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Obstetrics and Gynecology – Secondary Amenorrhea
Whiteboard Animation Transcript
with Paul Davies, MD
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Amenorrhea is defined as the absence of menses and can be classified as either primary or secondary. Primary amenorrhea is failure to undergo menarche by a certain age where as secondary amenorrhea is the absence of menses for more than 6 months in someone who was previously having menstrual cycles. They are two distinct entities and therefore should be considered as such. Secondary amenorrhea will be reviewed here.

Most importantly, the absence of menses is caused by pregnancy until proven otherwise. This holds true even for those who assure you that pregnancy is not a possibility.
Once pregnancy has been rule out then a systematic approach can be taken. Underlying etiologies can best be delineated by considering the hypothalamic-pituitary-ovarian-uterine axis.

Hypothalamus
Functional hypothalamic amenorrhea is a common cause of secondary amenorrhea. By definition, it implies that there is no underlying pathology. Common causes are emotional stress or physical stress that can be associated with systemic disease or extreme weight loss.

Pituitary
The most common pituitary cause of secondary amenorrhea is a pituitary secreting adenoma such as a prolactinoma. As such, serum prolactin levels should be measured in all cases of secondary amenorrhea whether there are symptoms present or not.

Ovary
Polycystic ovarian syndrome can be considered an ovarian cause and is one of the most common etiologies of secondary amenorrhea. However, PCOS is a complex disorder and can effect multiple endocrine levels. For those wishing fertility, premature ovarian insufficiency must be considered.

Uterus
Intrauterine adhesions are the most common uterine cause of secondary amenorrhea. This is otherwise known as Asherman’s syndrome and should be considered in those who have had previous uterine curettage.

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