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