SECONDARY AMENORRHOEA

Absence of menses for more than 3 months in women with previously regular cycles and absence of menses for 6-9 months in a women with previous irregular cycle is defined as secondary amenorrhoea.
Causes
Related to genital organs
• Pregnancy is most common cause of secondary amenorrhea
• Anovulation
• Menopause: It is the physiological cessation of menses around age of 45-50 years.
• Premature menopause
• Polycystic ovary syndrome (PCOS) – Disturbance in releasing of female sex hormones and increase amount of male hormone leads failure of development of egg each month in ovary result in amenorrhea. PCOS may affect a women at any age of her reproductive life, hence amenorrhea because of PCOS may be primary or secondary.
• Drug-induced
• Breastfeeding
• Celiac disease
Related to Hypothalamic-pituitary-ovarian axis
• Exercise amenorrhoea related to physical exercise,
• Stress amenorrhoea,
• Eating disorders and weight loss (obesity, anorexia nervosa, or bulimia)
• Hypothyroidism
• Hyperthyroidism Amenorrhea
Diagnosis of secondary amenorrhea
It is necessary that in all cases of secondary amenorrhea a detailed history should be taken followed by a careful examination. A complete menstrual history with special attention to the onset of amenorrhea, whether it is gradual or sudden and whether preceded by oligomenorrhea. In all cases of amenorrhea of short duration during the child bearing period, pregnancy should be excluded. Psychological stress, severe dieting and weight loss associated with any environmental chances should be considered. History of tuberculosis, drug intake, contraceptive use, infection, previous pregnancy complications should be looked in to.
• Physical examination, physical examination mainly include
• Nutritional status emaciation or extreme obesity
• Milk discharge from the breast
• Cervical adenitis or scar in the neck
• Presence of hirsutism, if any
During a pelvic examination, any evidence of clitromegaly should be examined. Atrophic changes in the vaginal epithelium suggest premature ovarian failure. The size of uterus, and the presence of adnexal masses and their mobility should be ascertained.
• Special investigations to diagnose secondary amenorrhea
• Hemoglobin, total and differential counts and ESR
• Blood sugar to rule out diabetes
• Mantoux test for tuberculosis
• Endometrial histopathology following D/C for tubercular endometritis; culture for acid fast bacilli
• Vaginal cytology for hormonal status
• Hormonal estimation including T3, T4, TSH, FSH, LH, Testosterone
• USG of uterus and ovaries
• Laparoscopy to confirm sonographic findings
• Hysteroscopy to rule out endometrial tuberculosis and uterine synechiae
• X-RAY chest, X-ray of the skull, MRI may also be required in some cases
• GnRH stimulation test