Secondary Amenorrhea Algorithm

Question 1

Overview

Answer 1

• Exclude pregnancy
• TSH, prolactin
• Progestin challenge
• Estrogen/progestin challenge
• FSH levels

Question 2

• Exclude pregnancy
• TSH, prolactin: high PRL
• Head MRI: normal

Answer 2

Pituitary Microadenoma

Prolactinoma

Question 3

• Exclude pregnancy
• TSH, prolactin: high PRL
• Head MRI: pituitary lesion

Answer 3

Pituitary Macroadenoma

Prolactinoma

Question 4

• Exclude pregnancy
• TSH, prolactin: high TSH

Answer 4

Hypothyroidism

Question 5

• Exclude pregnancy
• TSH, prolactin: normal
• Progestin challenge: +

Answer 5

Anovulation
* PCOS

Question 6

• Exclude pregnancy
• TSH, prolactin: normal
• Progestin challenge: -
• Estrogen/progestin challenge: -

Answer 6

Asherman Syndrome

Question 7

• Exclude pregnancy
• TSH, prolactin: normal
• Progestin challenge: -
• Estrogen/progestin challenge: +
• FSH: high

Answer 7

Primary Ovarian Failure (POF)
* Turner’s mosaic; Fragile X
* Autoimmune ovarian damage

Hypergonadotropic Hypogonadism

Question 8

• Exclude pregnancy
• TSH, prolactin: normal
• Progestin challenge: -
• Estrogen/progestin challenge: +
• FSH: low
• Head MRI: CNS lesions

Answer 8

• Empty Sella Syndrome
• Sheehan’s Syndrome

Hypogonadotropic Hypogonadism

Question 9

• Exclude pregnancy
• TSH, prolactin: normal
• Progestin challenge: -
• Estrogen/progestin challenge: +
• FSH: low
• Head MRI: no CNS lesions

Answer 9

Severe Hypothalamic Dysfunction
* Drug-induced
* Energy Deficit
* Stress

Hypogonadotropic Hypogonadism

Question 10

• Exclude pregnancy
• TSH, prolactin: normal
• Progestin challenge: -
• Estrogen/progestin challenge: +
• FSH: low
• Head MRI: CNS lesionsa

Answer 10

• Empty Sella Syndrome
• Sheehan’s Syndrome

Hypogonadotropic Hypogonadism