panhypopitutarism and abense of menses along with hypothyroidism , cortisol deficiency .asherman syndrome is post dialation and curettage condition which leads to synechie formation inside the uterine cavity and infrequent and cessation of menstruation. Past history of chemotherapy , radiotherapy may lead to ovarian failure and secondary amenorrhea .drugs which leads to high prolactin level such as dopamine antagonist,methyl dopa antipsychotics , metoclopromide lead to drug induced amenorrhea. Contraception like depot medroxy progesterone acetate injection, ius like Mirena can lead to prolonged period of amenorrhea.Premature ovarian failure which is idiopathic in most of the cases leads to secondary amenorrhea. Clinical assessment Appropriate history and examination should be done to guide further management. Detail menstural history , age at menarche, pattern of menstual cycle, regularity is inquired . Her obstetric history , history of excessive bleeding immediate in post partum period, failure of lactation, previous surgical termination of pregnancy should be asked. Feeling of morning sickness, weight gain may indicate pregnancy.History of galactorrhea, frontal headache , vision defects will be feature of prolactinoma. Endocrine pathologies such as adrenal hyperplasia may present as weight gain, signs of virilisation such as deepening of voice, breast atrophy, clitoromegaly, male pattern distribution of hair and increase libido. Androgen secreting tumour present with rapid onset of above symptoms . History drug intake , past history of cancer needing chemotherapy , radiotherapy should be inquired . Her contraceptive history and cervical smear testing noted. Her social history, use of recreational drugs asked. Patient with ovarian failure may present with hot flushes, vaginal dryness, loss of libido, women's family history of autoimmune disorder like hypothyroidism , pernicious anaemia,insulin dependent diabetes should be inquired. Family history of fragile x syndrome done. Past history chronic illnesses, tuberculosis ruled out. Patient weight and height noted and body mass index calculated and any signs karyotype abnormality as shield chest, low hair line, wide carrying angle noted ,If history is suggestive of excess prolactin breast examined for any milky secretion,neck for any swelling, per abdominal examination done to exclude any masses as pregnancy , tumour,signs of virilisation noted and ferryman galleway scoring system used for distribution of hair. Per speculum and pelvic examination done for vaginal atrophy due to menopause and and pelvic masses. Investigations Urine pregnancy test along with if needed quantitative assessment of beta human chorionic gonadotropin is done . Hormonal assay consist of follicular stimulating hormone, luetinising hormone done . Both FSH and LH will be low in Sheehan syndrome while elevated in premature ovarian failure along with low estrogen levels. If history is suggestive of hyperproctinoma serum prolactin and tosh is measured. Further levels more than 1000 u need assessment with x ray skull or ct scan to exclude any pituitary tumour, in case of Sheehan there will be feature of atropic gland. Ultrasound pelvic and trasvaginal will be simple ,inexpensive investigation to rule out pregnancy , any masses arising from ovary or adrenal gland. Serum testosterone , androstenedione helpful for adrenal tumor . 17 hydroxyprogestone level will be elevated in suspected cah. In cases of premature varin failure karyotype to rule out chromosomal abnormality such as turner syndrme( 45x0) ,fragile x permutation to see trineucliotide repeat sequence more than 200 is done even though mostly in 70percetage it is idiopathic . Hysteroslpingography is gold standard for diagnosis of asherman syndrome.chest X-ray in suspected TB, renal and liver function test , electrolyte if history is suggestive of chronic disease.
sec amenorrhea answer Posted by Tarannum Rukhsa K.

When patient has presented with secondary amenorrhra first thing we have to rule out that she might be pregnant . If she is lactating that can also result in amenorrhea in some women  . Problem in previous child birth such as Post partum hemorrhage can lead to sheehan's syndrome .History of currettage  can lead to Asherman Syndrome .  Polycystic ovaries that may present with the same complaint .contraception such as progesterone depot  or levonorgesterol intrauterine system  may result in amenorrhea .galactorrhea or any space occupying lesion such as micro or macro prolactinoma also need to be ruled out .some autoimmune condition (eg .hypothyroidism )if not well controlled might result in amenorrhea .Premature ovarian failure is another possibility ,usally associated with menopausal symptoms  .Excessive exercise, recent weight loss,anorexia nervosa  can also result into amenorrhea . Cancer treatment such as chemo or radiotherapy which might cause ovarian failure and can present as secondary amenorrhea .

B we need to know her  history of fertility as patient with infertility more prone to develop early menopause might associated with chromosomal abnormalities such as super female 47 xxy .we have to ask about menstrual history ,regulation  of cycle menstrual flow as scanty and irregular menses is a sign for polycystic ovaries. we need to know about any excessive hair growth also is a sign of polycystic ovaries or any endocrine problem such as late onset congenital adrenal hyperplasia or androgen secreting tumor  might have other associated symptomshirsutism, deepening of voice ,clitoral enlargement .drug history eg danazol can also cause the same problem .we have to ask about the symptoms of hypothyroidism eg weight gain, lethargy , cold intolerence ,constipation .we have to ask about lactation history and also ask about any milky discharge from breast (galactorrhea )if she is not ,breast feeding .Recent  weight loss or heavy exercise, need to know .we have to ask about the symptoms of space occupying lesion diplopa or headech which might present as amenorrhea ,any previous history of radiation or chemotherapy for cancer treatment Iwe have to ask about postmenopausal symptoms such as night sweart ,hotfushes ,mood disturbance to rule out premature ovarian failure .history of currettage as this may result in endometrial synaechae and result into secondary amenorrhea .

on examination :we have to measure wt and BMI ,look for any thyroid enlargement and measure blood pressure .we have to look for galactorrhea ,diplopia .any excessive hair growth or male pattern hair growth .

abdominal examination for any palpaple mass andp/v  bimanual examination for any mass .

we have to examine external genitalia for any clitoral enlargement .

C,we have to do measure follicle stimulating hormone and luitinising hormone FSH/LH  level as it will be raised in premature ovarian failure ,BUT not helpful in polycystic ovaries .low FSH /LH and low estrogen level will be in anorexia nervosa  .testosterone and SHBG is useful in polycystic ovaries .prolactin level should always be checked as micro adenoma may not be symptomatic but can result into amenorrhea .Pelvic ultrasound to rule out any ovarian pathology PCO ,can indicate ovarian morphology and endometrial atrophy in premature ovarian failure .karyotyping to rule out Tunrner  syndromme45 xo or 47 XXY .Thyroid fuction test if patient is symtomatic .

 

Posted by Tarannum Rukhsa K.

sorry i missed pregnancy test to rule out the pregnancy .

Posted by Maili Q.

(a)

Pregnancy and breastfeeding should be ruled out in the first place in women of reproductive age. Contraceptives e.g. continuous use of COCP, Mirena, Implanon and Depo-provera often cause amenorrhea. Anovulatory disorders are common causes of secondary amenorrhea, among which polycystic ovarian syndrome accounts for most of the cases. Excessive exercise, eating disorder and stress may lead to hypogonadotrophic status and thus amenorrhea. Endocrine disorders including hyperprolactinaemia and thyroid dysfunction may present first with menstrual disturbance. Late-onset congenital adrenal hyperplasia, Cushing’s syndrome and androgen secreting tumours should be suspected in women with hyperandrogenic symptoms. Premature ovarian failure (mosaic Turner’s syndrome, autoimmune, idiopathic) is seen in 1% of population. Local lesions like uterine adhesion (Asherman’s syndrome) and cervical stenosis are also known causes of secondary amenorrhea although uncommon without history of genital tract surgery.

 

(b)

I will ask about her menstrual history including age of menarche, cyclicity, menstrual flow and any associated dysmenorrhea. I will need to know about her obstetric history including abortion with dilatation and curettage. Sexual history including contraception use and fertility intention will be asked about. Issues with eating, exercise and stress will be addressed. Hyperandrogenic symptoms like acne, hirusutim, and virilization (deep voice, balding) will be looked for. Symptoms related to endocrinopathy like visual disturbance and galactorrhea (prolactinoma), cold/heat intolerance, palpitation, weight gain/loss (thyroid dysfunction) should be asked about. Climateric symptoms like hot flushes, bone pain should be asked about. Family history of early menopause is also to be mentioned

On physical examination, blood pressure and BMI will be recorded. Secondary sexual characteristics should be examined. Evidence of hirsutism (Ferriman-Callway score) and virilization  (balding, cliteromegaly) will be looked for. Acanthosis nigricans may indicate insulin resistance associated with PCOS. Breast and visual field examination should be performed if there is concern of prolactinoma. Abdomen and pelvis should be examined to exclude pelvic mass. Speculum inspection may reveal a stenosed looking cervix although it’s not diagnostic.

 

(c)

Urine pregnancy test will be performed to rule out pregnancy. FSH/LH/estrogen level should be tested. A persistently high FSH would be diagnostic for ovarian failure. Karyotyping would be advised in this case to exclude (mosaic) Turner’s syndrome. Serum testosterone and sexual hormone binding globulin should be checked, and free androgen index calculated.  Mild to moderately increased testosterone and FAI would be suggestive of PCOS, whereas very high testosterone (> 2.8ng/ml) should prompt suspicion for androgen secreting tumour. DHEA and DHEAS would identify adrenal hyperandrogenaemia; serum 17-OHP is helpful to exclude late-onset CAH and 24hr urine cortisol to exclude Cushing’s syndrome. Serum prolactin and thyroid function should be performed in suspicion of endocrine disorders. Pelvic ultrasound may identify polycystic ovaries or ovarian tumour. Adrenal imaging (ultrasound or MRI) may be needed if androgen-secreting tumour is suspected. Hysterocopy may confirm intrauterine adhesion band if suspicion on pelvic ultrasound.

Posted by shipra K.

a)   A patient in reproductive age group with secondary ammenorrhoea pregnancy should be always kept in mind. Lactational ammenorrhoea can also cause secondary amenorrhoea. Other causes include polycystic ovaries, hypothyroidism, hyperprolactinemia. Androgen producing tumours of ovary and adrenal tumours may also cause this. Late onset congenital adrenal hyperplasia ,ashmerman’s syndrome also are important causes. Drugs like-  medications for psychiatric illness, danazol etc  contraceptive like DMPA should be kept in mind. Premature menopause is also a likely possibility. Chronic illness like renal failure and rarely Sheehan’s syndrome may be seen.

 

    b)      History of previous menstrual cycles whether regular and irregular should be taken. Acne, weight gain, hirsutism would suggest polycystic ovaries. Change in voice, excessive hair growth, breast atrophy suggest testosterone producing tumours. History of galactorrheoa, headache suggest hyperprolactenemia, while cold intolerance, lethargy favour hypothyroidism and hot flushes, irritability suggest premature ovarian failure. Obstetrical history include history of last delivery and if she is  breast feeding at present. PPH at the time of delivery suggest Sheehaan’s syndrome. History of dilation and currettage, drugs which the patient is currently taking should be noted. Family history of premature menopause is important.

           On examination BMI noted thyromegaly, glactorrhoea should be looked for. Whether hirsutism is present (ferriman galliway scoring should be done). Per abdomen any lump if present should be noted.  On local examination Clitoromegaly noted. Per vaginum examination to note the size of uterus and any adenexal mass.

 

c)Investigations include a urine for pregnancy test, Full blood count,renal function tests for renal failure. Thyroid profile with prolactin levels to rule out hypothyroidism .Serum Testosterone levels and free androgen index to see for hyperandrogenemia. DHEAS would be important for adrenal tumour and 17 oh progesterone if suspicion for late onset congenital adrenal.Serum FSH LH if raised  above 40IU/ml suggest premature ovarian failure. Ultraound of pelvis to see for polycystic ovaries ,ovarian tumors ,also endometrial thickness if reduced would suggest asherman’s.Whole abdomen scan to rule out adrenal tumours ,CT MRI may be required if adrenal or ovarian tumor is suspected.

Posted by ixi C.

a)

Pregnancy is a likely cause of secondary amenorrhoea in this patient. Endocrinological causes such as polycystic ovarian syndrome, congenital adrenal hyperplasia, hyperprolactinemia are also likely. It can also be due to extremes of body weight and BMI. 

b)

I will take a menstrual history, asking her for prior menstrual cycle length, duration, amount and presence of intermenstrual and postcoital bleeding. I will ascertain if she is sexually active and take a contraception history as this will help to assess the likelihood of pregnancy. Contraceptive agents such as the levonorgestrel intrauterine system can also result in amenorrhoea. I will also take a drug history as these may cause amenorrhoea. I will enquire about recent weight changes, excessive exercise and stress. I will ask for symptoms of hyperandrogenism such as hirsutism and acne, which will suggest polycystic ovaries. Headaches, visual disturbances and galactorrhoea suggest prolactinoma. I will ask if she has been under psychological stress as this will suggest hypothalamic cause of amenorrhoea. I will also ask for climacteric symptoms such as hot flushes as these may be present in premature ovarian failure. On physical examination, I will take a body weight and height and assess her body mass index as obesity or a low BMI can cause amenorrhoea. I will assess for features of hyperandrogenism such as acne and hirsutism which will suggest polycystic ovaries or congenital adrenal hyperplasia. I will do a breast examination to check for breast discharge and assess her visual fields to look for underlying prolactinoma. I will exclude a goitre which can be present in thyroid dysfunction. On examination of the abdomen and pelvis, I will rule out an advanced pregnancy by assessing the size of the uterus. 

c)

I will do a urine pregnancy test to rule out pregnancy. I will also do serum FSH, LH and estrogen levels. High FSH and LH and low estrogen levels will point to premature ovarian failure. A raised LH/FSH ratio will suggest polycystic ovarian syndrome, although this is not a criteria for making the diagnosis. Elevated testosterone levels will be present in polycystic ovarian syndrome or congenital adrenal hyperplasia. If testosterone levels are raised, DHEAS levels should be checked. Raised DHEAS levels will reflect an adrenal source of testosterone. Thyroid function tests (fT4 and TSH) should be done to look for thyroid dysfunction. Prolactin levels will be elevated in prolactinomas. MRI of the pituitary gland can be performed to confirm this. An ultrasound scan of the pelvis should be performed to look for polycystic ovaries and also to confirm the location and gestation of a pregnancy if the urine pregnancy test is positive. 

 

Posted by ASB A.

obgat

(A)

Pregnancy is the most common cause of secondary amenorrhea in women of childbearing age . breastfeeding (lactational amenorrhea is another cause .

Certain contraceptives drugs e.g medroxyprogesterone acetate and progestogen only implants are often associated with amenorrhea .

Hypothalamic amenorrhea can be due to emotional stress , eating disorders e.g anorexia nervosa or excessive exercise (e.g ballet dancer and distance runner ) .

Polycystic ovary syndrome (PCOS) accounts for about 30% of cases of amenorrhea . It is characterised by chronic anovulation secondary to hypothalamic -pituitary dysfunction .

Hyperprolactinemia is another cause of amenorrhea . It may be due to physiologic causes (e.g stress , lactation) , drugs ( e.g bromocriptine , phenothiazine ) or pituitary adenoma .

hypothyroidism may be a cause of amenorrhea . Low T4 is associated with increased secretion of thyrotropin releasing horomne which also stimulate prolactin secretion .

Premature ovarian failure is the cessation of ovarian function before the age of 40 . It is associated with amenorrhea and infertility , although , fertility and menstruation can sometimes resume spontaneously . It may represent an autoimmune disease and it may also follow radiotherapy or chemotherapy .

Asherman syndrome is intrauterine adhesions which may follow excessive uterine curretage and is associated with amenorrhea .

 

(B)

During history taking ,  menstrual history should be obtained including age of menarche , prior cycle length and regularity .

obstetric history should be obtained including number and mode of prior deliveries and complications in prior deliveries e.g severe postpartum haemorrhage ( suggest sheehan syndrome ) or postpartum dilatation and curretage ( suggest asherman) .

Ask about breastfeeding to rule out lactational amenorrhea .

enquire about contraceptive history - Certain contraceptives drugs e.g medroxyprogesterone acetate and progestogen only implants are often associated with amenorrhea . the woman fertility wishes should also be considered .

ask about emotional stress , eating habits and exercise as emotional stress , eating disorders e.g anorexia nervosa or excessive exercise (e.g ballet dancer and distance runner ) can cause hypothalamic amenorrhea .

ask about manifestations of androgen excess . If present , ask about onset and rate of progression of these manifestations . acute onset and rapid progress suggest an androgen secreting tumor , wheras , slowly progressing manifestations may be associated with polycystic ovary syndrome or late onset congenital adrenal hyperplasia .

Enquire about galactorrhea ( suggest hyperprolactinemia ) and manifestations suggestive of thyroid dysfunction e.g cold intolerance and weight changes . 

Enquire about menopausal symtopms e.g hot flushes , night sweats and vaginal dryness ( suggestive of premature ovarian failure ) 

Obtain drug history - some drugs  may cause hyperprolactinemia e.g bromocriptine and antipsychotic drugs .

 

During examination , body weight and height should be measured and body mass index (BMI) calculated . BMI > 30 is present in about 50% of cases of polycystic ovary syndrome . BMI < 19 may suggest eating disorder or excessive excercise associated with hypothalamic amenorrhea 

Check for signs of excess androgen e.g hirsutism and acne 

examine the thyroid gland for signs of thyroid enlargment 

examine breasts for galactorrhea 

abdominal examination may identify abdominal mass.

 

(C)

Urine or serum pregnancy test should be performed first to exclude pregnancy .

Serum FSH and LH should be measured . elevated FSH is associated with ovarian failure .low levels suggest hypothalamic - pituitary failure .

serum prolactin should be measured to exclude hyperprolactinemia . if the level is high , repaet testing is advised as this may be due to a transient cause such as stress . For persistently elevated serum prolactin , cranial MRI is indicated to rule out pituitary adenoma .

Thyroid function test ( TSH , T4 , T3) is indicated to rule out overactive or underactive thyroid gland .

Measure serum testosterone  , Sex hormone binding globulin (SHBG ) and calculate the Free Androgen Index ( FAI)  . Moderately elevated levels of testosterone may be associated with PCOS . However , total testosterone is often normal in PCOS but FAI is raised due to to suprresed SHBG .significantly elevated testosterone (>5 nmol/l) may be associated with androgen secreting tumor or cushing syndrome and further tests are required to identify the cause .Pelvic and abdominal ultrasound may identify ovarian or adrenal mass . measurement of dehydrepiandrostendion sulphate  is helpful as it is maily of adrenal origin and when elevated suggest an adrenal origin of hyperandrgenemia . measurement of 24 hour urine cortisol exclude cushing syndrome .

ultrasound may identify polycystic ovaries 

karyotyping is helpful to identify a cause of premature ovarian failure .

 

 

Padma Posted by shreya S.

a. Causes could include pregnancy, lactational amenorrhoea if breast feeding. Premature ovarian failure, usually no cause, could be familial or secondary to autoimmune diseases, radiotherapy or surgery eg hysterectomy. Factors affecting the HPOaxis eg significant loss of weight, stress, chronic illnessess. Pituitary macro or micro prolactinomas increasing serum prolactin levels. Medication eg antipsychotics or contraceptives like DMPA and mirena IUS can cause amenorrhoea. Ashermans syndrome secondary to surgical TOP, or sheehans syndrome secondary to a massive PPH can cause amenorrhoea.

b. Assessment will include a detailed history including possible predisposing factors.Any symptoms of menopause eg hot flushes suggesting ovarian failure.Past obstetric history including any history of PPH causing Sheehans syndrome, if currently breast feeding. History of current medical problems and medication. Contraceptive history and surgical history or terminations / miscarriage.Look for any endocrine problems eg symptoms of hypo or hyperthyroidism. Any galactorhea or visual disturbances suggesting pituitary tumours. Any symptoms of PCOS eg change in voice, hirsutism. Family history of autoimmune disorders eg graves disease. Recent weight loss, social history of any recreational drugs or psychological stress. Cervical smear history including any treatment eg LLETZ which could cause stenosis.

Examination would include BP, P and measuring BMI. Signs of virilisation eg hirsutism ( Ferriman Gallway score), body habitus ( Central obesity with thin limbs in Cushings syndrome). Abdominal palpation for any masses ( eg ovarian tumours).

c.Pregnancy test to rule out pregnancy. Further investigations will include blood tests including FSH, LH and oestrogen. A high FSH and low oestrogen suggesing ovarian failure while low FSH suggesting hypothalamo/pituitary cause. Serum testostrone, moderately raised levels could suggest PCOS, but very high levels suggesting an androgen secreting ovarian or adrenal tumour. Further tests based on clinical suspicion, DHEA or 24 hour urine cortisol for cushings syndrome,thyroid function tests. Ultrasound pelvis may show polycystic ovaries or ovarian tumours. If subfertility and features of Turners syndrome ( eg low hariline, short stature) karyotyping can be requested. Hysteroscopy if asherman s syndrome suspected.

 

Posted by XX ..

 

a) Secondary ammenorrhoea may be caused by pregnancy or lactation. Functional causes such as excessive exercise, stress, emotional or eating disorders may result in hypothalamic hypogonadotrophic amenorrhoea. Rarely, Sheehan's syndrome is also a cause. Pituitary causes such as adenoma, hypothyroidism or drug use such as antipyschotics,can result in hyperprolactinaemia that causes ammenorrhoea. Drugs such as Depoprovera and  levonogesterol contraception device can also affect menses and cause amenorrhoea. Genetic causes include Turner's syndrome and Fragile syndrome X. Premature ovarian failure can also result from autoimmune disease, glactossaemia or idopathic in most cases. Endocrine causes include Cushing's disease, adult late onset congenital adrenal hyperplasia and Polycystic ovarian syndrome.

b) History is taken to illicit any possible stressors, including excessive exercise, emotional or eating disorders. Ask for any visual defects or galactorrhoea. Ask for climateric symptoms that may indicate premature ovarian failure, such as mood changes, vasomotor and urogenital symptoms. Ask for history of excessive hair growth, alopecia, acne or any symptoms suggestive of virilisation. Ask for past obstetric history and their complications, including history of any postpartum haemorrhage. Ask for history of previous uterine manupilation. Ask for family history of early menopause, autoimmune disease or of any genetic problems, such as Fragile X syndrome. Ask for her fertility wishes and contraceptive use. Take a drug history to exclude iatrogenic causes. 

Perform an examination to check for body mass index and blood pressure. Look for general signs of dysmorphism that may suggest Turner's syndrome, including webbed neck and broadly spaced nipples. Look for signs of hyperandrogenism and acanthosis nigricans. Check her visual fields and breasts for galactorrhoea to exclude pituitary disease. Look for signs of other endocrine disease, including thyroid and Cushing's disease, which may include thin skin and hair, myotonia, moon face and buffalo hump. Do an abdominal and pelvic examination to check for any pelvic masses. Examine the genitalia for clitoramegaly and signs of estrogenism.

 

c) Do a urine pregnancy test to exclude pregnancy. Check bloods for follicle stimulating hormone (FSH), luteinising hormone (LH) and estradiol, where raised follicle stimulating hormome level >15iu/L may indicate premature ovarian failure. Low FSH and LH suggest hypogodanotrophic hypogonadism. Check prolactin and thyroid levels as hyperprolactinaemia and hypothyroidism is also associated with secondary ammenorrhoea. Check testosterone levels. If there are clinical or biochemical signs of hyperandrogenism, check DHEA, DHEA-S, 17OH progesterone levels to determine source of androgens and short synacthen test to exclude congenital adrenal hyperplasia.If there are signs of Cushing's disease, do 24h urinary cortisol and dexamethaseon suppression test. Do an ultrasound pelvis to check for any uterine abnormality and screen the ovaries for polycystic ovarian syndrome. Check the antral follicle count where a low count may indicate premature ovarian failure. if ovarian or adrenal tumour is suspected, a CT or an MRI scan may be necessary. Other investigations depend on clinical findings and history. If there is premature menopause, do karyotyping and FMR-2 premutation analysis to exclude Turner's syndrome and Fragile X syndrome. 

sec amenorrhoes Posted by rasheeda B.

a)likely causes -Pregnancy the commonest cause.Need to know if delivered a few months ago ,and is breast feeding,thats lactational amenorrhoea.Thirdly PCOS is an important cause for sec. amenorrhoea.Premature ovarian failure is alikely cause.Hyperandrogenism too is a cause. If any d and c done in the past 10 months could  lead to Ashermans syndrome,thus causing sec. amenorrhoea.

b)clinically assess.enquire in her history if she had nausea and vomiting a few months ago,or even presently,even ask her if she feels any foetal movements per abdomen.This to check for pregnancy.Whether she delivered a few months ago-and is breast feeding for this is  lactational amenorrhoea.Check her BMI,and to look out for acne, hirsuitism,for PCOS.Check her breasts for galactorrhoea,this indicates hyperprolactinoma.Ask her if she has any hot flushes or anxiety ,this points to premature ovarian failure.Ask about cold intolerance for hypo thyroidism.To enquire of any rapid hirsuitism,ferriman callway scoring to be done.breast atrophy,male type baldness,muscle size increase,clitoromegaly.,as this suggestive of androgen producing tumours.Examine her breast(for galactorrhoea) and abdomen(mass) .Ask if she has a family history of early or premature menopause,as this points to premature ov. failure (fragile X synd)

c)justify investigations-serum beta hcg test,for pregnancy  confirmation.,lh and fsh to sheck for POF.S. testosterone and shbg  for free androgen index. If testosterone is moderately raised indicates PCOS but if very high,androgen tumour.Check serum prolactin.Tsh.If hirsuitism,for karyotyping.Ultrasound for pelvis.Hsg to check for Ashermans syndrome.

Secondary amenorrhea Posted by Yuliya A.
The pregnancy needs to be excluded at the initial presentation. Secondary amenorrhea could associated with number of factors, including recent pregnancy followed by lactational amenorrhea, or history of massive obstetrics haemorrhage which can cause total pituitary apoplexy (Sheehan's syndrome) or Asherman' syndrome which could be the consequence of scarring in the uterine cavity due to excessive curettage at TOP or ERPC. If history is not contained pregnancy therefore other causes should be considered such as premature ovarian failure (premature ovarian insufficiency- POI). Also weight or stress -related amenorrhea, vigorous exercises (athletic) amenorrhea, or contraception - related should be excluded. Unlikely amenorrhea in this case would be related to Secondary amenorrhea due to underlying serious condition or diseases as the statement stated a healthy woman. One should also take into account the possibility of a late onset of PCOS, which apart from oligo- and amenorrhea will have symptoms of hyperandrogenemia. Also the history of LLeTZ procedure with subsequent cervical stenosis has to be excluded. b) Clinical assessment will be based on additional history. Detailed menstrual history, age of menarche, regularity, symptoms of dysmenorrhea, amount of blood loss should be asked at visit. At consultation the above causes of amenorrhea should be thought, paying attention on the presence of facial, body hirsutism, pattern of hair distribution, deepening of voice, beast atrophy can be attributed to signs of hyperandrogenemia, General habitus, raised BMI or underweight, BP should be checked, urine pregnancy test performed. The signs and symptoms of menopause such as hot flashes, nights sweats, vaginal dryness has to be assessed in this woman. Recent weight gain, drug history, any medications which woman is taking will need to be documented, type of contraception and patient's wishes of the future reproductive function. The breast examination should be performed, looking for Galactorrhea, frontal headache, defects of visual fields is associated likely with hyperprolactinaemia. Looking for cervical stenosis on speculum examination may be helpful if relevant history pointed toward this possibility. c) Investigations will be related to the history, pregnancy test to exclude ongoing pregnancy, hormone profile (FSH, LH, SHBG - low in PCOS, oestradiol, progesterone, testosterone, FAI, prolactin, AMH, TFT's - look for hypothyroidism). 17-OHP and DHEA, DHEA-S, androstendione will be necessary to check in cases of suspected adrenal tumours or late onset of CAH. USS TVS of pelvis will be required to check the endometrial thickness and look for the presence of Polycystic ovaries. If Premature ovarian insufficiency suspected family history of that condition with possible karyotyping maybe helpful in diagnosis (mosaic Turner's syndrome XX/X0, Fragile X syndrome). FSH and LH will be raised in POI with low oestradiol level. Sometimes EUA with hysteroscopy or HSG might be required to confirm diagnosis of Asherman's syndrome. With significant hyperprolactinaemia (>1000 IU/L) imaging of head MRI or X-Ray of skull should be arranged to look for Micro or macroplolactinoma.
secondary ammenorrhea Posted by farzana S.

A)Pregnancy is the most important cause that should be considered in this woman of reproductive age. Polycystic ovarian syndrome is another cause if there are associated features of hyperandrogenism and polycystic ovaries onUSS.Menopausal symptoms such as hot flush and night sweats  with ammenorrhea will suggest premature ovarian failure. Presence of galactorrhea would suggest hyperprolactinemia.History of abortion is found in case of uterine synechae-Asherman's syndrome.B) History of associated symptoms should be taken such as nausea and vomiting and abdominal distension may suggest pregnancy. Abnormal hair growth on face,-hirsutism,acne with excessive weight gain may suggest PCOS. Abnormal increase in muscle mass and hoarse voice would be due to hyperandrogenism. History of menopausal symptoms such as hot flashes and night sweats is inquired ,this will suggest premature ovarian failure. History of galactorrhea is taken which would suggest hyperprolactinemia.History of headaches and visual disturbance may be found in case of pituitary tumors.Menstrual history is taken ,age at menarche,LMP,Regularity of cycle, duration and amount of bleeding,. Contraceptive history as long acting contraceptives depot MPA and Mirena IUS Can cause ammenorrhea.Obstetric history about her parity,age of youngest child, as she may have lactation- ammenorhea. Any history of infertility is inquired asPCOS Is associated with infertility.History of excessive exercises is taken ,it is hypothalamic cause .F amily history of PCOS or hirsutism is enqired ,as PCOS is found to run in families.On examination height, weight and BMI is noted. Presence of hirsutism,acne is noted.Visual fields are examined.Areas of excessive pigmentation, acanthaosis nigricans is noted.Thyroid examined for any enlargement. Breasts  are examined and any galactorrhea is leaked for. Abdominal examination done for any abdominal masses. Pelvic examination is done and any clitoromegaly is noted.C) Pregnancy test is done to rule out pregnancy.Endocrine investigations, FSH, LH,prolactin and testosterone are done. In PCOS,LH is found higher than FSH.Progesterone challenge test is positive in case of PCOS.Both LH and FSH are elevated in case of ovarian failure,and low or normal levels are found in hypothalamic cause. Prolactin levels are elevated in hyperprolactinemia and level more than 1500 may be associated with prolactinomas.Testosterone levels are raised in hyperandrogenism and if if more than 5nmol/l,DHEA and DHEA-S levels are checked to find source of androgen-ovarian or adrenal.SHBG Levels are done to find free androgen index.USS is done to see polycystic ovaries. HSG may  be done if history suggestive of Ashermen syndrome.MRI may be required if intracranial mass is suspected.Karyotype will be needed in case of premature ovarian failure or if any dysmorphic features are seen

Posted by Purnima D.

 

 

a) Most common cause of secondary amenorrhea in a 30year old women (reproductive age group ) could be pregnancy related. Need to rule out ongoing pregnancy or lactational amenorrhea post pregnancy if breastfeeding. I need to enquire last menstrual period, method of contraception, Other common cause could be stress at work or body image issues.

 

b) I need to take relevant history with details about:

  • Menstrual cycles: age at menarche, regularity, amount of bleeding in past
  • Circumstances when periods stopped: stress at work or studies/ excessive exercise or contraceptive related
  • Dietary details to rule out body image issues as anorexia
  • Features of hot flushes, dryness, irregular cycles prior to periods stopping ?POF
  • Medication / over the counter therapies/ complementary medicine use
  • Family h/o secondary amenorrhoea or premature ovarian failure (POF)
  • Chromosomal or genetic disorders which could cause POF
  • Previous obstetric history to know last child birth, complication as PPH post delivery which could lead to pituitary necrosis, h/o evacuation or TOP  which was complicated to rule out Ashermann syndrome
  • Symptoms suggestive of syndroms as Cushing’s  or thyroid disorders
  • Features of hyperandrogenism/ virilisation ( deepening of voice, facial hair) as associated with PCOS or adrenal/ovarian  malignancies
  • Any white discharge from breast suggestive of Prolactima  or tumors
  • History of TB/ chronic infection

 

Examination

  • Height/ weight and BMI
  •  Central obesity, striae, cushonoid features to look for
  • Acanthosis nigricans suggestive of hyperinsulinaemia in PCOS
  • Abdominal / pelvis examination to identify tumors
  • If hirsutism, Ferriman Gallway scoring  needed
  • Palpitations, tremor, heat intolerance indicative of thyroid dysfunction

 

c)

Investigations

Main aim is to identify the diagnosis. USG and symptomatology based blood levels are enough to diagnose and cost effective  however no cause may be found

 

LH/ FSH levels checked to identify POF when LH, FSH will be high and low oestradiol levels . Will be more indicative of POF if complains of hot flushes and family history of POF

  Pituitary necrosis is likely if past history of massive PPH and LH/ FSH low

 

USG  abdomen pelvis to identify tumors ovarian/ adrenal, if present will need CT/ MRI  to know details of tumor

 

USG / HSG and/ or Hysteroscopy will reveal  synechae formation in uterus confirming Ashermann as diagnosis

 

Dexamethasone suppression test with an endocrinologist to rule out Cushing’s syndrome

 

If POF will need Karyotype if scan suggestive of streak gonads and physical appearances suggestive ( short stature, cubitus valgus, webbed neck) of Turner (XO) syndrome

 

TFT  or prolactin level checked  if hyperthyroidism  or prolactinoma symptoms ( visual field defect - homonymous hemianopia, galactorrhoea)

 

Free androgen index/ DHEA/ DHEAS  high in CAH

Chest X Ray to rule out TB or any chronic infections

 

H. Fawaz Posted by HIND A.

A-The most common causes in her case to be excluded first pregnancy, then lactational amenorrhea if she is breast feeding post delivery.Other possible causes include hypothalamic amenorrhea resulting form excessive exrsize, eating disorders or stress, Pituitary adenomas and prolactinomas could result in hypogonadotropic hypogonadism, brain tumor, empty sella tursica and craniopharyngioma possible causes but not here since she is healthy.Endocrinopathies such hypothyroidism, Cushing's syndrome are possible causes. hyperandrogenism as aresult of Polycystic ovarian syndrome could be a cause, in addition to late onset congenital adrenal hyperplasia and adrenal tumor.contraception mode such as  levonorgestrel intra uterine system can result in secondary amenorrhea & post pills amenorrhea.

B-starting with enquiry about her last menstrual period, and history of  on going lactation, mode of contraception should be assessed, assess her sign & symptoms of pregnancy like morning sickness.any history of eating problem, stresses, change in body image to rule out hypothalamic amenorrhea.any headache or visual field disturbances to rule out brain tumor or pituitary adenoma since it can press on optic chisma & result in bitemporal hemianopia.any feeling of neck mass in case of hypothyroidism. any change in hair distribution pattern like male type balding(temporal), acne appearance, any change in abdominal girth, any associatedfeeling of hot flushes & vaginal dryness to suggest prematur ovarian failure as acause.enquire about any cold intolerance & constipation to aid in diagnosis of hypothyroidism,then detialed family history for any premature menopause, any chromosomal abnormalties. any history of previous radiation or chemotherapy exposure.any surgeries inclding oopherectomies, dilatation &cureettage to rule out iatrogenic menopause or ashermans' syndrome&cervical stenosis respectively.check her body weight & height & calculate BMI for her. look for any stigmata of turner syndrome as a chromosomal cause of POF like webbed neck , wide carrying angle.look for features of cushing syndrome like cushnoid face , central obesity. look for features of hyperandrogenism such as deepening of the voice, hirsuitism , male pattern balding*&hair distribution. abdominal palpation for any masses including funda height for pregnancy.assess her visual field by checking visual acuity.examine her vagina for any signs of estrogen deficiency like loss of vagina rugae. look for clitoral enlargement for virilization.breast examination for any evidence of galactorrhea.

C- I nvestigation should be started with urine/serum pregnancy test to rule out pregnancy as acause.then hormonal profile including thyroid function tests to rule out hypothyroidism, FSH/LH to asses whether hypthalamic piyuitary gonadal axis is intact, if FSH high could indicate POF especially if associated with low estradiol level which also need to be assessed & if FSH low could by hypopituitarism..& if normal could be outflow tract related abnormality such ase asherman's syndrome or cervical stenosis. Serum prolactin manditory to rule out hyperprolactnaemia.DEAS-S&DEAS need to be performed to assess access androgen level with 17-alpha hydroxy preogesterone level if deficient could be late onset CAH.late night salivary cortisol & 24hrs cortisol to assess for cushing syndrome. karyotyping need to be performed to rule out turner syndrome as acause since in mosaic form they can menstruate but eventually suffer POF & brain CT may be indicated of high serum prolactin or headache 7 visual symptoms presene to rule out pituitary adenoma or prolactinoma or brain tumor,abdomino pelvic U/S orMRI coulde be indicated to check PCOS  appearnace on U/S & any pregnancy, pevic or adrenal tumor.FASTING INSULIN LEVEL TO CHECK FOR INSULIN RESISTANCE IN pcos.

Posted by rahul G.

a)

Most common cause of secondary amenorrhea in a reproductive age group is pregnancy. Also, stress,severe  exercise induced weight loss can often lead to amenorrhea.

If woman suffers from any endocrinological problem, such as hyperprolactinism (pituitary tumour/drug induced) or hyperadrenalism (adrenal tumour), she may not always be symptomatic.

Some of the medications like - H2 antagonists, steroids, antihypertensives- methyldopa, contraceptives- Depot-Provera, Mirena (intrauterine levonorgestrel) & antipsychotics are known to stop menses.

Also, Asherman's syndrome, i.e. intrauterine adhesions formation due to any procedure like currettage for miscarriage/management of PPH, myomectomy or infection like tuberculosis can cease menses.

Premature menopause can also be one of the cause and when sometimes there could not be any cause (ideopathic).

 

b)

Clinical assessment should focus on revealing possible cause and to help in the managent.

One should do basic measurements like height, weight and BMI calculation to rule out obesity due to PCOS and extreme under-weight due to excessive exercise. External features of hyperandrogenism - like distended abdomen, oedema, excessive hair growth should be looked for to rule out Cushings syndrome/ adrenal tumour/ effects of external steroids.

Also, signs of thyroid dysfunction should be looked for like - neck lump, tremors & protruded eyeballs.

Lymphadenopathy & chest examination should be done for tuberculosis.

Skin of neck, back, armpits & groin often reveals features of acanthosis nigricans seen in PCOS/ Cushings. Skin might be shiny or pigmented in Cushings syndrome.

Careful inspection of genitalia & secondary sexual characters - like pubic hairs, axiallary hairs, breast development.  Breast examination also rules out galactorrhea.

Abdominal inspection to see obvious distension / striae / fetal movements. Abdominal examination to palpate any mass (pregnant uterus, palpable fetal parts/ tumour / adnexal mass) or ascites (Cushings syndrome)

Auscultation of abdomen should be done for fetal heart sounds.

Careful bimanual examination should be done to rule out any pelvic pathology including adnexal masses.

 

c)

First investigation should be urine pregnancy test, which is inexpensive, easy to perform & quickest test and rules out the most common cause, i.e. pregnancy.

Hormonal tests should be perfomed i.e. LH, FSH (to rule out PCOS,premature menopause), Prolactin (to rule out pituitary tumour/ hyperprolactinemia due to medicines), T4 & TSH (to rule out thyroid dysfunction), Testosterone & DHEA (to rule out adrenal tumour).

Ultrasound of abdomen & pelvis should rule out any adrenal or ovarian pathology - like tumour / PCOS. Ultrasound also detects pregnancy or intrauterine contraceptive device / adhesions (Asherman's).

Hysterosalphingography is inexpensive, outpatient investigation which helps to diagnose Asherman's but it is not therapeutic.

Hysteroscopy is not only diagnostic but also therapeutic for Asherman's syndrome.

Tuberculin tests (Mountox test) and chest Xray help to diagnose underlying tuberculosis infection.

CT scan or MRI brain helps to detect pituitary tumours if suspected.

 

secondary amenorrhoea pd Posted by Purnima D.

 

a) Most common cause of secondary amenorrhea in a 30year old women (reproductive age group ) could be pregnancy related. Need to rule out ongoing pregnancy or lactational amenorrhea post pregnancy if breastfeeding. I need to enquire last menstrual period, method of contraception, Other common cause could be stress at work or body image issues.

 

b) I need to take relevant history with details about:

  • Menstrual cycles: age at menarche, regularity, amount of bleeding in past
  • Circumstances when periods stopped: stress at work or studies/ excessive exercise or contraceptive related
  • Dietary details to rule out body image issues as anorexia
  • Features of hot flushes, dryness, irregular cycles prior to periods stopping ?POF
  • Medication / over the counter therapies/ complementary medicine use
  • Family h/o secondary amenorrhoea or premature ovarian failure (POF)
  • Chromosomal or genetic disorders which could cause POF
  • Previous obstetric history to know last child birth, complication as PPH post delivery which could lead to pituitary necrosis, h/o evacuation or TOP  which was complicated to rule out Ashermann syndrome
  • Symptoms suggestive of syndroms as Cushing’s  or thyroid disorders
  • Features of hyperandrogenism/ virilisation ( deepening of voice, facial hair) as associated with PCOS or adrenal/ovarian  malignancies
  • Any white discharge from breast suggestive of Prolactima  or tumors
  • History of TB/ chronic infection

 

Examination

  • Height/ weight and BMI
  •  Central obesity, striae, cushonoid features to look for
  • Acanthosis nigricans suggestive of hyperinsulinaemia in PCOS
  • Abdominal / pelvis examination to identify tumors
  • If hirsutism, Ferriman Gallway scoring  needed
  • Palpitations, tremor, heat intolerance indicative of thyroid dysfunction

 

c)

Investigations

Pregnancy test to rule out pregnancy

 

Main aim is to identify the diagnosis. USG and symptomatology based blood levels are enough to diagnose and cost effective  however no cause may be found

 

LH/ FSH levels checked to identify POF when LH, FSH will be high and low oestradiol levels . Will be more indicative of POF if complains of hot flushes and family history of POF

  Pituitary necrosis is likely if past history of massive PPH and LH/ FSH low

 

USG  abdomen pelvis to identify tumors ovarian/ adrenal, if present will need CT/ MRI  to know details of tumor

 

USG / HSG and/ or Hysteroscopy will reveal  synechae formation in uterus confirming Ashermann as diagnosis

 

Dexamethasone suppression test with an endocrinologist to rule out Cushing’s syndrome

 

If POF will need Karyotype if scan suggestive of streak gonads and physical appearances suggestive ( short stature, cubitus valgus, webbed neck) of Turner (XO) syndrome

 

TFT  or prolactin level checked  if hyperthyroidism  or prolactinoma symptoms ( visual field defect - homonymous hemianopia, galactorrhoea)

 

Free androgen index/ DHEA/ DHEAS  high in CAH

Chest X Ray to rule out TB or any chronic infections

Posted by Anoop R.

(a) After excluding pregnancy, the commonest cause of secondary amenorrhoea is polycystic ovarian syndrome. However, the causes can be classified according to the origin. Cranial causes of secondary amenorrhoea include mass occupying lesions involving the hypothalamus. Pituitary causes include micro or macro adenomas; Sheehan's syndrome may be a cause if she has recently had a delivery with a postpartum haemorrhage. Endocrine causes include hypo or hyperthyroidism and Cushing's syndrome. Ovarian causes are PCOS or hormone producing ovarian tumours. Drugs may also cause secondary amenorrhoea. Exercise and stress may also contribute. If she has had multiple LLETZ procedures this may cause cervical stenosis and therefore secondary amenorrhoea. Ashermans syndrome may also be a cause. Premature ovairan failure may also be a cause.

(b) I would take a history asking about any virilising features, galactorrhoea, headaches, weight loss or gain. I would take an obstetric and a smear history. I would ask what contraception she is on. I would measure her BMI and BP. I would perform an abdominal and pelvic examination to identify masses and look for sites of hirsuitism. I would look for features of Cushing's syndrome and hypo/hyperthyroidism. Past medical history would be important especially if she has had any operations on her uterus or cervix.

(c) I would perform a urine pregnancy test. I would test her blood for baseline FBC and a random glucose as if the diagnosis is PCOS then the incidence of diabetes is high. I would test pituitary hormones namely FSH, LH, prolactin and thyroid function tests. I would also measure serum testosterone. I would perform a pelvic ultrasound scan to measure ovarian volume and number of peripheral follicles. If the assessment suggested a cranial cause I would do an MRI to look for adenomas.

Posted by gunjan S.

a)  Secondary amenorrhea may be physiological due to pregnancy and lactation.Stress, excessive exercise ,recent weight loss, dietary restriction associated with anorexia nervosa, cranial irradiation , chemotherapy and surgery can all cause secondary amenorrhea due to hypothalamic .Drugs like tricyclic antidepressants, Selective serotonergic reuptake inhibitors, antihypertensives like methyl dopa and sulpride lower dopamine levels and can cause hyperprolactinemia.This causes secondary amenorrhea and galactorrhea.Pituitary  prolactinoma, stalk compression likewise cause amenorrhea.Pituitary apoplexy follwing postpartum haemorrhage causes sheehans syndrome and amenorrhea.Galactosemia, autoimmune disorders,premature ovarian failure,mosaic Turner are all associated with secondary amenorhea.Late onset 17 hydroxylase deficiency in congenital adrenal hyperplasia and Cushings syndrome can also cause secondary amenorhea.Intrauterine adhesions secondary to genital Tuberculosis, dilation curretage or PID leading to Ashermans syndrome and endometrial supression secondary to MIRENA and injectable Depot Medroxy progesterone are also potential causes.Polycystic Ovarian syndrome is common cause secondary to anovulation and lack of progesterone follwing endometrial estrogenisation.

b)I will ask about menstrual cycle irregularity, and amount of bleed as irregular scanty menses are associated with polycystic ovaries, History of contraception like Mirena and Depo provera  ,both of which cause reversible amenorrhea which resumes after variable period of discontinuation.I will ask about fertility aspirations and whether she is trying for pregnancy and whether she is lactating .

 I will take history of recent weight loss , exercise ,body image problems and  dietary intake ,binge eating and induced vomitting to rule out anorexia nervosa,and hypothalamic causes.I will ask about recent weight gain,, hair growth on  face and abdomen to rule out Polycystic Ovarian Disease.I will check for complaints of easy bruising,striae on abdomen,weight gain for Cushings disease and deepening of voice and enlargement of genitalia with weight gain  and positive family history for Congenital adrenal Hyperplasia.Tiredness ,weight gain and dull skin and hairfall will indicate hypothyroidism and weight loss, bulging eyes, heat intolerance indicate Hyperthyroidism.I will enquire about Dilation curretage, Pelvic infection,tuberculosis  which can cause endometrial destruction, Ashermans syndrome with intrauterine bands and adhesions.I will take history of cervical surgery, cervical conisation leading to stenosis and hematometra and amenorrhea.Family history of early menopause ,metabolic disorder with cataract and Ovarian failure is suggestive of galalctosemia.History to rule out other autoimmune disorders like hypothyroidism,vitiligo, pernicious anemia with coexisting ovarian failure.Headaches and Visual disturbance point to Space occupying cranial lesion either pressing on Pituitary stalk or Prolactinoma.Whether she is on any over the counter prescriptions and drug history causing hyperprolactinemia.

Clinical examination include Blood Presure, BMI as less than 18 is associated withanorexia and high with PCO, Hyperthyroidism, Cushings and CAH.I will asess Hyperandrogenism by acne,  hirsutism by ferrimen Gallweys score , male body fat distribution and acanthosis nigricans and darkening of skin behind neck as it is associated with PCO . Galactorhea  and visual field chart to rule out bitemporal hemianopia for Hyperprolactinemia.Cataract will point to Galactosemia.Palpable boggy,uterus  on abdominal examination and speculum survey suggestive of stenosed cervix will point to hematometra.Onycholysis, exophthalmos ,tremors will indicate likely hyperthyroidism.Cold intolerance, weightgain , rough skin and hair  will point to hypothyroidism.Skin depigmentation of vitiligo, and smooth tongue of pernicious anemia point to autoimmunity.Turner  body habitus with webbed neck, short stature and wide carrying angle of arms will prompt further investigation.

c Investigations will be based on clinical findings.Urine pregnancy test to exclude pregnancy.Progesterone challenge test to rule out estrogenisation and anovulation ,as in PCO.If FSH / LH are low, anorexia nevosa, sheehans syndrome and high, premature ovarian failure  familial or auto immune are suspected, I f clinical features of PCO are associated with high LH FSH , they are not diagnostic but  moderately high prolactin ,HighFree androgen index and testosterone may be present. High urinary cortisol suggestive of Cushings and high 17 -oh progesterone of CAH.Thyroid function test to rule out thyroid disorder and reversed T3 is raised in anorexia .Raised antibody profile confirm presence of autoimmune disorder.Transvaginal scan for  ovarian volume more than 10 ml and more than /equal to 12 peripheral follicles in 1 or both ovaries for PCO, forgotten MIrena,HEMATOMETRA, STREAK OVARIES in Turners. Xray sella turcica for Pituitary tumor, CT/ MRI brain with contrast and Fundoscopy for papilloedema associated with Intracranial tumors.CTabdomen  imaging for adrenal tumors and adrenal artery blood sampling to make definitive diagnosis if still not clear by imaging and ovarian tumors.