Secondary Amenorrhea Case Review

Amenorrhea Investigation: Initial Patient Presentation

• Patient: 24-year-old female.

• Chief Complaint: Amenorrhea (absence of menstruation) for 18 months.

• Initial Investigations:

  • FSH: Low

  • LH: Low

  • Estrogen: Low

  • Thyroid: Normal

  • Prolactin: Normal

Comprehensive Patient History: Detailed Inquiry

• Menstrual History:

  • Prior Periods: Did the patient have periods before?

  • Regularity: Were periods regular or irregular?

  • Menstrual Cycle Details: Cycle length (how many days?), duration of bleeding (how many days?)

  • Pain: Excessive pain during periods?

  • Irregular Bleeding: Bleeding between periods?

• Partner and Sexual Activity:

  • Sexual Activity: Are you sexually active?

  • Pregnancy Risk: Any chance of pregnancy?

• Pregnancy Symptoms:

  • Tiredness.

  • Morning sickness.

  • Breast tenderness.

• Contraception History:

  • Past Use: Have you ever used contraception?

  • Type: What type of contraception?

• Prior Pregnancies:

  • History: Have you ever been pregnant?

  • Complications: Any complications during past pregnancies?

• Surgical History:

  • Dilation and Curettage (D & C): Any surgeries like D & C done?

  • Surgical Terminations: History of surgical terminations of pregnancy?

• Breastfeeding: Are you currently breastfeeding?

• Cervical Screening: Relevant if the patient is over 25 years old

Ruling Out Differential Diagnoses

Hypothalamic Causes:

• Stress: Any stress at home or work?

• Exercise: Do you exercise? If yes, how much?

• Dieting: Excessive or crash dieting?

• Laxative Use: Any laxative use?

• Medications: Current medications?

• Crash Dieting: Any recent crash diets to lose weight?

Prolactinoma:

• Headache.

• Blurring of vision.

• Discharge from breasts/nipples.

Thyroid Issues:

• Weather Preference.

• Constipation and diarrhea.

Polycystic Ovary Syndrome (PCOS):

• Acne.

• Excessive hair growth (hirsutism).

• Recent weight gain.

Premature Ovarian Failure:

• Hot flushes.

Medications:

• Regular Medications: Current regular medications?

General Medical History:

• Smoking, alcohol, illicit drugs.

• Allergies.

• Relevant past medical history.

• Family History:

  • PCOS.

  • Thyroid disease.

Patient's Specific History and Diagnosis

• Exercise: Ballerina, exercises 10 hours per day.

• Recent Wedding: Upcoming wedding motivated increased exercise.

• Curettage: History of curettage due to miscarriage.

• Likely Diagnosis: Hypothalamic amenorrhea due to excessive exercise and dieting.

  • Mechanism: Suppression of hormone production in the hypothalamus.

  • Hormone Levels: Low levels of hypothalamic hormones like LH and FSH.

Other Potential Diagnoses Considered:

• Stress.

• Pituitary tumors.

• Hypopituitarism.

• Prolactinoma.

• Thyroid problems.

• Polycystic ovarian syndrome.

• Premature ovarian failure.

• Contraceptive pills.

• Pregnancy.

• Chronic illnesses.

Risks and Implications of Amenorrhea

• Infertility.

• Osteoporosis: Weak and fragile bones.

• Cardiovascular Disease: Increased risk.

  • Heart disease

  • Heart attack

  • Stroke