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let's now talk about secondary
amenorrhea you've had a period once but
now it's gone
that's secondary amenorrhea as opposed
to primary amenorrhea which means you
never had a menstrual cycle secondary
amenorrhea is defined as no period for
three cycle lengths or for three to six
months that's atypical something has
gone wrong and now it's our job to find
out what let's not list the common
causes of secondary amenorrhea when you
have a low or normal FSH it can be due
to weight loss so if you've lost weight
in a very quick time your FSH might be
quite low if you have an eating disorder
such as anorexia or perhaps bulimia your
FSH is low you can have nonspecific
hypothalamic amenorrhea for some reason
your hypothalamus just stops firing and
your anterior pituitary does not release
kenetic opens a very common cause is
chronic and ovulation including PCOS for
more information about PCOS there is a
lectures about that you can have it with
hypothyroidism so that's when your
thyroid is not functioning as it should
be you can also see a normal or low FSH
with Cushing's syndrome a pituitary
tumor or an empty sella or Sheehan
syndrome can also cause a low or normal
FSH let's talk a little bit about Chien
syndrome
she and syndrome is often tested on us
Emily it usually occurs after a
postpartum hemorrhage postpartum
hemorrhage still occurs worldwide as the
number one cause of maternal death in
the u.s. it's less so but when she and
syndrome
you get pituitary apoplexy because the
pituitary loses blood flow during a
postpartum hemorrhage these women
typically cannot lactate postpartum and
they also lose their axillary hair and
they never have a return to menses so
watch out for this on your exam let's
now talk about high FSH as a cause of
secondary amenorrhea this can occur with
46 xx individuals who have primary
ovarian sufficiency
you can have an abnormal karyotype that
leads to early cessation of menstrual
cycles this is the case with Turner
syndrome patients the majority of cases
with Turner syndrome presents with
primary aim in areia secondary
amenorrhea appears in less than 10% of
patients usually in those who carry a
partial deletion of the X chromosome or
have sex chromosome mosaicism you can
also have a high prolactin that causes
secondary aim in area there is another
lecture set that you can download to
learn more information there are also
anatomic causes of secondary amenorrhea
this is the case an Asscher Minh
syndrome you typically see a Sherman
syndrome after a pregnancy where some
type of dilation and curettage has
occurred this can occur as a result of a
postpartum hemorrhage or post abortive
these adhesions because the uterus to
actually have adhesions between the two
walls and can obstruct any menstrual
flow you can also find secondary
amenorrhea and hyper androgenic states
this happens with an ovarian tumor
non-classical congenital adrenal
hyperplasia and also undiagnosed
hyperandrogenism there are a lot more
causes but we're going to review just
the large ones here functional
hypothalamic amenorrhea
is actually the most common cause of
secondary Aemon area you can also have
hyperandrogenism and polycystic ovarian
syndrome hyperprolactinemia is third
premature menopause or ovarian
insufficiency comes in fourth a Sherman
syndrome is last and then you can have
other uncommon causes of secondary
materia but I wouldn't worry so much
about those in your us Emily try to
remember the above now we'll go over
what we should do when a patient
presents with secondary Aemon area first
you need to complete a thorough history
and physical examination second don't
forget to rule out pregnancy as this is
a common cause and the reproductive age
third we need to get an FSH usually in
conjunction
with an estradiol on the third day of
the menstrual cycle and a prolactin a
prolactin needs to be taken in the am
and fasting if the FSH is actually
equivalent or not high or not low you
should suspect an anatomic defect such
as mullerian a genesis or dis genesis if
the prolactin is high you should do a
radiographic evaluation for prolactin
oma unless there is an obvious cause as
to why the prolactin is high again
there's another lecture that you can
listen to that talks about prolactin if
the FSH is elevated this can indicate
ovarian failure or ovarian insufficiency
this is seen in gonadal dis genesis if
the FSH is low or equivocal this can
mean chronic and ovulation as you see
with PCOS and functional hypothalamic a
mini Rhea
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you