Secondary Amenorrhoea

 

Definition- when menstruation has previously occurred but it has stopped for at least 6 consecutive months.

 

Referral:

Consider the cause of the amenorrhoea to guide appropriate referral

• General gynae (Suspected PCOS, Primary ovarian insufficiency (POI), Hypogonadism)
• Endocrinology (Hyperprolactinaemia, Thyroid disease, Rare endocrine disorders)
• Infertility Service (If trying to get pregnant)
• Eating disorders service

 

Causes and Investigations:

• Pregnancy- urinary or serum BHCG
• Menopause inc premature ovarian failure ie menopause <40yrs- raised FSH
• Contraception- depot/ implant/ POP/ Mirena/ post pill amenorrhoea
• Weight loss  >10% of body weight loss- low FSH and LH
• PCOS- FAI/LH/FSH/prolactin/TSH- see PCOS guidelines
• Cervical Stenosis/intra uterine adhesions- From previous surgery - USS                                               
• Pituitary tumour- Prolactin often >1000. Assess visual fields
• Drugs- causing raised prolactin inc heroin/phenothiazines/metoclopromide/ tri-cyclics
• Rare Endocrine Disorders- Cushing’s, Adrenal ca, Congenital Hyperplasia (testosterone >5) Sheehan’s syndrome (low prolactin)

 

Information to include in the referral:

• History and examination inc menstrual Hx taking into consideration the possible cause.
• DHx
• BMI
• Past gynae Hx inc surgery
• Significant PMHx

 

Investigations - as above

• FAI, LH, FSH, TFT, prolactin, SHBG
• Pelvic USS

Offer Contraceptive advice to women who do not wish to become pregnant

If amenorrhoea persists for >12 months consider osteoporosis prophylaxis (http://cks.nice.org.uk/topics/amenorrhoea/management/secondary-amenorrhoea/#managing-osteoporosis-risk)

 

References:NICE CKS Ammenorhoea Revised November 2019

Author:Dr S Burns GP

              Dr M Schick GP

Contributors: Miss S Bates Consultant Gynaecologist RCHT

Date:      August 2024                                Review Date: August 2026