Clerking secondary amenorrhoea

Secondary amenorrhoea is lack of menses in a non-pregnant female for at least 3 cycles of her previous interval, or lack of menses for 6 months in a patient who was previously menstruating. In clerking secondary amenorrhoea, it is important to remember that even with a thorough history and physical examination, ancilliary investigations are often necessary for diagnosis. 

The usual approach to history taking is applied as follows:

Greet the patient and establish rapport.

Obtain the biodata.

Find out the duration of absence of menses.

Ask questions based on the possible aetiologies of secondary amenorrhoea as follows:

  • Eating disorders or female athlete triad: 

weight loss, anorexia, altered bowel habits, sleep disturbances, dry skin, competitive sports

  • Emotional or physical stress:

weight loss, anorexia, sleep disturbances, dry skin, prescription drugs

  • Post-contraception with depot medroxyprogesterone:

Hx of depot medroxyprogesterone

  • Hyperprolactinaemia:

galactorrhoea (some patients), headache or visual disturbances (prolactinoma); may present with oligomenorrhoea if prolactin levels are not extremely elevated

  • Polycystic ovary syndrome (PCOS):

slowly progressive symptoms, deepening of voice, male-pattern hair growth or loss, oily skin, weight gain, oligoanovulatory cycles to amenorrhoea (if peripubertal onset, may present with delayed menarche), history of premature pubarche, depression

  • Idiopathic premature ovarian failure:

age <40 years, vasomotor symptoms, vaginal dryness, decreased libido, fatigue, weight gain

  • Post-chemoradiation ovarian failure:

vasomotor symptoms, vaginal dryness, decreased libido, fatigue, weight gain

  • Chromosomal abnormality (Fragile X carrier, Turner’s syndrome mosaic):

age <40 years, vasomotor symptoms, vaginal dryness, decreased libido, fatigue, weight gain; may lack hypo-oestrogenic complaints but stop cycling

  • Non-classic congenital adrenal hyperplasia:

presents in late childhood to early adult life; obesity, hirsutism, acne, weight gain, hx of premature pubarche

  • Hypothyroidism:

oligomenorrhoea more common than amenorrhoea; lethargy, dry skin, constipation, weight gain, paraesthesias, cold intolerance, galactorrhoea

  • Malnutrition or chronic disease state:

hx of chronic disorder (e.g., coeliac disease), weight loss, anorexia

  • Empty sella syndrome: 

mass in sella turcica or previous central nervous system surgery/radiation/infarction; headache, galactorrhoea, or visual disturbances may be seen with associated prolactinoma

  • Sheehan’s syndrome (postpartum pituitary necrosis):

severe obstetric haemorrhage, hypotension, and shock with postpartum panhypopituitarism (after volume and blood resuscitation), nausea, vomiting, lethargy, failure to breast-feed, slowed mental function, fatigue, weight loss, delayed symptoms of hypothyroidism

  • Post-encephalitis:

previous infectious process, headache, altered vision

  • Androgen-producing ovarian tumour:

rapidly progressive symptoms, obesity, hirsutism, acne, deepening voice, male-pattern hair growth or loss, oily skin, weight gain, oligoanovulatory cycles to amenorrhoea

  • Autoimmune premature ovarian failure:

age <40 years, vasomotor symptoms, vaginal dryness, decreased libido, fatigue, weight gain

  • Androgen-producing adrenal tumour:

rapidly progressive symptoms, obesity, hirsutism, acne, deepening voice, male-pattern hair growth or loss, oily skin, weight gain, oligoanovulatory cycles to amenorrhoea

  • Cushing’s syndrome:

easily bruised, poor healing, weakness, weight gain, hirsutism, DM, HTN, galactorrhoea (some patients), headache or visual disturbances (pituitary adenoma), may present with oligomenorrhoea

  • Asherman’s syndrome:

amenorrhoea following an intrauterine procedure (dilatation and curettage for second-trimester abortion or pregnancy loss, or complication of post-procedural endometritis, myomectomy, caesarean delivery), moliminal symptoms (these are a useful clinical indicator of a normal reproductive cycle; they include increase in mid-cycle thin cervical secretions, and premenstrual symptoms such as menstrual cramps, breast tenderness, fluid retention, and mood or appetite changes)

  • Drug-induced: 

Hx of oral contraceptive use (however, this should not cause secondary amenorrhoea, as most users have return of function within 2 months of discontinuing), long-acting progestogens, androgens, antipsychotics (may down-regulate HPO axis by way of dopaminergic pathways), or chronic opioid use.

Physical examination

  • Eating disorders or female athlete triad: 

low BMI (10% less than ideal body weight), normal secondary sexual characteristics, normal external and internal genitalia

  • Emotional or physical stress:

low BMI (10% less than ideal body weight), normal secondary sexual characteristics, normal external and internal genitalia

  • Post-contraception with depot medroxyprogesterone:

normal secondary sexual characteristics, normal external and internal genitalia

  • Hyperprolactinaemia:

visual field deficit (some patients)

  • Polycystic ovary syndrome (PCOS):

androgenic alopecia, acanthosis nigricans, increased waist-hip ratio, clitoromegaly, acne, hirsutism, obesity (BMI >30)

  • Idiopathic premature ovarian failure:

post-pubertal external genitalia, adult secondary sexual characteristics

  • Post-chemoradiation ovarian failure:

normal adult secondary sexual characteristics

  • Chromosomal abnormality (Fragile X carrier, Turner’s syndrome mosaic):

Turner’s mosaic: fewer physical manifestations as compared with full syndrome; may have isolated oligoamenorrhoea; Fragile X carrier: may have large ears

  • Non-classic congenital adrenal hyperplasia:

androgenic alopecia

  • Hypothyroidism:

low resting heart rate, peri-orbital puffiness, delayed ankle deep tendon reflexes, cold and coarse skin

  • Malnutrition or chronic disease state:

low BMI (10% less than ideal body weight), normal secondary sexual characteristics, normal external and internal genitalia

  • Empty sella syndrome: 

visual field deficit (some patients)

  • Sheehan’s syndrome (postpartum pituitary necrosis):

postural hypotension, loss of axillary and pubic hair, adrenal crisis (with skin de-pigmentation), rapidly involuting breasts, peri-orbital oedema

  • Post-encephalitis:

visual field defects, normal phenotypic female

  • Androgen-producing ovarian tumour:

androgenic alopecia, clitoromegaly, male-pattern hair growth, increased muscle mass

  • Autoimmune premature ovarian failure:

normal adult secondary sexual characteristics

  • Androgen-producing adrenal tumour:

androgenic alopecia, clitoromegaly, male-pattern hair growth, increased muscle mass

  • Cushing’s syndrome:

central obesity with thin extremities, nuchal fat pad, moon facies, purple striae

  • Asherman’s syndrome:

normal adult secondary sexual characteristics and external genitalia

  • Drug-induced: 

usually normal; some psychotropics may cause galactorrhoea