CASE 6: SECONDARY AMENORRHEA: HYPERANDROGENISM
CASE 6
32 year old G2P1 (1011) consulted because of absence of menses for the past 3 months. ROS & PMH: unremarkable; LMP – 5
months ago; OB History: 2008 – term NSD BW: 6 lbs; hospital delivery: 3 months prior to consult, she was diagnosed to have
missed abortion, for which she underwent completion curettage. PE: breast & pelvic examination were normal.
CASE DX: Secondary to ASHERMANN’S SYNDROME following
D&C for the missed abortion
SECONDARY AMENORRHEA:
Absence of menses in a woman who was previously
menstruating
Most common cause: PREGNANCY (In puberty, age will not
exempt from the probability of pregnancy)
The 2 main causes are HYPERANDROGENISM &
HYPERPROLACTINEMIA
Evaluation:
1. CC: missed menses/ absent of menses
2. When did you stop menstruating?
3. Sexual contact: Is there a possibility that you could be
pregnant?
4. Ask presumptive symptoms of pregnancy. (Breast,
Nausea, Vomiting, Easy Fatigability, Urinary Frequency)
5. Intake of drugs:
After prolonged intake of OCP (3 years) - "post pill
amenorrhea"
6. Personal: where there any stressful situations that
happened lately?
7. Weight gain/ weight loss – (Hypothalamus) women on
severe athletic training, do not like to eat (anorexia
nervosa) or those that balloon out.
8. Have you had any gynecologic procedure or previous
history of curettage from an incomplete abortion or
diagnostic curettage from AUB
PE:
Head:
Signs of Hyperandrogenism: Acne, Excess hair & Alopecia
Neck
Signs of Hyperthyroidism: Exophthalmos
Breast
Galactorrhea – check for nipple discharge
st
1 Rule out: Lactation causing Physiologic Amenorrhea
Pelvic exam
Distribution of the pubic hair assuming a male
distribution (diamond)
Check for probable signs of pregnancy: Chadwicks sign,
Hegar’s  sign   menopause expect an elevation of gonadotrophin
Normal uterus BUT sometimes there is palpable bilateral
adnexal masses (BMI 18 & 19 - easy to feel ovaries, but
BMI 24 - 25 difficult to palpate)
Different Causes:
Hypothalamus – Pituitary – Ovaries – Uterus
From the HPO axis, anything that will go wrong may be a
cause of amenorrhea
More practical standpoint:
Is there anything from the lower genital tract (vagina &
cervix) that will give rise to secondary amenorrhea?
Cervix - Adhesions:
PMH: Cervical operation (Cryotherapy, Electrocautery)
Cervical Stenosis: External Os became obstructed.
Patient may develop hematometra, stop menstruating &
regular cyclic pain corresponding to the time she must be
menstruating
This would be like transverse septum except there is no
Hematocolpos (the blood will never go to the vagina
because the cervix is obstructed)
Uterus
Development of intrauterine adhesions
Take note if she had pregnancy, OB history: abortion,
undergone completion curettage, diagnostic D&C for AUB
Endometrial cavity will oppose to one another rendered
functionless condition known as ASHERMANN'S
SYNDROME
Infection
Remember puerperium (6 - 8 weeks after delivery)
Infection may give rise to:
o AUB: Endometritis Following delivery or curettage
O
o 2 Amenorrhea: TB of the endometrium
Ovaries:
Infection of the Ovaries:
Oophoritis (not common)
Ovarian abscess
POF, Premature Ovarian Failure
Aka Premature Menopause
Women went into premature menopause when she is not
supposed to stop menstruating yet
Menapause (Age: 48 - 52), if 45 years old: just early
menopause, NOT POF
Possible causes:
Less # in follicles
At birth, you have millions of follicles but by the time of
menarche, it will be about 300 000 follicles & about 20 follicles
are used up every month. Finally by the time of menopause, all
follicles are consumed & a woman can’t produce an egg.
More common cause: usually look back in the history & ask
how was your mother when she was pregnant with you in her
womb, did she have anything that could have affected the
development of your follicles?
IF endometrium is thin, it means nothing is stimulating the
endometrium
Take gonadotrophins, because if she truly has premature
hormones
This   is   similar   to   a   patient   with   Turner’s   syndrome  
Hypergonadotropic hypogonadism
If she really has high gonadotrophic hormones, the next
step is karyotyping of the patient
Any form of treatment as an aftermath for any malignancy:
Chemotherapy or ovary has been partly radiated
Related to POF
Operations on the ovaries
Cystectomy (part of the ovaries, little remaining ovarian
tissue that will respond to gonadotropin hormones)
Masculinizing tumor of the ovary
Functioning or hormonally active cysts of the ovaries
Produces androgen initial effects: Defeminization starting
with breast atrophy then eventually amenorrhea
PCOS Case 6:
Although it looks like a problem in the ovary, it is a A 31y/o, married for 3mos, consulted because of missed
multisystem problem of Hypothalamus & Pituitary also menses for the past 4mos. LMP May 1st wk, 2014. PMP-
Problem is GnRH pulsatility March 2nd wk, 2014. Shhe noted that her cycle interval
was 40-6-days for the past year. Ht-5ft Wt-161lbs. She
History: has coarse hair on her lower extremities. Pelvic exam: no
FIRST QUESTION: gross lesion, (+) coarse hair on the mons pubis & inner
Since when did you start having irregular menstruation? aspect of the thighs; IE: Cervix - firm, long, closed; uterus
Was it at the onset of menarche or recently? - normal size, anteverted; adnexa - no mass/tenderness
TRIAD
1. OLIGO (Cycles: q 4 - 5 mo) & or CHRONIC ANOVULATION
(Irregular menses)

2. HYPERANDROGENISM may be:

Clinical: Hirsutism
An abnormal hair growth, usually coarse & assumes a
male pattern growth distribution on (upper lip, infra-
umbilical, anterior chest)
Biochemical by showing elevated androgen levels or
testosterone

3. POLYCYSTIC OVARIES
Via UTZ: like a pearl necklace with follicles all around
Should be about 12 follicles peripherally located
measuring < 10 mm

TO DX PCOS: 2 / 3 ROTTERDAM CRITERIA

DX EXAM: UTZ

Other things needed to know:

General Survey: OBESITY (BMI)
PMH & Personal History: Diabetes
Pelvic exam: may or may not have palpable cystic ovaries

TX:
1. Most important: LIFE MODIFICATION, losing weight will
simply restore menstrual cycle

2. REGULATE THE MENSES

Start the progesterone challenge test (Result: Bleeding)
Give combination of E & P (start at the OCP) to regulate
the menstrual cycle

3. Prevent complications
Insulin sensitizing drugs: METFORMIN because PCOS
causes hyperinsulinemia which makes them at risk for
Type 2 DM